1. Clinical perspectives on referrals
Dr Nithya Nanda
Clinical lead GP for diabetes
East Berkshire
07/07/2016
Taunton
Service provided by

2. Overview Existing locally enhanced service Options for referral
Development of the ‘How to Guide’
Development of referral forms
Berkshire referral criteria
Description of progamme
Comments on cases referred to date

3. Pre-existing Work helped..
In Slough, we had started the process 2 years earlier.
SilverStar charity partnership helped case identification in public places—mosques, gurdwaras, temples and churches.
GP incentive scheme Pre-Diabetes LES helped create NDH Register.
£ 3 for creating a register and £23 for face-to-face reviews .
Hence Slough’s prevalance of Diabetes jumped from 7.5% to 8.4% and our estimated to actual prevalence proportion is nearly 95%

4. Options of Referral-pathways
Two pronged approach.
1. Referring NDH patients opportunistically at annual review as part of LES. High hit rate in terms of engagement, participation, and completion of the program. This results in gradual but good uptake of the program.
2. Data extraction using CHART query and digital invitation and referral thereof.

5. How To Guide - national audit

6. Referral forms for EMIS and Vision

7. Referral criteria Aged 18 years or older
Be registered to a Berkshire GP practice (by postcode)
Not diagnosed with Type 2 diabetes
Not pregnant at the time of referral
With a valid HbA1c of mmol/ml ( %) or
an FPG of mmol/l tested in last 12 months

8. Options for practices to refer
910 patients on existing prediabetes audit
206 patients on NDH audit
Single
cases

9. Road Show
GP practice visitation by Reed Momenta provider explaining the program and getting the buy in from the practice Staff.
Banners and promotional material in the waiting room.
Good timing as filming going on for ‘GPs behind closed doors’
In the second year, public place identification and self referral and digital offer needs robust implementation?

10. Programme Content
Four curriculum strands: Health (Be Aware), Behaviour Change (Take Control), Nutrition (Eat Well), Physical Activity (Move More)
Delivery kit is provided to H&W Coaches
Participants receive a comprehensive set of resources including Workbook, DPP Points, pedometer and access to Applications

11. 18 week local programme
Free, nine month community-based behaviour change programme to help people prevent the onset of Type 2 diabetes
18 supportive, group-based sessions for up to 20 people delivered by trained, local staff
Programme designed by experts and underpinned by a decade of research into community-based diabetes prevention

12. Thank you