SCHEDULE 2 – THE SERVICES
A.
1.
Service Specifications
Service Specification No.
TBD
Service
NHS Diabetes Prevention Programme: Case finding and
referral for patients with non-diabetic hyperglycaemia
2016/17
Commissioner Lead
Alice Ehrlich – Camden & Islington Public Health
Provider Lead
ICS Health & Wellbeing
Period
November 2016 – 2017
Date of Review
September 2017
Population Needs
1.1 National/local context and evidence base
1.1.1
The National Context
The NHS Diabetes Prevention Programme (DPP) is a high profile national initiative being led by NHS England.
The service will support patients with non-diabetic hyperglycaemia (pre-diabetes) to prevent the onset of diabetes.
The behavioural intervention will be delivered to patients over a minimum of nine months. Patients will be offered
group and/or one-to-one assessment sessions each week over a period of 12 weeks. This will be followed by four
monthly group maintenance sessions. Participants also receive one-to-one progress review sessions with a health
and wellbeing coach.
1.1.2
The Local Context
Locally, Camden, Islington and Haringey CCGs and Local Authorities put together a joint bid in October 2015 and
were selected by NHS England to roll out the programme over 24 months between 2016 and 2018, requiring a
rapid response from bid areas to comply with NHSE’s very tight timeframe.
Across the three boroughs, there are around 56,000 adults with non-diabetic hyperglycaemia with prevalence
estimated between 8.6% and 10.1%, reflecting the ethnic diversity of our populations and higher levels of obesity.
However, only around 12,500 are currently diagnosed as pre-diabetic on primary care registers.
Within Camden, there are approximately 5,500 patients on the pre-diabetes register, and of these approximately
3,500 are eligible for the DPP.
UKICS Pulse (ICS Health & Wellbeing) has been chosen to join CCGs/LAs to deliver the service for the area, with
the option of local sub-commissioning or partnership working. While the service will open for opportunistic
invitations of all eligible patients in the borough, it is intended that a number of primary practices will send a mass
communication to eligible patients asking them if they would like to be referred into the DPP by December 2016.
Those practices who have not sent mass communications by December 2016 will be asked to send out their mass
communication from January 2017 onwards, whilst in the interim being able to refer patients both opportunistically
and via NHS Health Checks.
1
2.
Outcomes
2.1
NHS Outcomes Framework Domains & Indicators
Domain 1
Domain 2
Domain 3
Domain 4
Domain 5
2.2
Preventing people from dying prematurely
Enhancing quality of life for people with long-term
conditions
Helping people to recover from episodes of ill-health or
following injury
Ensuring people have a positive experience of care
Treating and caring for people in safe environment and
protecting them from avoidable harm
X
X
X
Local defined outcomes

To promote wellbeing, reduce health inequalities and improve health outcomes for local people

To improve the health and quality of life for people by commissioning integrated health and social care
delivered closer to home
To provide appropriate lifestyle advice to patients with non-diabetic hyperglycaemia
Reduction in the number of CCG patients with the risk of diabetes
Reduction in the number of patients who would otherwise go on to develop Type II diabetes



3.
Scope
3.1
Aims and objectives of service
Strategic aim
The strategic aim of the scheme is to increase the number of people identified to be at risk from developing
diabetes and help them make changes so that they fall out of the risk category.
Service aims
At a local level, the key aim of the service is to support practices to refer patients with non-diabetic
hyperglycaemia (pre-diabetes) to the DPP delivered by UKICS Pulse.
Practices will be required to record invitations and referrals for all pre-diabetic patients who are invited to the
programme using the codes identified in Section 3.3 of the service specification.
The services objectives will be to:
1. Provide a clear pathway into which GPs can refer pre-diabetic patients for lifestyle advice and appropriate
exercise sessions
2. Enable patients to self-manage their condition to reduce their risk of developing diabetes
3.2 Service description/care pathway
3.2.1 Service description
NHS England has informed local commissioners that the pilot phase of the DPP will run from September 2016
until August 2018.
NHS England have made available a small amount of pump-priming money to enable local areas to embed the
DPP within the first year of the programme. This money is being passed on directly to practices as outlined in
Appendix C.
2
Participating practices would be expected to complete the following elements for payment according to the
schedules below:
1. The practice offers referral into the DPP via invitation to 80% of all patients currently eligible for the DPP
(as of 20.06.16), within 12 months of signing up to the LIS; the numbers of which are specified in
Appendix C. Practices will be asked to invite their patients either between November – December 2016,
or from January 2017 onwards. Patients with a high QDiabetes score can be invited first if practices
wish to further stagger their referrals
2. Offer opportunistic referrals into the DPP from contract commencement at any point via routine
appointments and NHS Health Checks
3. Aim to refer as many eligible patients into the DPP following patient consent for referral
4. The practice ensures patient consents to referral, and codes the invitation using the codes provided in
Section 3.3.
5. The practice codes the outcomes of the intervention for patients who initiated into the service using
codes provided in Section 3.3. Information will be sent by the DPP provider in order for practices to do
this.
Please see Appendix C for the invitation targets for individual practices.
The practice may decide the most appropriate way of engaging with the patient for example through letter, phone
call, email or face-to-face. An invitation letter template is available as part of the DPP IT tools.
3.2.2 Definitions of terms
Invitation – Communication with patients eligible for referral to DPP, offering them a place on the intervention via
channels of preference, i.e. letter, phone call, or email.
Referral – A person shall be considered to have been referred to the DPP where they meet the relevant criteria
for referral as outlined in this service specification, where consent for referral from the patient has been secured
and where sufficient details are provided to the provider to enable contact with the individual or when the
individual makes direct contact with the provider following invitation with a self-referral form from the practice.
3.2.3 Invitation and referral routes
The referral pathway shown in Figure 1 outlines the two main referral routes in to the DPP following the
identification of eligible individuals.
1. Referral following NHS Health Check or opportunistic identification
Where eligibility for the NHS DPP is established as part of the NHS Health Check performed by a GP or as part
of opportunistic detection a referral may be made with the consent of the patient. The referral, with
accompanying information (form provided by the DPP provider) must be communicated electronically and
securely to the DPP provider. The NHSHC template has been altered accordingly to support electronic referrals
directly to the DPP provider.
2. Identification of existing cases known eligible individuals on GP registers
Searches can be run on the registers held on practice systems to identify individuals that meet the current
eligibility criteria for the programme. This query creates a list of eligible patients and their contact details, which
are then used to invite them to consent to referral into the Programme.
The practice may choose the most appropriate form of engagement with the identified at eligible patients, e.g.
letter, phone call or email.
Where consent for referral from the patient has been secured, sufficient details must be submitted to the DPP
provider using the electronic form provided. Alternatively, the individual can be sent a self-referral form to make
direct contact with the provider.
3
IT tools have been developed by Camden CCG’s IT & System Team and are either available centrally or via the
Camden GP website. Tools include searches, referral forms, protocols / pop-ups, and invitation letter and can be
downloaded from: https://gps.camdenccg.nhs.uk/practice-management/gp-it/it-tools/overview-of-it-tools
Figure 1: DPP – referral pathway
3.2.3 Staggered roll-out in the pilot phase
Practices will be asked to coordinate mass communications with the DPP provider.
While the service will open for opportunistic invitations of all eligible patients in the borough, it is intended that the
launch will take a staggered approach to rolling out the service locations across the borough. Therefore in the
period between November and December 2016 the CCG will work with a number of practices on coordinating
mass communications to eligible patients. From mid-January 2017 all other practices participating in the LIS will
be able to roll out mass communications to their patients.
Opportunistic referrals via NHSHC or routine appointments can be made at any time.
3.2.4 Increasing pool of people eligible for referral
The practices may choose to invite any of the following groups to glucose test to increase the pool of the people
to refer:
Invite any ‘pre-diabetic’ patients who do not have a recent (last 12 months) glucose/ HbA1c reading
Invite people with QDiabetes score ≥20% or meeting the thresholds for formal screening for diabetes
mellitus, i.e. BMI≥30 (>27.5 for Black African, African–Caribbean and Asian groups) or BP ≥140/90.
3.3 Monitoring and evaluation of the service
Monitoring will be undertaken monthly.
4
Monthly extraction of data coordinated by Camden CCG will include:



Number of invitations to DPP
Number of referrals to DPP
Number of people who started, declined, completed and did not complete DPP
By signing up to the LIS, practices agree to have their servers accessed by the Camden CCG GP IT team on a
monthly basis, and to ‘Read Codes’ relevant to this pilot being extracted remotely. Data extracted remotely will be
anonymous and used by the CCG for payment and evaluation purposes and on aggregated level to report to NHS
England. Practices will be notified in advance before their servers are accessed remotely.
Practices will need to use the following read codes in order for the service to be monitored and payments made:
Table 1: Invitation Read Codes
NHS diabetes prevention programme (NHS DPP) administration
EMISNQNH17
Sub-code: NHS diabetes prevention programme invitation
ENISNQNH18
Sub-code: NHS diabetes prevention programme invitation first letter
EMISNQNH19
Sub-code: NHS diabetes prevention programme invitation second letter
EMISNQNH20
Sub-code: NHS diabetes prevention programme invitation third letter
EMISNQNH21
Sub-code: NHS diabetes prevention programme telephone invitation
EMISNQNH22
Sub-code: NHS diabetes prevention programme verbal invitation
EMISNQNH23
Table 2: Referrals
RSP No
V2
V3
SNOMED CT
Qdiabetes
calculator- 38GJ
19517
679m4
Referr
ed to NHS Diabetes
Prevention
Programme
XaeDH
Referr
ed to NHS Diabetes
Prevention
Programme
1025321000000109 Referred to
National Health Service Diabetes
Prevention Programme
(procedure)
19518
679m3
Referr
al to NHS Diabetes
Prevention
Programme declined
XaeDG
Referr
al to NHS Diabetes
Prevention
Programme declined
1025301000000100 Referral to
National Health Service Diabetes
Prevention Programme declined
(situation)
19519
679m2
NHS Diabetes
Prevention
Programme
started
XaeD0
N
HS Diabetes
Prevention
Programme started
1025271000000103 National Health
Service Diabetes Prevention
Programme started (situation)
19520
679m1
HS Diabetes
Prevention
Programme
completed
XaeCz
HS Diabetes
Prevention
Programme
completed
1025251000000107 National Health
Service Diabetes Prevention
Programme completed (situation)
N
N
5
19521
679m0
Natio
nal Health Service
Diabetes Prevention
Programme not
completed
XaeCw
HS Diabetes
Prevention
Programme not
completed
N
1025211000000108 National Health
Service Diabetes Prevention
Programme not completed (situation)
3.4 Key Performance Indicators (KPIs)
Practices are expected to invite 80% of their known eligible population to the programme within the first year of
the LIS through a mass communication method (letter, phone calls, email).
In addition, practices are asked to aim to refer as many eligible patients as possible into the DPP.
3.5 Payment for Service
The payment for this service will be as follows:
Payment type
Payment trigger
Payment value
Practice will receive an
upfront capacity payment
to cover the costs of
inviting eligible patients
to the programme.
Completed sign-up form (Appendix A) received from
practice.
£2.70 per eligible patient
on practice register.
Please note - where practices do not meet the
invitation targets(see KPI, above) the CCG will
reserve the right to claw back the capacity
payment.
Please see Appendix C for payments and targets for individual practices.
3.5 Training
Making Every Contact Count (MECC) is a training package for all front line staff to make the most of each and
every opportunity to help local people improve their health, wellbeing and quality of life that includes:
E-learning – available for all staff, providing basic level training including what issues to look out for, recognising
the need for support and how to ask questions and signpost to support in a sensitive and appropriate way.
Free face-to-face training – targeted at staff who have regular contact with local people to put into practice and
further develop skills in delivering brief advice and interventions.
For more information and to sign up, please visit:
www.camdenmecc.org.uk
3.6 Populations covered
Adult patients with non-diabetic hyperglycaemia (pre-diabetes) who are registered with a GP practice in Camden
and who currently meet the DPP eligibility criteria. Inclusion and exclusion criteria are outlined in section 3.7.
3.7 Inclusion and exclusion criteria
Inclusion criteria:
1. 18 years or over
2. Have ‘non-diabetic hyperglycaemia’, defined as having an HbA1c of 42 – 47 mmol/mol (6.0 – 6.4%) or an
FPG of 5.5 – 6.9 mmol/l
3. Reading within the 12 months prior to referral
6
Exclusion criteria:
1.
2.
3.
4.
Blood results confirming a diagnosis of Type 2 diabetes
Normal blood glucose reading on referral to the service
Individuals aged under 18 years
Pregnant women
3.8 Interdependence with other services/providers
The eligibility criteria for the NHS DPP and adult weight management services overlap. Referral decisions should
be discussed with patients and take into account the health status of individuals and the presence of any weight
related co-morbidities such as Type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia,
and sleep apnoea.
Organisations that practices will be expected to work with:
3. UK ICS Health And Wellbeing (Trading as Pulse) (DPP provider)
4. Weight management services
5. One You provider
6. Nutrition and Dietician Services
7. Camden CCG IT & Systems Team
4. Applicable Service Standards
4.1 Applicable national standards (eg NICE)
This service seeks to support practices to work towards best practice evidence based care for people with nondiabetic hyper-glycaemia and supports implementation of the National Diabetes Prevention Programme and
NICE guidance on Diabetes Prevention PH38.
4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal Colleges)
Practices will comply with the Department of Health and Royal College of General Practitioners regulations and
Guidelines
4.3 Applicable local standards
Practices will be required to follow the relevant referral pathways see Appendix B
5.
Location of Provider Premises
The Provider’s Premises are located at:
The DPP service will be delivered in venues across Haringey, Islington and Camden.
Patients may attend venues across all three boroughs, regardless of the location of their GP practice.
Venues will include GP practices and other community venues.
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Appendix A - Sign-up form
Agreement to provide the Diabetes Prevention Programme Pilot Scheme from 1st
August 2016 to 31 July 2018
Please complete details below
Practice:
Named Lead GP for
the pilot:
Responsible Partner
Date:
Signature:
Signed on behalf of Camden CCG………………………………………………………….
Print name…………………………Date: ……………………….
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Appendix B – Identification and Referral Pathway
Referral following NHS Health Check or opportunistic identification
Where eligibility for the NHS DPP is established as part of the NHS Health Check performed by a GP or as part
of opportunistic detection a referral may be made with the consent of the patient. The referral, with
accompanying information (form provided by the DPP provider) must be communicated electronically and
securely to the DPP provider.
Identification of existing cases known eligible individuals on GP registers
Queries / searches can be run on the registers held on practice systems to identify individuals that meet the
current eligibility criteria for the programme. This search creates a list of eligible patients and their contact details,
which are then used to invite them to consent to referral into the Programme.
The practice may choose the most appropriate form of engagement with the identified at eligible patients, e.g.
letter, phone call, text, face-to-face.
Where consent for referral from the patient has been secured sufficient details must be submitted to the DPP
provider using the form provided. Alternatively, the individual can be sent a self-referral form to make direct
contact with the provider.
IT tools have been developed by Camden CCG’s IT & System Team and are either available centrally or via the
Camden GP website. Tools include searches, referral forms, protocols / pop-ups, and templates.
Referral Pathway
9
Appendix C – Payments to practices and targets
DPP criteria
Practice Name
Target - eligible patients
invited (%)
Payment
Estimated
current
eligible
patients*
80.0%
BELSIZE PRIORY MEDICAL PRACTICE (GROUP)
67
54
£
180.90
JAMES WIGG GROUP PRACTICE
338
270
£
912.60
Brondesbury Medical Centre
215
172
£
580.50
The Abbey Medical Centre
175
140
£
472.50
HAMPSTEAD GROUP PRACTICE
230
184
£
621.00
Swiss Cottage Surgery
110
88
£
297.00
Park End Surgery
97
78
£
261.90
BROOKFIELD PARK SURGERY
89
71
£
240.30
Adelaide Medical Centre
175
140
£
472.50
Primrose Hill Surgery
101
81
£
272.70
Ridgmount Practice (Formerly Gower Place Practice)
27
22
£
72.90
KEATS GROUP PRACTICE
124
99
£
334.80
West Hampstead Medical Centre
112
90
£
302.40
PRINCE OF WALES MEDICAL CENTRE
173
138
£
467.10
PARLIAMENT HILL MEDICAL CENTRE
81
65
£
218.70
Ampthill Practice
184
147
£
496.80
Four Trees Surgery
36
29
£
97.20
Museum Practice
62
50
£
167.40
HOLBORN MEDICAL CENTRE
74
59
£
199.80
CHOMLEY GARDENS SURGERY
66
53
£
178.20
ST PHILIPS MEDICAL CENTRE
8
6
£
21.60
Kings Cross Surgery
64
51
£
172.80
Regents Park Practice
160
128
£
432.00
Gower Street Practice
40
32
£
108.00
GRAY'S INN ROAD MEDICAL CENTRE
74
59
£
199.80
Daleham Gardens Health Centre
14
11
£
37.80
PRINCE OF WALES ROAD PRACTICE (SINGLE)
21
17
£
56.70
SOMERS TOWN MEDICAL CENTRE
62
50
£
167.40
THE BLOOMSBURY SURGERY
81
65
£
218.70
Rosslyn Hill Surgery
16
13
£
43.20
QUEENS CRESCENT SURGERY
61
49
£
164.70
Fortune Green Practice
50
40
£
135.00
Brunswick Medical Centre
107
86
£
288.90
CAMDEN HEALTH IMPROVEMENT PRACTICE
27
22
£
72.90
10
CAVERSHAM GROUP PRACTICE
172
138
£
464.40
Total
3493
2794.4
£
9,431.10
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