National Diabetes Prevention Programme (NDPP)

*The NDPP in Gloucestershire is rolling out by locality in a phased approach.  The CCG NDPP Programme Co-ordinator will contact practices in advance of their scheduled rollout therefore please do not begin referring onto this service until this contact has been made.

The NHS Diabetes Prevention Programme (DPP) is a joint initiative between NHS England, Public Health England and Diabetes UK aiming to deliver services at a large scale, which identify those with non-diabetic hyperglycaemia (those at high risk of developing type 2 diabetes) and offer them a free lifestyle intervention encompassing group educational sessions subject to an evidence-based specification, in order to reduce their weight and increase physical activity, thus reducing their risk of developing the condition.

Gloucestershire is part of wave 2 of the national rollout of the service, which will be delivered locally by the provider Living Well, Taking Control and practices will be mobilised in phases dictated by locality.

A recent audit shows that there are currently approximately 11,860 patients identified in Gloucestershire as having non-diabetic hyperglycaemia- a figure which has almost doubled since January 2016 when it was around 6,600 patients and continues to rise year on year.

The initiative featured in Gloucestershire’s Primary Care Core Offer which required coding of patients with NDH (‘pre-diabetes’) to be coded appropriately by July 2017.  It is also a key part of the self-care & prevention strand of the Gloucestershire STP.

Restrospective (previous 12 months) referrals:

When practices come to mobilise, there will be an initial requirement to pull off a register of patients who have been identified within the previous 12 months as having non-diabetic hyperglycaemia (NDH).

A referral letter will then need to be sent to all of these patients using a mailshot approach.

To noteFace-to-face clinical engagement has proven to result in a much higher patient uptake of the service and is advised where manageable.


Prospective (newly-diagnosed) patients:

Management to begin following a HbA1c result indicating non-diabetic hyperglycaemia or ‘pre-diabetes’.

Eligible patients are to be offered a referral onto their local HEALTHIER YOU programme (NDPP) within 1 month of their blood result via electronic referral form or referral letter

Exclusion Criteria:

  • Patients with previous diagnosis of diabetes
  • Gestational diabetes mellitus
  • Pregnancy
  • People who are end of life or on palliative care



Many practices are opting to re-run their clinical search at the end of every month in order to pick up any newly-diagnosed patients in bulk and either:

  • Having a conversation with the patient to gain verbal consent and sending the electronic referral form to the provider or;
  • Sending the referral letter to these patients (no requirement for consent at this point as the patient must self-refer and no patient info being passed to provider).

To noteFace-to-face clinical engagement has proven to result in a much higher patient uptake of the service and is advised where manageable.


A text message reminder (wording below) should be sent to the patient 4 weeks after the invitation letter is sent.

A second text message reminder should be sent to the patient 8 weeks after initial letter.

This ensures every patient is offered 3 opportunities to refer themselves onto the NDPP service.

From your GP: We care about your health!

Take up your free place on

the NHS Diabetes Prevention Programme,‘HEALTHIER YOU’

by calling 0330 2233706

Or visiting

We will need your NHS number and HbA1c

(3 month average blood glucose) measurement-

if unknown contact your practice.

If you have already booked your place

please disregard this message.


If the patient does not wish to accept their place on the programme, the following could be considered:

if other co-morbidities are present;

  • Offer the relevant lifestyle advice

an initial assessment, 7 weekly group sessions at 90 minutes each at a local community venue; and follow ups at 29, 35, 42 and 52 weeks.

The programme consists of: 

  • Information on diet
  • Information of physical activity
  • Managing stress and emotional wellbeing
  • The importance of monitoring weight

The practice will be informed when a patient:

  • Takes up the service and attends the initial assessment
  • Drops out of the programme for any reason
  • Completes the programme.

Following a diagnosis of non-diabetic hyperglycaemia (NDH), practices are expected to continue to monitor the patient’s blood glucose levels annually, in line with national guidance.

  • Read Code V2 (Emis Web, Vision and Microtest) – C317
  • Read Code V3 (SystmOne) – XaaeP