The NHS Diabetes Prevention Programme: Here to support our population at high risk of type 2 diabetes

Key points

• The Healthier You: NHS Diabetes Prevention Programme is a nationally commissioned, evidence-based programme for people at high risk of type 2 diabetes, providing tailored support to reduce their risk through lifestyle change.
• All GP practices in England can refer eligible people with non-diabetic hyperglycaemia (HbA_1c 42–47 mmol/mol [6.0–6.5] or fasting plasma glucose 5.5–6.9 mmol/L), or normoglycaemic women with previous gestational diabetes, to the programme.
• Due to the COVID-19 pandemic, Healthier You is currently delivered entirely remotely, with virtual groups over video or telephone, or with app/web-based one-to-one coaching and peer support through the digital service.
• Nearly 800 000 people have been referred to the programme since it launched. Published outcomes data are encouraging, with mean weight loss of 3.3 kg and mean HbA_1c reduction of 2.0 mmol/mol for people who completed the programme.
• As well as offering appropriate referral to Healthier You, it is important to code “Non-diabetic hyperglycaemia” (NDH) when it is identified, and annual glycaemic review of people with NDH is now incentivised through the Quality and Outcomes Framework.

Now, nearly 5 years on from launch, Healthier You continues to expand and adapt to meet changing needs and to further support our population to reduce their risk of developing type 2 diabetes. With the increased focus on risks relating to excess body weight and type 2 diabetes emerging from the COVID-19 pandemic, such help to empower people to take control of their health and make lasting lifestyle change is arguably more important now than ever before.

Referral and outcomes data

There have been nearly 800 000 referrals to Healthier You since the programme launched. Analyses of referrals, uptake and participant characteristics were first published in 2017, and attendance rates for men, people in minority ethnic groups and people living in areas within the most socioeconomically deprived quintiles suggested that the programme was successfully reaching both those with greater risk of developing type 2 diabetes and those who typically face greater barriers to accessing health and care services (Barron et al, 2018).

Outcomes from the first few years of Healthier You were published in early 2020 and are similar to those reported in meta-analyses of pragmatic studies (Valabhji et al, 2020). Over half of people who attended an initial session went on to complete the programme (defined as attending at least 60% of sessions). People who attended at least one session had a mean HbA_1c reduction of 1.26 mmol/mol and a mean weight loss of 2.3 kg; these were amplified to reductions of 2.04 mmol/mol and 3.3 kg in those who completed the programme, with people living with obesity who completed the programme having a greater mean weight loss of 3.9 kg. Although a formal, independent evaluation of the programme is currently underway, these results are highly suggestive of future reductions in type 2 diabetes incidence in Healthier You participants.

Evolution of the programme

As well as pushing forward the evidence base for real-world diabetes prevention programmes, Healthier You has continually developed since it launched, with new features being informed and driven by data. Publication of its digital pilot evaluation is expected later this year, following the earlier release of data showing the improved reach of digital over face-to-face services amongst younger age groups (McGough et al, 2019). Guided by this evidence, the programme was enhanced with a new specification, moving from solely face-to-face, group-based delivery to also offering a digital service. This provided app/web-based one-to-one coaching and peer support, improving access to Healthier You for those unable or unwilling to attend face-to-face sessions, and was joined by a number of other measures designed to reduce inequalities.

At the outset of the COVID-19 pandemic, the programme had a further major shift in mode of delivery; face-to-face sessions stopped prior to the first lockdown and, within just a few weeks, Healthier You had moved to entirely remote provision. Rather than taking place in person, group sessions have continued over video or telephone, with the existing app/web-based digital service expanded as a choice to all new referrals.

Changes to enhance access

As well as adaptations to service delivery, a number of measures to enhance access to Healthier You have been implemented in the last year. These were particularly important in view of the associations of both type 2 diabetes and obesity with increased mortality relating to COVID-19 (Barron et al, 2020; Holman et al, 2020).

Recognising the pressures facing healthcare services during the pandemic, a temporary self-referral route into the programme became available from August 2020 via the Diabetes UK Know Your Risk tool. This was supported by a focused national marketing campaign aimed at reaching black and South Asian communities. This route was designed to supplement rather than replace referrals from General Practice and is currently scheduled to run until September 2021.

The acceptable timeframe for people with blood results indicating non-diabetic hyperglycaemia (NDH; HbA_1c 42–47 mmol/mol [6.0–6.5%] or fasting plasma glucose 5.5–6.9 mmol/L) to access the programme has also been extended. Previously, referrals to the programme required a blood result demonstrating NDH within the last 12 months. This timeframe has been temporarily increased to 24 months in order to support access to Healthier You for people with NDH who may have missed a glycaemic check during the pandemic.

In addition, eligibility for the programme has been expanded to include normoglycaemic women with previous gestational diabetes (GDM). Referral forms have been updated to reflect the new eligibility criteria; referrals for normoglycaemic women with previous GDM are sent using the same form as those for people with NDH, and require a section regarding history of GDM to be marked accordingly.

Glycaemic monitoring

People with NDH and/or previous GDM are at high risk of developing type 2 diabetes; NICE guidance therefore recommends regular recall for these individuals, with a glycaemic check at least yearly (NICE, 2012; 2015).

The glycaemic check provides an opportunity to monitor progress, reinforce lifestyle goals and offer referral to Healthier You to these individuals as appropriate. It also allows timely diagnosis of type 2 diabetes if progression has occurred; taking action early to control glycaemia and manage cardiovascular risk factors has a significant impact on the future risk of diabetes complications.

The annual glycaemic check of people with NDH has recently become incentivised through a Quality and Outcomes Framework (QOF) indicator. When NDH is identified, it is therefore important to code “Non-diabetic hyperglycaemia” to enable effective recall and support QOF achievement.

Keep the referrals coming

The Healthier You programme has been continually evolving since it launched, while also developing the evidence base for real-world initiatives to prevent type 2 diabetes. From the start of the pandemic it has made a number of key changes, including new modes of delivery and expanded eligibility, to respond to the needs of our population and the pressures facing our health service. The programme continues to help people at high risk of type 2 diabetes make lasting lifestyle changes, and it remains ready to receive your referrals, having ramped up capacity to support up to 200 000 people per year. With greater focus than ever before on the risks associated with excess body weight and type 2 diabetes, there has never been a better time to offer your eligible population referral to the Healthier You: NHS Diabetes Prevention Programme.