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NHS Diabetes Prevention Programme

ProspectusKENT, SURREY & SUSSEX

NHS ENGLAND SOUTH (SOUTH

1. Partnership Information

Lead organisation SOUTH EAST CLINICAL NETWORK

Partner Organisations Clinical Commissioning Group Local Authority

AshfordBrighton & HoveCanterbury & CoastalCoastal West SussexCrawleyDartford Gravesham & SwanleyEastbourne Hailsham & SeafordEast SurreyGuildford & WaverleyHastings & RotherHigh Weald Lewes HavensHorsham & Mid SussexMedwayNorth East Hampshire & FarnhamNorth West SurreySouth Kent CoastSurrey DownsSurrey HeathSwaleThanetWest Kent

Surrey CCBrighton and Hove CCMedway CCKent CCWest Sussex CCEast Sussex CC

Lead contact for partnership NICKY JONASnickyjonas@nhs.netJACKIE HUDDLESTONJackie.huddleston@nhs.net

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2. Call off volumes

Referral Numbers Total referral Lower uptake 25% Upper uptake 40%

2016/17

August 0Q2 0 0 0

September 0October 285

Q3 856 214 342November 285December 286January 407

Q4 1222 306 489February 407March 408

2017/18

April 874Q1 2622 656 1049May 874

June 874July 1080

Q2 3240 810 1296August 1080September 1080October 1171

Q3 3513 878 1405November 1171December 1171January 1220

Q4 3660 915 1464February 1220March 1220

2018/19

April 1220Q1 3660 915 1464May 1220

June 1220July 1220

Q2 3660 915 1464August 1220September 1220

Y1 TOTAL 2078 520 831Y2 TOTAL 13035 3259 5214Y3 TOTAL 7320 1830 2928ALL TOTAL 22433 5608 8973

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3. Partnership Geography

OverviewTotal population of 4.5 million spread across approx. 3600 square miles There are real extremes of affluence and deprivation - Surrey and West Sussex are amongst the most affluent areas in the country, while areas of north Kent and East Sussex have high levels of deprivation.

The urban to rural split is 20%: 80%.

Much of the area is well served by road, rail and bus links, however road congestion, overcrowding, poor transport in rural areas, lack of parking and non-car ownership may produce barriers to people accessing behavioural Intervention courses in certain areas.

KSS partners will be interested in learning how Providers can address some of these issues in order to optimise take up and attendance on courses

Geographical spread Urban/Rural Transport LinksBrighton & Hove

Brighton & Hove is the largest conurbation in Sussex, a hilly city located in a geographic administrative area of approximately 40 square kilometres /15 square miles with 11 kilometres of seafront and a population of almost 275,000 people.

The urban area is contained within the A27 road by-pass which represents a barrier to the chalk downland to the north and constitutes the general boundary of the national park in the west. Between the built-up area and the South Downs National Park lie more than fifty varied parcels of ‘urban fringe’ land) which cover a total area of 479 ha (~6% of BHCC) especially in east Brighton

Transport links in the city are good with no person being more than 0.6km from their GP surgery. 38% of households have no car in Brighton and Hove compared with 26% across England Brighton is a congested city, and not easy to drive or park in.There is an extensive bus network in Brighton and Hove. In the city centre, services are very frequent. The service isn't cheap with a flat fare of £2 for single journeys or £4.60 for an all-day ticket Brighton Railway Station is one of the most important rail terminals in the South East and from here the city of Brighton has a small suburban rail network with trains serving areas of Hove, Preston Park and also to the main campuses of the universities (Moulsecoomb, Falmer)

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East Sussex

East Sussex covers an area of 660 square miles (1,725 sq. km). The county includes the boroughs of Eastbourne and Hastings and the districts of Lewes, Rother and Wealden, each with a distinct identity and particular local issues to address. It is home to around 500,000 people, with about 1 in 4 (24%) people are aged 65 years and over and 4% are aged 85 years and over. Within the county Bexhill and Seaford and parts of Eastbourne and the surrounding areas, have the oldest age profiles.

The most significant areas of deprivation are concentrated in the county’s coastal towns. Hastings is the most deprived of the local authority areas. However, there are pockets of deprivation scattered across some of the smaller towns and the more rural parts of the county.

East Sussex is a predominantly rural county of varied landscapes with remote rural and environmentally sensitive areas, interspersed with villages and historic market towns. Two thirds of the county is designated as an Area of Outstanding Natural Beauty (AONB) or National Park. More than half the population living on the coastal fringe in three main urban areas – Hastings, Bexhill, Eastbourne and surrounding settlements, and the coastal towns of Newhaven, Seaford and Peacehaven, with 26% of the population residing in rural communities.

The main coastal urban areas are linked east-west by parallel road (A27/ A259) and rail (East Coastway) links. There are two strategic corridors from the county north towards London – from Brighton via the A23/M23 and the Brighton Mainline and from Hastings via the A21 and the Hastings to Tonbridge rail line – whilst the Uckfield line provides a link to London from the centre of the county.

The main transport infrastructure challenges are: lack of a high standard road infrastructure; restricted rail network; road; traffic level growth;

The urban areas of the county are generally well served by commercial bus operators; however the needs of the rural areas and small market towns are less well served.

Surrey Surrey is the one of the most densely populated shire counties in England with 6.9 persons per hectare. The overall population density of England is 4.1 persons per hectare. Woking is the most diverse district in Surrey with 75.0 per cent of its population identified

In the most urban districts, Epsom & Ewell and Spelthorne, there are more than 20 persons per hectare, but in the highly rural districts, Mole Valley, Tandridge and Waverley, there a fewer than 4 persons per hectare. 87% of inhabitants live in urban areas and yet 73% of land in Surrey is green belt.

As one of the most densely populated counties in the UK with traffic flows on A roads almost double the national average, transport related problems are a major concern for people living and working in Surrey.

Car ownership levels in Surrey are considerably higher than in England as a whole. However the complex geography of the county means there

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as White British. Waverley is the least diverse with 90.6 per cent White British.Elmbridge has the highest proportion (10.4 per cent) in all other white groups with Tandridge the lowest (4.6 per cent) Spelthorne has the highest proportion of Indian ethnic group (4.2 per cent) and Woking has the highest proportion of Pakistani ethnic group (5.7 per cent).

are significant concerns regards access to services and transport in the rural parts of Surrey.While the county has a generally comprehensive rail network and a large number of rail stations, many services are at capacity and suffer from peak time overcrowding.

West Sussex

West Sussex covers 769 square miles, bordering Hampshire to the west, Surrey to the north, Brighton, Hove and East Sussex to the east and the sea to the south. 821,370 people reside in West Sussex, living mainly, along the coastline, a rural inland with key market towns and the economic area around Gatwick Airport. There are 7 districts, Arun, Chichester, Horsham, Crawley, Mid Sussex, Worthing, and Adur. The largest towns are Crawley, Worthing, Horsham and Bognor Regis. Deprived wards sit alongside some of the most affluent. The most deprived wards are located in Arun, (6 wards) Adur, (6 wards) Worthing (4 wards) Crawley (3 wards) and Chichester (1 ward).

Urban RuralWest Sussex 76.3% 23.7%Adur 98.7% 1.3%Arun 83.0% 17.0%Chichester 47.0% 53.0%Crawley 99.7% 0.3%Horsham 39.4% 60.6%Mid Sussex 82.0% 18.0%Worthing 100.0

% 0.0%

M23 runs north from Bolney connecting to the M25

A23, A24, to Brighton and Worthing respectively. The A27, A29, A259, (coastal) A272 (mid Sussex) traverse the county east to west. The A27 connects to the M27 and M3 in Hampshire.

Rail links to London - connecting hubs at Barnham, Horsham, Haywards Heath and Brighton.

Coastal rail links run east to west connecting towns and larger villages from Brighton to Portsmouth and Southampton.

Buses serve all towns and villages - rural village services may be less frequent – some local community transport. The 700 Coast-Liner runs between Portsmouth and Brighton.

Gatwick Airport – Crawley

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Medway Demonstrator Site – NDPP will not be delivering a service in this area

Kent Kent has a land area of 1,368 square miles and just over 350 miles of coastline. The map below sets out the towns, the economic zones and main transport routes which follow the Downs east and west in and through KentIts population is 1,510,400. 89.1% are recorded as being white, 6.3% as BME, and 1.24% as Asian (British). 3.5% are from other ethnic groups.Thanet is the most deprived area and Sevenoaks the least. Deprivation has increased in Shepway, Thanet, Swale and Dover. Margate Central is the most deprived ward

People living in urban areas make up 73% of the Kent population but they only occupy 22% of the total land area.

85% of the land area is classed as green space,

6% of land accounts for domestic gardens

Less than 2% of the land is covered by buildings.

The deprivation map below gives a sense of the mainly coastal and urban nature and of Kent’s deprivation challenge.

The rural areas tend not to have high levels of deprivation.

Kent has the UK’s only high speed rail line to London and northern European destinations via the Channel Tunnel. It is home to the country’s busiest and most successful ferry port at Dover. Kent has been identified by the previous Government as an area for significant growth in housing and employment, containing two of the UK’s four Growth Areas in Thames Gateway Kent and Ashford, along with the Growth Points of Dover and Maidstone.This planned growth alone is predicted to result in 250,000 extra journeys on Kent’s roads by 2026 increasing congestion further. Kent’s population is ageing and this will put pressure on local community services. Providing access to these services for those without a car will continue to be a challenge.

Additional informationThe South East is a highly complex healthcare landscape with 21 Clinical Commissioning Groups (CCGs), 13 acute provider NHS Trusts (some Foundation) across 19 acute hospitals, one ambulance service Foundation Trust, 3 Mental Health Partnership Trusts, 6 Community providers with a range of community hospitals, 6 Health & Wellbeing Boards, 5 Local Authorities and 600 GP practices

There is a high burden of long term conditions with 17.6% of Kent's population having an illness or condition which limits their day to day activities in some way.

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4. Partnership Demographics

Population total with breakdown

Total:

Age Male Female

18-44yrs 740,123 752,378

45-64yrs 588,068 605,566

65+yrs 401,098 493,626

Number of GP Practices

CCG Number of PracticesNHS Ashford CCG 14NHS Canterbury and Coastal CCG 21NHS Dartford, Gravesham and Swanley CCG 34NHS Medway CCG 56NHS South Kent Coast CCG 30NHS Swale CCG 19NHS Thanet CCG 17NHS West Kent CCG 61NHS Brighton and Hove CCG 45NHS Coastal West Sussex CCG 54NHS Crawley CCG 12NHS East Surrey CCG 18NHS Eastbourne, Hailsham and Seaford CCG 21NHS Guildford and Waverley CCG 21NHS Hastings and Rother CCG 32NHS High Weald Lewes Havens CCG 21NHS Horsham and Mid Sussex CCG 23NHS North West Surrey CCG 42

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NHS Surrey Downs CCG 33NHS Surrey Heath CCG 9NHS Farnham and North Hants CCG 24

Number of NHS Health Check Providers

Primary CareIn-house (by LA)

Other provider (e.g. 3rd

sector outreach providers, etc.)

CommentsGP practice Pharmacy

Surrey 80 59 1 Bank advisor team, work on ad hoc bases, targeted delivery e.g., workplace and carers

3 leisure Centres

West Sussex 72 71 Providing outreach in the community and workplaces) - 1 NHS Community Trust and 1 commercial 3rd sector company.

East Sussex 71 ES commissions GP providers in primary care only, and that is from all 71 GP practices in East Sussex

Medway 54 Medway only providers are GPs

Kent 199 40 5 -District Authorities, only 2 delivering

1 Private provider Kent Community NHS Foundation Trust –Commissioned Provider (in house Checks: community clinics/ outreach)

These are all the providers that can provide checks, but not all of them are currently doing so; for example we have 5 district authorities listed but only 2 are actively

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delivering checks this year

Ethnic MixCCG

Population from Black ethnic groups

Population from Asian ethnic groups

NHS Ashford CCG 1.17% 3.38%NHS Canterbury and Coastal CCG 1.04% 2.79%NHS Dartford, Gravesham and Swanley CCG 2.89% 7.01%NHS Medway CCG 2.52% 5.16%NHS South Kent Coast CCG 0.40% 2.74%NHS Swale CCG 1.24% 1.22%NHS Thanet CCG 0.68% 1.87%NHS West Kent CCG 0.58% 2.51%NHS Brighton and Hove CCG 1.53% 4.13%NHS Coastal West Sussex CCG 0.49% 1.83%NHS Crawley CCG 3.25% 12.97%NHS East Surrey CCG 1.39% 4.17%NHS Eastbourne, Hailsham and Seaford CCG 0.55% 2.11%NHS Guildford and Waverley CCG 0.91% 3.73%NHS Hastings and Rother CCG 0.76% 1.79%NHS High Weald Lewes Havens CCG 0.33% 1.27%NHS Horsham and Mid Sussex CCG 0.60% 2.63%NHS North West Surrey CCG 1.27% 7.89%NHS Surrey Downs CCG 0.95% 5.19%NHS Surrey Heath CCG 0.99% 5.96%NHS Farnham and North Hants CCG 1.20% 6.20%

Languages spoken

OverviewKSS enjoys a diverse population with many languages spoken, and significant numbers of people who do not have English as a preferred language.

The KSS Partnership will be interested to hear how providers can encourage participation in the Behaviour Intervention (BI)

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Courses, not just in terms of languages spoken, but understanding of cultural factors - especially around food choices, exercise and attitudes to health.

We are also interested in hearing about how providers have thought about offering people a range of opportunities (in consideration of cultural requirements) for attending and participation in courses, in person/remotely/group/1:1

Brighton & Hove 8.3% do not have English as their preferred or first language. 0.8% is Arabic; 0.8%, Polish; and 0.7%, Chinese.

East Sussex The proportion of the population from non-white Black and Minority Ethnic (BME) groups was 8%, compared to 20% nationally and 15% regionally. This group tends to be younger than the White British and Northern Irish group. (Census 2011)

Surrey Nearly 65,000 Surrey residents speak a main language other than English, the most common other languages spoken are Polish (6.634 speakers) and Chinese languages (4,426 speakers). Most can speak English, but almost 7,500 residents cannot speak English well.Nepalese, Polish, Somalian, Spanish, Italian and South Asian languages such as Urdu, Hindi, and Guajarati are also spoken

West Sussex The population is predominantly white British (88.9%). White other and Asians hold the second and third largest shares with 4.0% and 3.3% respectively. 37,000 (4.7%) of the total population has a main language other than English; of which over 30,000 can speak English “well” to “very well”. 36% of those that do not have English as a main language reside in Crawley.Other languages include French, Spanish and Portuguese (12% of 37k); Other EU ( 23% of 37k), West Asian/African ( 9% of 37k) and South East Asian – various languages (21% of 37k); and Chinese (4% of 37k)

Medway Demonstrator Site – NDPP does not need to offer a service in Medway.

Kent According to the census approximately 1,350,000 of the population speak English. The details of all languages can be found in the link below:Of note, in South Kent there are Polish, Greek, Romanian and Nepalese speaking communitiesIn Gravesend the main languages spoken after English are Slovak, Russian, Polish and Turkish.Dartford has a high proportion of Mandarin speakers and Swanley has an Italian community.Gujarati, Punjabi, Hindu, and Urdu are some of the main Asian languages spoken.In West Kent, after English, the following are the top 10 most commonly spoken languages in

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Kent and Medway: Nepali, Bengali, Polish, Panjabi (Gurumukhi), Panjabi, Tamil, Slovak, Yoruba, French, Malayalam.In Thanet, after English, Polish and Slovak are the only languages spoken by more than 0.5% (0.8% and 0.6% respectively)

Type 2 diabetes prevalence

CCG Recorded Prevalence Estimated prevalenceNHS Ashford CCG 6.1 7.1NHS Canterbury and Coastal CCG 5.8 7.2NHS Dartford, Gravesham and Swanley CCG 6.3 7.2NHS Medway CCG 6.7 6.7NHS South Kent Coast CCG 6.9 7.9NHS Swale CCG 7.1 7.1NHS Thanet CCG 7.2 8.2NHS West Kent CCG 5.5 6.7NHS Brighton and Hove CCG 4.1 6.2NHS Coastal West Sussex CCG 6.5 7.9NHS Crawley CCG 6.2 6.9NHS East Surrey CCG 5.0 6.7NHS Eastbourne, Hailsham and Seaford CCG 6.2 8.2NHS Guildford and Waverley CCG 4.3 6.4NHS Hastings and Rother CCG 6.5 8.4NHS High Weald Lewes Havens CCG 5.4 7.3NHS Horsham and Mid Sussex CCG 5.1 6.5NHS North West Surrey CCG 5.4 6.8NHS Surrey Downs CCG 4.8 6.8NHS Surrey Heath CCG 5.3 6.6NHS Farnham and North Hants CCG 5.2 6.3

There are an estimated 266,350 people in the South East coast with diabetes, when adjustments are made for age, sex, ethnic group and deprivation. This is 7.3% of the adult population, higher than the average prevalence for diabetes for England as a whole of 7.4%.

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Diabetes Public Health Profile. PHE

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Modelled Numbers at risk of Type 2 diabetes

CCGAt risk population

(registered)

Prevalence

NHS Ashford CCG 11,030 10.9%NHS Brighton & Hove CCG 22,013 8.4%NHS Canterbury and Coastal CCG 19,773 10.9%NHS Coastal West Sussex CCG 52,484 12.5%NHS Crawley CCG 10,804 10.4%NHS Dartford, Gravesham and Swanley CCG 23,005 11.1%NHS East Surrey CCG 15,546 10.9%NHS Eastbourne, Hailsham and Seaford CCG 20,703 12.9%NHS Guildford and Waverley CCG 19,598 10.8%NHS Hastings & Rother CCG 19,474 12.6%NHS High Weald Lewes Havens CCG 16,746 12.1%NHS Horsham and Mid Sussex CCG 21,508 11.4%NHS Medway CCG 24,707 10.6%NHS North East Hampshire and Farnham CCG 19,350 10.8%NHS North West Surrey CCG 32,114 11.0%NHS South Kent Coast CCG 19,740 12.0%NHS Surrey Downs CCG 28,083 11.5%NHS Surrey Heath CCG 8,435 11.0%NHS Swale CCG 9,268 10.7%NHS Thanet CCG 13,841 11.9%

NHS West Kent CCG 42,754 11.1%

TOTAL 520,761Total ‘at risk’ population in SE England = 11.1%

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(Cardiovascular Intelligence Network – August 26th 2015)Data source Health Survey for England 2009, 2010, 2011, 2012 and 2013 012-based Subnational Population Projections. Clinical commissioning groups in England, mid-2012 to mid-2037,

Population Projections Unit, ONS. Crown copyright 2014 Number of patients registered at a GP practice – April 2015 The Health and Social Care Information Centre Hospital Episode Statistics (HES), 2011/12 - 2013/14, Copyright © 2015, Re‐used with the permission of The Health and

Social Care Information Centre. All rights reserved Active people survey, Sport England, 2012

Additional Information

5. Existing local service provision for diabetes prevention and weight managementNHS England does not anticipate that TUPE will apply to transfer staff from any existing service provider to any bidder. However NHS England is not in a position to give any warranty in respect of TUPE and bidders should rely on their own assessment of the likelihood that TUPE might applyOverviewThe KSS partnership will work with new and existing providers to ensure patient referral pathways into existing weight management and diabetes prevention programmes complement the development of new pathways/additional choices for patients referred into the NDPP.

Diabetes Prevention

Brighton & Hove

Walking Away from Diabetes is a 3 hour group intervention for people who have been identified at risk of developing Type 2 diabetes. It explores individual risk factors and how these might impact on the risk of developing diabetes and long term-health. It emphasises the importance of increased physical activity and food choices to reduce the risk of developing diabetes.

East Sussex Hastings & Rother CCG and Eastbourne Hailsham and Seaford CCG have a locally commissioned service for diabetes including identification and management of Impaired Glucose Regulation, including lifestyle advice and referral to existing local lifestyle services. The programme is delivered in 6 visits over one year.

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High Weald Lewes Havens CCG has committed to modify its current diabetes locally commissioned service to include identification and management of non-diabetic hyperglycaemia.

Surrey There are no specific diabetes prevention services in SurreyHowever, prevention strategies are in place with all the CCGs which focus on prevention, early detection and control of long term conditions.There is currently considerable work going into the screening and identification of pre-diabetes and diabetes with these patients being highlighted on the GP registers

West Sussex

The county-wide Wellbeing Hubs offer a pre-diabetes programme. The programme consists of a 2-3 hour information session for those identified as having pre-diabetes. Each programme is delivered in a slightly different format and may include a physical activity session. 1:1 support and onward access to local exercise and weight management services is offered.Coastal West Sussex CCG has commissioned a local Year of Care service which includes pre-diabetes education programme and annual testing.

Medway Demonstrator Site – NDPP is not delivering a service in this area

Kent None of the Kent CCGs has a diabetes prevention programmes. Some GP practices keep a register of patients with non-diabetic hyperglycaemia who are assessed (usually) annually

Weight Management Services

Brighton & Hove

Healthy Weight Referral Service accepts referrals 5 days a week which are triaged into the adult programmes which offer 4 options for weight management within a BMI criterion of 25-43kg/m2.Shape Up Group/Shape Up with the Albion/ Shape Up After Baby are 10 week courses for adults who want to achieve weight loss in a supportive group environment.Shape Up One-to-One offers up to 12 appointments for individual help and guidance that combines nutrition and behaviour change.Weight Management Coaches offer flexible one-to-one support and guidance around behaviour and dietary change in the client’s homeShape Up in the Kitchen is a follow on 5 week course for people who have attended a Shape Up course but lack the cookery skills to help achieve a healthy weight.First Time Cook Cookery classes are a 5 week course for people who can‘t cook.Eat well for adults are delivered by registered dieticians and nutritionists.

East Sussex While there are not specific lifestyle interventions in place tailored for those with NDH, adults with a high BMI would follow the 12 week Tier 2 Weight Management Pathway and would be offered lifestyle interventions, including healthy weight planning, individual and group support, and post programme support at 26 and 52 weeks

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Surrey The tier 2 adult weight management services will come to an end 31/03/16.Some of the providers will be offering a service next year based on the same model (patients will have to pay but there may be concessions).Some tier 3 weight management services are available which offer further support for people who have tried Tier 2

West Sussex

The Weight Management Centre provides a county-wide Tier2 service for adults, children and young people who have BMI over 30 or 28+ with comorbidities. The service also supports the Why Weight phone line which triages onto the appropriate weight management service.Seven Wellbeing Hubs are located across the county. 6 hubs deliver Tier 2 weight management services which offer a 12 week group intervention covering food and exercise using a behaviour change approach.Some tier 3 weight management services are available which offer further support for people who have tried Tier 2

Medway Demonstrator Site

Kent The Healthy Weight Team signpost to healthy weight services which are available to support clients through discussing healthy eating tips and ways to increase physical activity.Tier 2 family weight management programmes such as ‘Don’t sit get fit’.A Tier 3 service called ‘4 healthy weight’ offers a specialist approach to weight loss for people with a BMI of 35+.Take Off Peer Support offer preparation and eating a healthy meal,Healthy Eating Classes for primary school aged children.Health Walks are free, volunteer-led, regular local walks, aimed at anyone wanting to be more active.Exercise Referral Scheme aims to increase physical activity among people who are inactive or sedentary.The Specialist Weight Management Service (SWMS) is a 12 month weight loss intervention programme that addresses the key underlying features involved in obesity.The Fresh Start Scheme supports overweight and obese clients delivered through Pharmacies and GP surgeriesReady Steady Go (RSG) – This is a family weight management programme targeting suitable families through schools.Food Champion Programme. Offers support and practical cooking sessions.

6. Data

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IT systems used throughout the partnership

CLINICAL SYSTEM KENT SUSSEX SURREYEDICS 0 0 1EMIS LV 1 8 0EMIS PCS 1 0 0EMIS WEB 155 113 140EVOLUTION 0 3 0SYSTMONE 9 92 0VISION 109 16 23VISION VES 79 0 0VISION 3 ENTERPRISE 0 19 0

Data management Data management will be managed and owned by each practice and CCG but the group may explore sharing and pooling of data as implementation progresses i.e. referral process.We would like for the provider to provide a secure system as per the national service specification, to report back to the GP so that this could be added to the electronic patient record.

Information governance

All written communications should be conducted through secure systems.The partnership and BI Provider will ensure robust processes to deliver information between Partners and BIPThe Lead Organisation, Partners and BI provider will be bound by information governance requirements in the national service specification.

Quality assurance The KSS Partnership will be interested in learning about the quality assurance programme within Provider organisations. It is anticipated that Providers will work with the partnership to develop additional quality assurance processes where neededThe Lead Organisation, Partners and BI provider will be bound by monitoring and reporting requirements in the national Service Specification.

Additional InformationIt is anticipated that the provider will work with us to establish a clear referral pathway so that referrers have information about the programme and how to refer easily. There also needs to be information for patients to take away.

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7. Mobilisation

OverviewThe Lead Organisation has project management dedicated to the successful mobilisation of the NDPP across Kent, Surrey and Sussex. Its role is to provide governance and programme management, coordination of the overall programme and to work with Partners and the Providers to ensure the success of the NDPP locally

The CCGs/LAs have submitted mobilisation plans which mainly focus on: Local project management/Clinical Leadership Case identification through GP registers and health checks Instigation of Read Coding Contacting and consulting patients Strategies to convert referrals to take-up Local publicity and media campaigns Developing Local Commissioned Service agreements where appropriate ‘Training’ of primary care practitioners to understand the patient pathway Referral into the Provider Timelines

The CCGs and LAs have developed mobilisation plans sensitive to the specific requirements within their communities as detailed below

Plans for roll out at pace and scale

Brighton & HoveAndBrighton and Hove CC

March – April 2016: The development of briefings and postal communications on the NDPP for practices and clusters.April to May 2016: The CCG will promote the National Diabetes Prevention Program within primary care initially through GP practices and clusters to support their sign up to enhanced/innovation part of the Diabetes Locally Commissioned Service (LCS) as part of their costed action plansMay – June 2016: Confirm numbers of practices who have signed up to the diabetes LCS and who have set up a clinical system search to identify existing patients through patient records/.health checks with NDH in the past 12 months. A register will be formed by adding an appropriate READ code to the patient record. New patients having blood tests for other reasons or an NHS health check will be READ coded if the blood test results show NDH.June – July 2016:Assessment of the numbers of patients in terms of volume, geography and clusters and potential referrals into the NDPP, to inform the roll out of the programme during the provider start-up period.July – September 2016: Practices to write to/telephone identified patients inviting them in for an appointment for a further HbA1c test (if required) or a FPG test, discuss the National

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Diabetes Prevention Programme and establish referral lists. During this time the Provider will also be initiating their services within the city, phased against demand.

Canterbury & Coastal, and Ashford

We plan to work with a few of our larger practices in the first year. We will ask that once the patients have been identified, the Health Trainer makes contact with them to signpost into the lifestyle (Behaviour Intervention) course. Having a 1:1 discussion with the patient will encourage them to attend a course. Further work with the Health Trainers will be to ensure they are signposting patients following a health check (if they are at risk of developing diabetes.)Posters will be made available and displayed in GP surgeries, walk-in centres etc. We have also discussed the possibility of displaying them in local shops and health facilities e.g. changing rooms.

Coastal West Sussex and West Sussex CC

72 GP practices out of 93 are commissioned to deliver health checks to their registered population – West Sussex is still to achieve full rollout. 71 pharmacies (approx.50%). 3 Prevention & Assessment Community Nursing teams (PATs) and a commercial company are commissioned to deliver third party health checks in the community. West Sussex intends to commission further pharmacies and to achieve provision across all GP practices.

Crawley Horsham & Mid Sussex

We do not hold pre-diabetes practice registers and these will be developed. It is anticipated that referral routes will be through:

Development of GP Practice registers NHS Health Checks Potential for opportunistic case finding Publicity and media campaigns From Care Coordinators/Health Trainers etc. Awareness campaigns

Therefore we will be looking to roll out NDPP as follows:Develop local process for practice register – June/July 2016Agree mechanisms for referrals – July/August 2016Case finding from practice systems – September 2016Begin providing referrals – October 2016

Dartford Gravesham & We have already begun developing our internal health informatics system HISBI. ‘Cubes’ have

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Swanley been established to capture pre diabetic patients, based on HBA1C, BMI & ethnicity.

A mail shot will be developed (either in house or via SCN with collective funding?) and will be issued to 2650 patients from 34 practices identified via HISBI. This will take place during Q1 2016. GPs will be responsible for referring patients registering an interest to the provider within a set time scale in order to minimise delays.

We anticipate the first cohort of patients attending the programme from Q2 onwards

East Sussex CCGs and East Sussex CC (Eastbourne Hailsham & Seaford, Hastings & Rother, High Weald Lewes Havens)

All 72 East Sussex GP practices are engaged with the NHS Health Check programme, offering and providing NHS Health Checks for their patients.

EHS and HR CCGs have pre-existing locally enhanced services including identification and management of IGR with existing lists of approximately 1000 patients already identified as having IGR.

HWLH CCG have committed to developing a similar approach by June 2016.89% of practices (n=64) in East Sussex are currently using Point of Care Testing.

East Surrey We are working closely with our Clinical Network who is supporting this work.  The CCG board is supportive of NDPP.We are proposing the NDPP goes in to the LCS so it is mandated for GPs to identify and refer patients on. We have patients from the MRC study who could potentially be recruited on to NDPP. We have a project manager supporting implementation.

Guildford & Waverley The CCG has committed to identifying 223 referrals in 2016/17 and 446 referrals in 2017/18. The CCG intends to distribute these referrals across GP practices in proportion to their list sizes.

Practices will undertake searches on their registered lists to identify suitable patients, and will also identify patients through opportunistic consultations. The CCG will support practices to issue letters to patients to facilitate self-referral where appropriate.

The CCG is currently putting in place mechanisms to ensure patients are coded with non-diabetic hyperglycaemia in order to ease the process of identification and referral.

The CCG anticipates a ramp up in 2016/17, with the majority of referrals expected to occur in the final 4 months of the financial year.

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Timescales as follows:

April 2016-May 2016 – initial communications to GP practices and practices asked to commence read coding for non-diabetic  hyperglycaemiaJune-July 2016 – development of searches for practices and case finding to commence. CCG/SCN to provide posters, letter templates and communications materials to practicesAugust 2016 – first referrals generated

Medway Demonstrator Site – not included in the NDPP

North East Hampshire & Farnham

Part of Diabetes work stream and included in 2016/17 planning Pre-diabetes register included as part of 2016/17 Local Service Contract where GP

practices are incentivised to implement this Planning to include in ICT strategy to streamline data collection for practices

NW Surrey The ''pre-diabetes'' registers established in GP practices provide a patient population already known to be at risk of diabetes, these patients will be contacted via phone and by post. Further interrogation of the GP record and routine, day to day, identification in General Practice will cumulatively add to this population over the course of the programme.Patients will be identified via face to face discussion through both Health Checks and GP/practice nurse/specialist nurse consultations. In addition, they will also be written to/contacted via telephone

South Kent Coast We plan to work with a few of our larger practices in the first year. We will ask that once the patients have been identified, the Health Trainer makes contact with them to signpost into the lifestyle course; we feel that having a discussion with the patient will encourage them to attend a course. Further work with the Health Trainers will be to ensure they are signposting patients following a health check (if they are at risk of developing diabetes.)

We will ensure that any posters available are displayed in GP surgeries, walk-in centres etc. We have also discussed the possibility of displaying them in local shops, e.g. changing rooms

Surrey Downs Surrey Downs CCG is planning to use the following approach to implement the National Diabetes Prevention Programme in the local area:

Engage clinicians – Provide a brief overview of the National Diabetes Prevention Programme via GP Commissioning Meetings and Start the Week

Engage patients – Promote services; Discuss risk factors and encourage screening and onward referral

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Incorporate screening, testing and referral into practice – Develop a small-scale incentive scheme within General Practice to support clinicians in identifying appropriate patients and referring into the programme. This may include the following:-

o Screening and identifying patients at risk of diabetes at their GP visito Sending letters to “at risk” patients

Surrey Downs CCG is aware that a Primary Care Standard (PCS) would need to be agreed by the CCGs Executive Committee and Local Medical Committee. As a result, it is unlikely that a PCS would be developed in time for the service launch in June 2016. The CCG is therefore considering developing a local quality improvement scheme with specific GP practices to target those with a high number of patients at risk of developing diabetes.

Surrey Heath Our roll out will be for each of our ten practices to identify 100 patients with a BMI 30+ between April and June with an expectation of 94 patients being referred into the scheme.

Searches will be conducted on a roll out practice by practice in conjunction with Medicines Management. The cohort identified will be checked by the practice and letters sent to invite participation. For those patients where a blood test has not been recorded in their notes one will be offered to ensure they are eligible to join the programme.

Communication and Engagement with practices started in February and regular updates will be completed between April and June.

Swale We will be focussing on ensuring that practices are signed up to the Diabetes community contract during 2016/17 which will enable them to proactively identify patients at risk of diabetes and refer them into the National Diabetes Prevention Programme.

Currently 10 out of the 19 practices are signed up to the current contract so plans are in place to achieve 75% sign up from practices to the amended 16/17 community contract. The community contract provides payment for the work undertaken by practices.

The first referrals will be made following a list cleanse of those patients currently on the diabetes risk register in the practices already signed up to the community contract. Practices submit monthly data to the CCG on the number of the patients on the risk register and the number of those patients who have been referred on to the NDPP.

After the first set of referrals has been made practices will begin to look at risk groups within

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their practice list and identify patients who need a review and could be at risk of diabetes. These patients will then form the next wave of referrals to the NDPP.

Thanet We plan to work with a couple of our larger practices in the first year and identify a champion practice. We will ask the GPs to identify the patients who would be appropriate for the programme. Our aim is to start with a small number of patients and increase this as the year progresses (phased approach).

We will also display posters in GP surgeries, walk-in centres etc. We have also discussed the possibility of displaying them in local shops, e.g. fast food restaurants

West Kent and Kent CC The “pre-diabetes” registers established in GP practices of those patients already known to be at high risk - Local Incentive SchemeIGR 15/16 and 16/17. These patients will be contacted via phone, SMS and by post. Publicity and media campaigns will be developed.NHS health check or other opportunistic screening will be a source of referrals and we will look into possibility of implementing a diabetes GRASP tool in 16/17 for patient identificationPeople can refer themselves/come forward via website (further discussion to be held to agree this process of referral)

Surrey County Council and Surrey CCGs

Currently there are 77 GP providers, 28 Pharmacy providers and 4 community based providers delivering Health Checks in Surrey. All providers will continue to follow best practice guidelines carry out an HbA1c test is threshold for triggered. For non-GP providers we need a safe web-based referral pathway.A Surrey side steering group of the CCGs and LA PH team has met and liaison continues on such issues as identifying a common tool for the purpose of auditing clinical management systems to identify cases and create dashboards and reports. The LA PH team will support CCGs with their plans for roll out and on an on-going basis.

Additional Information

The South East Clinical Network (Lead Organisation) will monitor the progress of the roll out of the NDPP across the three counties. We will be supporting CCGs, and LAs to identify issues and risks associated with the successful implementation of the programme. We will support the process of mitigating risk and addressing issues that arise.

We will encourage partners and their local Providers to develop local governance and collaborative arrangements

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We will also work with Partners and the Providers to develop systems and strategies to improve the take up and quality of provided services, and help to address contractual and service issues where they arise.

We will keep in contact with the National Team to report on progress and highlight any issues relevant to the overall success of the programme

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8. Additional Information

Please describe any other information not covered elsewhere that would be pertinent to the partnership (500 words max)

KSS Partners would like the Behavioural Intervention Provider to consider the following in their preparation for providing services in Kent, Surrey and Sussex:

The needs of students (in the University Towns), both international and UK citizens, who may have specific cultural needs.

Housebound people and those who are not able /do not have the resources to travel Services need to be accessible in local areas - particularly in rural districts, including for people who do not have access

to a car Accessing travelling communities and those who may not be registered with a GP Young parents. Facilities for feeding, nappy changing facilities, childcare Working people who need to be contacted out of work hours and attend programmes at weekends and out of hours People with learning disabilities People with mental health needs People with physical disabilities Providing a reasonable waiting time from referral to offer of a place on a course (suggested maximum = 4 weeks) Providing a reasonable waiting time for a place being made available on a course (suggested maximum = 8 weeks)

KSS partners would be interested in working with BI Providers over the span of the framework agreement towards:

Developing ways to enable easy, secure and fast transfer of patient information ideally electronically to ensure data capture in primary care systems

Production of patient leaflets, signposting and education resources Participating in local health agendas with regards to prevention of illness and healthy living Interfacing with other weight management and diabetes prevention services already in existence Developing a marketing strategy for the successful recruitment of patients

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