Frimley GP Information

The new one-year programme to support a healthier lifestyle, weight loss, and remission of Type 2 diabetes.

The following areas are covered by Frimley Health and Care:

  • Aldershot, Farnborough, Farnham, Fleet, Yateley (these are all within NE Hamps)
  • Bracknell & Ascot, Slough, and Windsor, Ascot & Maidenhead (these are all within E Berks).
  • Camberley, Bagshot, Lightwater, Frimley and Ash Vale (these are within Surrey Heath)

What is it?

  • A unique one-year programme combining specialist nutrition, psychology and physical activity
  • Supports rapid weight loss and long-term behaviour change
  • Support throughout from your Health & Wellbeing diabetes practitioner via regular contact, with online learning and supporting resources
  • Supported by GPs, practice nurses, diabetes practitioners, dietitians, clinical psychologists and exercise specialists

How does it work?

12 weeks of low-calorie diet (shakes and soups) followed by reintroducing food, focusing on movement and maintaining a new healthy eating lifestyle.

Features

The 12-month service will include:

  • An initial one-to-one assessment
  • 20 sessions with your Health & Wellbeing diabetes practitioner
  • 39 online support modules
  • Final one-to-one assessment

How to refer

This unique programme is being offered to patients across Frimley.

Healthcare professional requirements

Refer:

After discussing the service with your patient and confirming eligibility for the pathway please complete the referral form which is embedded into your clinical system and send it to: Scwcsu.frimleylcd@nhs.net

For more information and resources on how to refer please click here.

Who’s eligible?

To be eligible for the programme, you must be:

  • Aged 18 – 65 years
  • Duration of diabetes ≤ 6 years
  • BMI ≥ 27kg/m2 (adjusted to ≥25kg/m2 for people of Black, Asian, and Minority Ethnic (BAME) ethnic origin)
  • A HbA1c measurement taken within the last 12 months, with values as follows:
  • With diabetes medication, HbA1c 43-87 mmol/mol
  • Without diabetes medication, HbA1c 48-87 mmol/mol
  • Provided there is no concern from the referrer that the Service User’s HbA1c may have changed since last measured such that the individual would not be eligible for the Service at present
  • Have attended a monitoring and diabetes review when this was last offered, including retinal screening, and commit to continue attending annual reviews, even if remission is achieved. (If a Service User is newly diagnosed then there is no requirement to wait for retinal screening to take place before offering referral)

Exclusions:

  • Aged < 18 years or > 65 yearsDuration of diabetes > 6 yearsBMI <27kg/m(adjusted to ≤25kg/m2 for people of Black, Asian, and Minority Ethnic (BAME) ethnic origin)HbA1c > 87 mmol/mol or:
  • With diabetes medications, HbA1c <43 mmol/mol
  • Without diabetes medication, HbA1c <48 mmol/mol
  • Has not attended monitoring and diabetes review when it was last offered
  • Current insulin use
  • Pregnant or planning to become pregnant during next 6 months
  • Currently breastfeeding
  • Has one of the following significant co-morbidities:
    • Active cancer
    • Heart attack or stroke in last 6 months
    • Severe heart failure (defined as New York Heart Association grade 3 or 4)
    • Severe renal impairment (most recent eGFR < 30mls/min/1.73m2)
    • Active liver disease other than non-alcoholic fatty liver disease (NAFLD) (i.e. NAFLD is not an exclusion criterion);
    • Active eating disorder (including binge eating disorder)
    • Active substance use disorder
    • Porphyria
    • Known proliferative retinopathy that has not been treated (this does not exclude individuals who are newly diagnosed and have not yet had the opportunity for retinal screening)
  • Has had bariatric surgery
  • Health professional assessment that the person is unlikely to understand or meet the demands of the NHS LCD programme and/or monitoring requirements (due to physical or psychological conditions or co-morbidities)

Queries

Service queries: sarah.mair@xylahealth.com

Patient specific queries: scwcsu.frimleylcd@nhs.net

Download info sheet here