Pre-Diabetes and type 2 diabetes referrals (Guidelines)

Warning

The Pre-Diabetes and Type 2 Diabetes Referral and Self-Management Pathway has been developed as an information source for those working with people newly diagnosed with pre-diabetes and type 2 diabetes.

Referral pathway

 

Pathway

Pre-diabetes and type 2 diabetes referral and self-management pathway gives the practitioner / clinician an opportunity to provide a holistic conversation with those at risk of developing type 2 diabetes or newly diagnosed with type 2 diabetes by offering a choice of options depending on individual preference and needs at that particular time.  

We know it is important to offer the right health information at various stages throughout care and in a variety of formats therefore the pathway includes:

  • Online information / useful websites to signpost.
  • Information about services available in Highland for people with or at risk of type 2 diabetes.
  • NHS Highland website offers up-to-date patient information.  

Highland type 2 diabetes education resources

New to type 2 diabetes Highland app

This Highland digital app gives people information about type 2 diabetes. It has written information, video clips, local signposting opportunities and frequent asked questions. It covers key areas of:

  • Diabetes Health
  • Active Health
  • Food Health
  • Emotional Health
  • Personal Plan

New to Type 2 Highland  Android
New to Type 2 Highland  Apple


Live it Highland information pack  

Live it Highland is a patient information pack for people diagnosed with pre-diabetes or newly diagnosed with type 2 diabetes, ensuring everyone receives quality, baseline information across NHS Highland.  It supports health professional have holistic conversations with people around the following topics.  

  • What is diabetes 
  • Food, mood and diabetes
  • Activity and diabetes
  • Stress and soothing
  • Good sleep matters

The Live it Highland participants pack is available to all practice nurses GP’s, health practitioners working in diabetes care and can be ordered via Health Improvement Resource Service.            

Social signposting

iPad Loans

iPad loans could be helpful to access a digital device for near me appointments with:

  • Type 2 Diabetes Food and Health Service. 
  • CBT Service.
  • Any NHS service.

iPad loans could also be useful to access:

  • New to type 2 Highland app.
  • Diabetes Scotland including peer support.
  • MySelf-management.
  • Think health think nature.
  • SilverCloud.
  • High life highland
  • Paths for all.

iPads are available for FREE for anyone with pre-diabetes or newly diagnosed type 2 diabetes who is digitally excluded. Anyone who lacks confidence and would benefit from some training and support. Anyone who does not have access to a digital device (tablet/laptop/mobile) or internet connectivity.

  • An iPad is available to loan through any High Life Highland Library service.
  • SIM card to provide mobile data, if no internet available.
  • Training & support on how to use the iPad via AbilityNet.
  • Pre-populated with health information, access to online peer support, online education and appointments.  

Diabetes Scotland (DUK)

DUK website www.diabetes.org.uk  is where patients can access trusted information on all types of diabetes. Regular online information / Q&A events throughout the year are available for people to join. Look out for details on the website and social media.

The website includes a section specifically for healthcare professionals:

  • DUK learning zone
    diabetes.org.uk/learningzone
    videos, quizzes, interactive tools to enable people to get to grips with their diabetes when it suits them. 
     
  • DUK online support forum
    people can log on 24 / 7 to find help, tips and a friendly welcome from other people living with diabetes www.diabetes.org.uk/forum

  • Diabetes Scotland helpline
    call or email our specially trained counsellors to get advice and support from Monday to Friday 9am to 6pm. 0141 212 8710 helpline.scotland@diabetes.org.uk

  • Diabetes Scotland Peer Support Diabetes Scotland
    are currently offering online peer support for people living with diabetes. These groups are run by our trained facilitators and are giving people living with diabetes a chance to share knowledge and experiences, and gain confidence in managing their diabetes.  If you know of people who would benefit from talking to others online, or would like more information, please contact Mhairi Macdonald, mhairi.macdonald@diabetes.org.uk

MySelf-management

MySelf-management SCIO is a self-management charity for people with long term health conditions (whether physical or mental) and long covid. They focus on commonality of symptoms and approaches to enhance wellbeing.

They offer:

  • In-person living better peer support groups throughout Highland. Full details are available at www.myself-management.org/in-person

  • Online activities such as tai chi, mindfulness and breathing, seated movement, self-management themed chats, a 6 week self-management training course (starting Feb 2024), sound therapy, informal member chats and quizzes. www.myself-management.org/living-better-online

  • Closed Facebook groups just for members. Community networkers keep regular contact with group members.
  • Long covid specific e-learning courses available to anyone living in Scotland. 

Self-refer, or a health professional referral (seek permission first)

Tel: 07834 753766 Email: info@myself-management.org


Velocity Active Heath Project

This project, from social enterprise Velocity to support people to become more ACTIVE as a way of improving their health and wellbeing.

The link workers take a motivational, person-centred, trauma-informed and health-inequalities informed approach.

Participants meet the link worker via near me video or by telephone for an initial one-hour consultation to help form an activity plan, and usually two subsequent follow-up meetings over a three-month period (although the number and frequency of follow up appointments can be flexible depending on the individual).

They can refer on to other organisations, agencies or green health destinations, on a model similar to community link workers.

More info can be found here: www.velocitylove.co.uk/projects/activehealth
phone: 07514786218 / 07564166897

Referrals can be emailed to: activehealth@velocitylove.co.uk

  • Name
  • DOB
  • Postcode
  • Telephone number
  • Email address
  • Please do not include any clinical detail 
Highlight to patients that you are sharing information outside NHS and document verbal consent in patient notes.

Think health think nature 

Think Health Think Nature is a free online resource to help you explore your local greens and find activities to suit your interest and abilities that improve your physical and mental wellbeing through contact with nature. 
www.thinkhealththinknature.scot


High life highland

High life Highland is a charity which develops and promotes opportunities in culture, learning, sport, leisure, health and wellbeing across nine services throughout the whole of the Highlands, for both residents and visitors.

For information on everything from the hugely popular High Life leisure card (which offers affordable access to dozens of leisure facilities), to how to get the best out of our Highland Libraries, what happens at the Highland Archive & Registration Centre or a host of other aspects of cultural, sporting, leisure and learning life in Highland, just follow the links here: www.highlifehighland.com

Email: info@highlifehighland.com or phone 01349 781700.


Paths for all

Health walks are free, short, safe, social, fun and accessible low-level group walks led by trained volunteers.

Health walks are aimed at inactive people who would benefit most from doing more physical activity. This can include people who haven’t been active for a while and would like to start again, and people who are recovering from ill health or managing a long-term condition. No referral forms required.

Most health walk groups are open to all and booking is not required, but please contact the group first before attending. Contact details can be found in ‘more info’ tab on map: Health Walk projects in Highland


Highland mental wellbeing 

Highland mental wellbeing website is a list of services, information and training around the subject of mental health and wellbeing. It can be confusing to know where to start with online information, so it aims to help by highlighting some of the best websites and sources of help. It also provides information about training and resources for community / service volunteers or paid staff, in a ‘helping’ or supporting role. www.highlandmentalwellbeing.scot.nhs.uk


SilverCloud

SilverCloud is a website with courses you can do to improve your mental wellbeing. You can learn new ways to deal with the challenges you are facing. It is designed by clinical experts, and supported by the NHS and Scottish Government.

SilverCloud is:

  • Secure
  • Supportive
  • Free from stigma
  • Flexible so you can do a course at your own pace

SilverCloud is free, and you will need need an email address to sign up.www.silvercloudhealth.com

See: Computerised cognitive behavioural therapy (cCBT) (Guidelines)


Health improvement resource services (HIRS)

  • The Health information resource services (HIRS) provide health information and an extensive health improvement resources library which covers the Highland Health and Social Care Partnership.
  • The library offers a wide range of health related materials, to keep or loan, free of charge to everyone working or living within the Highlands.
  • For more details and to order resources, please visit the website HIRS.

Service available from community care

Type 2 diabetes food and health service

Delivering a holistic 1:1 intervention around food, health & wellbeing for people with prediabetes and type 2 diabetes. Food and weight will be discussed and explored as well as focusing on life circumstances and lifestyles.

NHS North Highland referral criteria

We accept referrals for patients:
  • Newly diagnosed prediabetes
  • Newly diagnosed T2Dm
  • Diagnosed T2Dm <6years

The following exclusions apply: 

  • Advanced dementia
  • Palliative care
  • Specific therapeutic diet e.g. renal disease
  • Pregnancy: however if at annual check-up IGT/T2Dm has developed post-natally, please refer as normal.
  • Diagnosed eating disorder
  • Additional learning needs

On receipt of the referral, the patient will be triaged and offered an assessment followed by 3 x fortnightly sessions and 3 reviews at 6, 9 and 12 months, or a group intervention. Referrers will get an update when the patient first opts into the programme, an interim update, and on discharge. Consultations will take place face-to-face, via telephone or using Near Me.

Where possible, please send referrals via SCI gateway: T2Dm Food and Health Service or Nutrition and Dietetics. If this is not possible, please send referrals via the generic email:  nhsh.communityfoodandhealth@nhs.scot

Please use this referral form to email referrals: Type 2 diabetes referral

See: Weight and Health (Guidelines)

Minimum information required to accept a referral:

  • patent’s name & CHI
  • telephone number
  • HbA1c
  • weight
  • height
  • BMI
  • Medical information

We would also encourage any relevant information on:

  • weight history
  • previous weight loss interventions, eg, types of diets, surgery, etc.
  • impact of weight on health and social activities

More information can be found here for GPs & practice nurses: GPs and practise nurses
 
For further information about the service, or to get in touch, please contact: nhsh.communityfoodandhealth@nhs.scot or 07483 143316 / 01463 704690 (Mon to Fri, 8am to 4pm) an answering service is available.


Smoking cessation

NHS Highland smoke free service provides an evidence based approach in supporting individuals to quit smoking through advice around medication and support through behaviour change techniques provided by a smoking cessation adviser. www.smokefreehighland.scot.nhs.uk

  • Smoking cessation advisers, encourage, motivate and support individuals at every step of their journey. They provide a tailored and unique programme for each individual and if they don’t succeed at first, there will be no judge or criticism.
  • It is known that willpower alone is not always enough to stop for good. There is now evidence to show that quitting with help is four times more successful and likely to stay smoke free.

Near me, telephone, text messaging or e-mail support appointments available if preferred. Fill out the contact form and a local adviser will get in touch. www.smokefreehighland.scot.nhs.uk/contact

Or go to the list of local advisors telephone numbers to contact the local adviser to talk to someone directly.
Alternatively, call or chat online at Quit Your Way Scotland on 0800 848484 (Monday – Friday 8am to 10pm, Saturday and Sunday 9am to 5pm) to get started.

See: Smoking cessation (Guidelines)


Community dietetics

Dieticians support people with diabetes to manage their condition in the context of their medical and social conditions through completing an assessment and then agreeing interventions and food and health outcomes.

This is a tier 2 service for adults with T2Dm and another comorbidity requiring a dietary intervention. Some areas will only see patients who are on maximum doses of oral hypoglycaemic agents and / or insulin. Please check with your local service for local criteria (below).

Referrals are accepted from professionals, self-referral may also be accepted.

Clinics are held on a regular basis, frequently will differ in different localities. Check with your local service for further information.

See: Weight and Health (Guidelines)

Referral form
The preferred pathway is through SCI store to your local dietetic team. 
In Easter Ross, Inverness, Nairn, Badenoch & Strathspey: nhsh.communitydieteticssm@nhs.scot
NHS Highland website has useful information.

Specialist support services

Psychological support for type 2 diabetes (Cognitive behavioural therapy)

Service information:
Overall aim: to consider the potential to improve psychological wellbeing in order to improve the outcomes of those diagnosed with pre-diabetes and newly diagnosed type 2 diabetes.

  • To provide psychological support for individuals experiencing distress and / or symptoms of common mental health problems as a result of pre- or early diagnosis of type 2 diabetes, particularly where self-management is impaired.
  • To provide support and resources to other health professionals supporting this cohort, including sharing of resources, provision of informal and formal education, and signposting to other supports.

Patient Group / Referral Criteria:

  • Individuals with pre-diagnosis or early diagnosis, being less than two years, of type 2 diabetes (including gestational diabetes) experiencing emotional burden of illness.
  • Willingness to engage (or curiosity to enquire) in a proactive treatment i.e. expectation of between-session tasks.
  • Not currently engaged with other psychological therapy (one at a time).
  • Not in crisis or dependent upon alcohol/substances requiring other specialist support.
  • Interventions are primarily delivered 1:1 however small group sessions (less than 5) may be offered for some topics.
  • Sessions are delivered via near me (equipment loan is possible, please note if the use of or access to technology may be a barrier).
  • Healthcare professionals can refer to this service.

Areas of difficulty may include:

  • Extensive worry and rumination
  • Health anxiety
  • Low mood and depressive symptoms
  • Sleep problems and insomnia
Clients will be offered an initial appointment in the first instance to scope areas for intervention and identify workable goals for change.

Further information for clinicians:
CBT T2Diabetes clinicians overview.pdf
What makes a good referral.pptx

Availability:
Monday to Thursday, 9am to 3.30pm
Referral form:
Referrals can be made via SCI Store sub-speciality code PSDIAB, or by email to: nhsh.psychologydiabetes@nhs.scot
Patient material:
Website: Cognitive behavioural therapy for diabetes | NHS Highland (scot.nhs.uk)
Plain text leaflet: Plain Text CBT for Diabetes patient leaflet.pdf

1:1 Specialist weight management

We support people with a high body mass index and complex needs to achieve a better relationship with food, mood and body, and so improve their health.

A tier 3 service, for patients who:

  • Meet Scottish criteria for bariatric surgery (Age 18 to 44 years; BMI 35 to 50kg/m2; type 2 diabetes less than 5 years).

Or:

  • Aged 18 years or over
  • High body mass index (BMI)
  • Completed tier 2 (within last 6 months)
  • Ready to engage

Plus one of the following:

  • Chronic dieting history
  • Weight cycling
  • Disordered eating
  • Social isolation due to weight issues

Professional referral please. Letter via SCI gateway or email: nhsh.communitydieteticssm@nhs.scot

Weekly Out-Patient Clinics: Mon, Tues, Wed. 9:00am to 5:00pm.

The service is based in Nairn Town and County Hospital. It is open to patients from all over The Highland Council area. Individuals are invited to come to the first assessment appointment. Near Me consultations are available to ensure easier access to the programme.

See:


Community specialist nurses

To provide support to people with complex diabetes needs and source of specialist advice for primary healthcare professionals:

  • People with type 2 diabetes requiring to commence on injectable therapies to manage their diabetes (insulin and / or GLP-1).
  • People with type 2 diabetes already on insulin requiring additional support to improve their glycaemic control.
  • New diagnosis of type 1 diabetes LADA.
  • Guidance for people with established Type 1 diabetes on how to improve their glycaemic control.
  • Diabetes management advice / commencement of therapy for steroid induced diabetes, MODY,   pancreatic pathology or other forms of diabetes in people over 21 years.
  • Healthcare professionals can refer to the service.
  • Self-referral from people with diabetes accepted.

Referral form available via Referral to community diabetes specialist nurses (Guidelines). Urgent referrals must be phoned through. Contact details are listed on referral form dependent on relevant area.

Patients must be blood glucose tested prior to referral.

Completed referral form or queries can be emailed to: nhsh.communitydiabetesnurses@nhs.scot


Diabetes specialist dieticians

To provide specialist dietary and lifestyle education and support to people with complex diabetes needs in highland and to provide support, education and information to other health professionals involved in their care:

  • Type 1 diabetes, MODY, LADA, pancreatic pathology.
  • Any diabetes patient considering pregnancy.
  • Diabetes in pregnancy.
  • Type 2 diabetes on triple therapy or injectable therapy.
  • Type 2 diabetes on insulin.
  • Recurrent or unpredictable hypoglycaemia.
  • Active foot disease.
  • Gastroparesis.
  • Nutrition support, food allergy, coeliac disease, IBD, IBS or renal patients, where glycaemic control is detrimental to outcomes.
  • Insulin pump therapy.
  • Type 1 diabetes structured education on carbohydrate counting.
  • Type 2 diabetes structured education for patients on insulin.
  • Healthcare professionals can refer to the service.
  • Self-referral from people with diabetes accepted.

Referrals can be made via SCI store or by e-mail: nhsh.diabetesdietitians@nhs.scot


ENGAGE programme

ENGAGE is an informative and interactive course to provide patients with skills, knowledge and support to take control of managing their own type 2 diabetes. For people with type 2 diabetes on insulin therapy.

Sessions run for half a day per week, over a 4-week period.

It allows patients time to build on the skills and knowledge developed from week to week, with the aim of feeling confident by the completion.

Referral Contact: nhsh.communitydiabetesnurses@nhs.scot or telephone: 01463 704625

Editorial Information

Last reviewed: 20/05/2024

Next review date: 30/06/2027

Author(s): Health Improvement Services.

Version: V3

Approved By: TAMSG of the ADTC

Reviewer name(s): F MacLeod, Health Improvement Specialist.

Document Id: TAM508