Resources for referrers to the NHS Type 2 Diabetes Path to Remission Programme

Cheshire & Merseyside

Welcome!  This webpage includes all the resources that GP practice staff may need to identify and refer eligible patients to the NHS Type 2 Diabetes Path to Remission Programme (T2DR), formerly the NHS Low Calorie Diet Programme.  It is designed for people who have referred previously or attended an education event or come to a weekly drop-in sessions – see below for details. 

This website is for referring health care professionals only – please do NOT forward to patients.  The patient information page is here – or you can print patient leaflets below.

If you have any questions or feedback please get in touch using the Contact information below.

Thank you very much and we look forward to your referrals.

If you are not from Cheshire & Merseyside ICS please click on the link at the bottom of this page for the correct referrers’ pages.

Table of contents

Service overview

The NHS Type 2 Diabetes Path to Remission Programme (T2DR) launched in Cheshire & Merseyside in 2024.  The service is provided by Momenta Newcastle, commissioned by NHS England and Cheshire & Merseyside ICB. 

The T2DR Programme offers support for people newly diagnosed with Type 2 diabetes and above a healthy weight. The 12 month programme is designed to support people to improve their diabetes control, reduce diabetes-related medication and in some cases, put their Type 2 diabetes into remission.  Coached support over 12 months is delivered one-to-one, either in-person or digitally according to patient choice

There are three phases:

  1. Total Diet Replacement: 12 weeks, with all meals replaced by TDR products
  2. Food re-introduction: 6 weeks, gradual reintroduction of real food
  3. Weight maintenance: To 52 weeks, ongoing support to build and maintain healthy lifestyles.

The whole programme, including coaching and all total diet replacement products, is free for participants.

On average participants lose 10-15% of their starting weight in the first three months.

Identifying interested patients

GP practices can choose from three approaches to identifying eligible patients prior to a referral appointment.

In all cases, interested and eligible patients should attend a referral appointment to discuss the programme and any adjustments they should make to their medications on the first day of taking TDR products. The GP practice must then send a completed Referral and Medications Adjustment form to Momenta.

As a guide, 15 minutes should suffice for a patient record review, patient discussion and completing and emailing the referral and medications adjustment form. Although the appointment can be with different healthcare professionals the medications adjustments must be signed off by an appropriate prescriber and clinical responsibility for the patient remains with the GP practice.

See below for supporting information and resources.

Referral pathway options

This one-page summary flowchart should be used in conjunction with detailed guidance and documents below

Referrer education session slides and recording

T2DR Education session slides coming soon (pdf)

Participant case studies

Some participants have shared their stories – you might find their experiences help you explain the programme to your patients – or they might just make you smile…

Juliet, Birmingham & Solihull

Juliet, Birmingham & Solihull

Juliet took part in our NHS Birmingham Type 2 Diabetes Path to Remission Programme. Juliet started on 120.9kg and finished…
Waqas, Birmingham & Solihull

Waqas, Birmingham & Solihull

Waqas has lost 21% of his starting weight
Faraza, Birmingham & Solihull

Faraza, Birmingham & Solihull

Faraza has lost 19% of her starting weight

Eligibility criteria

Inclusion criteria

  • Aged between 18-65 inclusive 
  • Diagnosed with Type 2 diabetes within last 6 years 
  • BMI of >=27kg/m² (adjusted to >=25kg/m² in people of BAME origin) 
  • Attended monitoring and diabetes review in last 12 months, incl. retinal screening and commit to continue annual reviews, even if achieve remission. (If newly diagnosed no need to wait for retinal screening before making offer of referral). 
  • HbA1c within 12 months, with values as follows:
    1. If on diabetes medication, HbA1c >=43 mmol/mol (6.1%)
    2. If not on diabetes medication, HbA1c >=48 mmol/mol (6.5%)
    3. In all cases, HbA1c must be <=87 mmol/mol (10.1%) 

Exclusion criteria

  • Current insulin user 
  • Currently breastfeeding 
  • Pregnant or planning to become pregnant within the next 6 months 
  • Heart attack or stroke in last 6 months; severe heart failure (New York Heart Association grade 3 or 4); severe renal impairment (most recent eGFR <30mls/min/1.73m2); active liver disease (not including NAFLD); active substance use disorder; active eating disorder (including binge eating); porphyria; or known proliferative retinopathy that has not been treated (not excluding individuals who are newly diagnosed and have not yet had the opportunity for retinal screening).
  • Had bariatric surgery  
  • Health professional assessment that patient is unable to understand or meet the demands and/or monitoring requirements of the NHS Programme; or for whom the programme is not appropriate clinically (consulting with relevant Specialist teams if required); or for whom safe and robust medications adjustment is not practical in a primary care setting.

Searches, Referral and Medications Adjustment Form

Referrals can be made by completing the referral form and emailing it to Momenta at momenta.t2dr-candm@nhs.net he referral form is available on clinical systems. Eligible patients will be identified by a pop up shown below. This will allow you to refer now, create a task, not refer now and to select the patient has declined a referral. 

If you have any queries regarding medication changes or completing the referral form please read the Medication adjustment guidelines below and then contact the Momenta support team if required at momenta.t2dr-candm@nhs.net

Patient invitation templates

As noted above, the most time-efficient way to raise awareness amongst your patient population is to do a search, followed by shortlisting and sending a text or letter with further information and next steps (as many practices do for the NHS Diabetes Prevention Programme, Healthier You). 

Summary steps include:

  • Run Register search (see above) to generate ‘longlist’
  • Conduct manual screen against non-searchable eligibility criteria
  • Send a bulk text message using AccuRx/iPlato/mJog templates
  • This will signpost them to a service landing page where they can find out more about the programme, eligibility criteria and assess their readiness before getting in touch with you to arrange a referral and medications adjustment appointment.

Suggested wording for text invitation – please amend as you like:

A <Practicename> screening has identified that you may be eligible for the NHS Type 2 Diabetes Path to Remission Programme, also known as the NHS ‘soups and shakes diet’.  This one-year programme helps you to lose weight, improve your blood sugar levels and reduce medication.  For details see https://momentanewcastle.com/t2dr-cm The programme and all products are FREE.

When you have read it, if you are interested in taking part please call the practice on <Practicenumber> and ask for an appointment to discuss a referral.

 As there are a limited number of places available across Cheshire & Merseyside please get in touch quickly. 

Notes to GP practice: 

– Most platforms automatically start the message with “Dear [patient name]”

– We recommend you ‘sign off’ with the name of an individual e.g. well-known doctor or other HCP to the text as this will improve the response rate over a generic practice sign-off

– It is best to either alert reception staff before sending the message or provide a specific response option e.g. email or phone/text number.

– Some practices also attach the patient information leaflet.

– Some practices follow-up with a second text and/or phone call to non-responders, depending on resource.

Patient information

You can send patients to this landing page for more information about the service – this is helpful to do when inviting patients by text (or email).  

Alternatively you can download an A4 PDF Patient Information Leaflet for local printing / attachment.

Medication adjustments guidelines

NHS England’s T2DR expert reference group has developed detailed deprescribing guidance for both medication impacting blood glucose and blood pressure.    

The NHSE document is available here. It is a lengthy document so we recommend using the table of contents to navigate to relevant sections.  Momenta have added summary pages at the back – these are for quick reference only and are not a substitute for reading the relevant pages of the full guidance.  

Patient journey

The NHS Type 2 Diabetes Path to Remission Programme is delivered to individuals at community or primary care venues.  Your patients will be offered a choice of in-person or digital pathways, the latter with app access and both supported by trained Coaches.  

It is a complex three-phase behavioural intervention over 12 months:

  • Phase 1 Reboot: Total Diet Replacement (12 weeks)
  • Phase 2 Rebalance: Food Reintroduction (6 weeks)
  • Phase 3 Retune: Weight Maintenance (until 12 months).

 

The 20-30 minute sessions focus on the following topics over the 12 months and include monitoring of weight and blood glucose (and blood pressure for those on blood pressure medications at referral). Participants also receive a range of resources at different points.

T2DR Participant Journey

Patient readiness (self-)assessment

You can use this standalone patient readiness (self-)assessment to either give to your patient to complete on their own or guide them through it. The patient landing page has a copy embedded. Alternatively you can download this document (for printing / emailing) and also view one-page instructions for healthcare professionals. Please note this has been developed by Momenta’s Clinical Director, a health and clinical psychologist, specifically to support decision-making but it is not an externally validated tool.

Key contacts

Referrals & Queries

momenta.t2dr-candm@nhs.net

PLEASE DO NOT SEND REFERRALS OR PID TO ANY OTHER EMAIL

Momenta host regular referrer support sessions which you can join for an overview of the service or to ask any specific questions. Please use the below link to book a slot.
Weekly referrer support session

Jon Scott

Momenta Newcastle
Service Manager for NHS Type 2 Diabetes Path to Remission Programme, (formerly the NHS Low Calorie Diet Programme)

Email: Jon.scott@momentanewcastle.com
Note: Please DO NOT send referral or patient identifiable information to this email

Complaints contacts and procedures

Complaints should be addressed to the Provider (Momenta Newcastle) and/or the CCG and/or the Commissioner (NHS England) as appropriate.  

– Momenta Newcastle (Provider):  complaints@momentanewcastle.com

https://momentanewcastle.com/complaints 

– NHS England and South, Central and West CSU (Commissioner):  scwcsu.lcdpilot@nhs.net or england.diabetestreatment@nhs.net  

Referring from a different area?

Momenta also provides the NHS Type 2 Diabetes Path to Remission Programme in other areas, each with their own referral forms, local contacts and minor differences. Please follow the links below for Referrer information from other areas: