The NHS Type 2 Diabetes Path to Remission (T2DR) Programme, formerly known as the NHS Low Calorie Diet provides patient choice of an in-person or digital coached one-to-one service over 12 months, including 12 weeks of 800-900 kcal/day formula diet.  It is delivered by Momenta.
Referrals can be made by health care professionals including GPs, nurses, pharmacists, dietitians and other approved individuals.  Clinical responsibility remains with the patient’s GP and medications adjustment guidance must be signed off by an appropriate professional.
Actions required by referring practitioner BEFORE referral:
1.	Review the patient in a telephone appointment or in person, to support completion of this Referral and Medication Adjustment form for all patients. 
2.	Discuss medication changes with the patient. Instruct them NOT to make changes immediately and to adjust their medications only on the day they start the meal replacements (TDR products).
3.	Give or send a copy of the Medication Adjustment Form to the patient whether medications need adjusting or not – even if the patient is NOT taking any relevant medications.
4.	Email the completed Referral and Medication Adjustment Form to the provider (Momenta) at momenta.t2dr-bnssg@nhs.net If you have any questions you can also call 0330 056 2457.
5.	Further information and referrer and patient resources including videos, guidance and leaflets are available here: www.momentanewcastle.com/hcp-t2dr-bnssg   

	Patient name*:              	Date of birth*:       	
Declaration*	By entering my name below I confirm that this patient:
-	Meets the inclusion criteria and does not meet the exclusion criteria for this programme (see below);
-	Understands the context and meaning of Type 2 diabetes ‘remission’;
-	Understands that the NHS T2DR programme is one year long, with 21 coached in-person or digital sessions;
-	Understands that this programme involves an initial 12 weeks of consuming formula diet with a fibre supplement where appropriate instead of their normal food;
-	Has discussed and agreed their medication changes to be undertaken on the first day of TDR and has been given a written copy of this;
-	Agrees that, if they proceed on the NHS T2DR Programme, they will: Continue attending yearly diabetes review appointments at their GP practice, regardless of whether remission is achieved; notify their GP practice of any unexpected or concerning symptoms considered urgent; and notify their GP practice if they disengage or drop out before the end of their intervention; and
-	Understands and consents to their data being shared as outlined in ‘Consent’ below. 	
Referrer’s organisation and contact details*	Name of GP practice:       	
	Registered Practice Code:       	
	GP practice email address 
This must be monitored regularly for patient safety purposes:
      	
Referrer’s name*	           	Referral date*	      	
Medications adjustment signed off by (if not above):      	
Information sharing:  Before referral, please confirm the patient understands the following:
•	In agreeing to the referral being made they are giving permission for information about them to be held, shared appropriately and received.
•	Their personal and medical information is being shared with Momenta Newcastle (“Momenta”) so they can participate in the programme.
•	Their personal and medical information will be stored securely on electronic systems and not used for any purpose other than programme delivery, ensuring patient safety and monitoring and evaluation.
•	The programme is delivered by Momenta Newcastle Limited, who will securely share this data and other programme-related data, including test results and outcomes, with their GP practice and NHS England to enable the programme to be delivered safely and evaluated.
•	Their data will be treated as confidential and held, shared and disposed of in line with all legal requirements (including the Data Protection Act) and NHS guidance (which includes the Caldicott Guidelines).

In addition to seeking their consent (in common law) as a patient to proceed with this referral, please inform patients of the GDPR legal basis relied upon to hold and use their personal confidential data.
Momenta Newcastle’s privacy policy is available at the bottom of every page on its website www.momentanewcastle.com 	

Please complete all sections of this form and ensure you have confirmed eligibility before referral, including checking the autopopulated fields highlighted in yellow.
Please note that missing information will delay the processing of the referral and require the Provider to request this from you before proceeding.

Patient information (essential information is marked*)
Patient name*: Full Name	Date of birth*: Date of Birth Note: Must be aged 18-65	
Sex*:       	Ethnicity*:       	
NHS number*:       	
Address*:       	Postcode*:       	
E-mail address:       	
Telephone*: - provide at least one phone number	Home*:       
	Mobile*:       
	
Can we leave a voicemail?   Yes /   No	Does the patient understand English?   Yes /  No	
What is the patient's preferred language?                	

Clinical information
Date of diagnosis of Type 2 diabetes*:
Note: Must be within 6 years of referral	       	
Weight (kg)*: must be within last 12 months:	       	Date*:        	
Height (cm)*:	       	Date*:        	
BMI (kg/m2):	       	Date:        	
HbA1c (mmol/mol)*: 
Note values must be within 12 months and:
-	>=48 if not on diabetes medication 
-	>=43 if on diabetes medication
-	<=87 for all.
	       	Date*:        	
Blood pressure* (mmHg):	       	Date*:        	
Is the patient on the Learning Disability Register?	 Yes /   No 	
Is the patient on the SMI Register?	 Yes /   No 	
Describe any relevant disability?	     	

Eligibility criteria – for referrer reference
Inclusion criteria	Exclusion criteria	
Aged between 18-65 inclusive	Current insulin user	
Diagnosed with Type 2 diabetes within last 6 years	Currently breastfeeding	
BMI of >=27kg/m² (adjusted to >=25kg/m² in people of BAME origin)	Pregnant or planning to become pregnant within the next 6 months	
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.	Has at least one of the following co-morbidities: Active cancer; 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 MLD); active substance use disorder; active eating disorder (including binge eating disorder); porphyria; or known proliferative retinopathy that has not been treated (not excluding newly diagnosed awaiting retinal screening)	
HbA1c within 12 months, with values as follows:
•	If on diabetes medication, HbA1c >=43 mmol/mol
•	If not on diabetes medication, HbA1c >=48 mmol/mol
In all cases, HbA1c must be <=87 mmol/mol		
	Had bariatric surgery 	
	Health professional assessment that patient is: Unable to understand or meet the demands of the NHS T2DR Programme and/or monitoring requirements; or for whom the programme is not appropriate clinically (consulting with relevant Specialist teams for patients with relevant conditions); or for whom safe and robust medications adjustment is not practical in a primary care setting.	

Note: Rapid weight loss can precipitate complications for people with known gallstones. Observation has also shown that individuals with active inflammatory bowel disease can experience more severe side-effects. Please counsel patients accordingly.

Current and repeat medication – for referrer reference
      

Please complete the Medications Adjustment Form below. This is an NHS England eligibility requirement.  Section A must be completed for ALL patients, whether they are taking any relevant medications or not.

Section B MUST be completed If the patient is taking:
-	Any diabetes medication 
-	Any medication that affects blood pressure (whether prescribed for blood pressure alone or not) 
-	Any medication whose dose may be affected by changes in weight or diet (low calorie diet followed by heathy eating advice).

The current and repeat medications listed above are for reference only. Please confirm with the patient.

The flowchart overleaf summarises the medications deprescribing. The complete NHS England medications adjustment guidelines (including restarting agents) is here: www.momentanewcastle.com/hcp-t2dr-bnssg 

Momenta will monitor blood glucose and weight for all patients on the programme and blood pressure for those on blood pressure lowering medications at referral. Momenta will notify the GP practice if further medications adjustments may be required. Monitoring frequency is weekly for the first four weeks after starting TDR, before moving to fortnightly and then monthly for the last 7 months. 

Medication Adjustment Form – NHS Type 2 Diabetes Path to Remission Programme (page 1 of 2)
Please note: Section A must be completed for all patients, whether or not any medications need adjusting. Section B must be completed for ALL diabetes and blood pressure medications (whether adjusted or not) and any other medications which need adjusting. 
Section A:

Is the patient currently taking any diabetes medications? * 
Please note that SGLT2 inhibitors, meglitinides and sulfonylureas MUST BE STOPPED on the first day of TDR products.  GLP-1s should generally be stopped.	  Yes /   No
	
Is the patient currently taking any medicines which affect blood pressure? *
Tick yes whether these are prescribed solely to lower blood pressure or not.	 Yes /   No
	
Is the patient currently taking any other medications which may need adjusting with significant weight loss or dietary changes? *
Please note hospital-prescribed medications may need additional monitoring.	 Yes /   No
	
Have all relevant medications and any changes / other instructions been noted in Section B below and discussed and agreed with the patient – or has the patient been informed that no adjustments are required? *
This includes all diabetes and blood pressure medications requiring no change. 	 Yes /   No
	
Date form completed*: 	     	

Instructions for Patient
1.	The table below lists ALL your relevant medications and any changes or continuations you must make on the first day you start meal replacement products on the NHS Type 2 Diabetes Path to Remission Programme.
2.	For your safety do NOT make any of these changes to your medications before you start the meal replacement products – unless you have been specifically told to do so by your GP, nurse, GP practice pharmacist or other healthcare professional, in which case you will need to ask them for an updated copy of this form.
3.	Please read this document and keep it safe. You will need to understand the medication changes you have been advised to make before you start the NHS Type 2 Diabetes Path to Remission Programme. If you cannot remember these, you will need to request another copy from your GP practice before you can start the programme.
4.	If you have any concerns or questions about this form please discuss with your GP, nurse, GP practice pharmacist or other referring health care professional.

Section B: (page 1 of 2)
Please note, to access more details about the medications, you will need to click on the N/A to access a dropdown menu.

Medication group	Medication name 
(Note to referrers: If medication names are not available in drop-downs please use the free text fields in the top row of the table)
	Action	Changes to be made ON THE FIRST DAY OF MEAL REPLACEMENT PRODUCTS (not before)	
Any other relevant medication requiring adjustment or monitoring e.g. diet (e.g. warfarin) or weight-based (e.g. DOACs)	     

     

     

     	     

     

     

     	     

     

     

     	
Metformin			     	
Sulfonylurea 
(e.g. Gliclazide)			     	
DPP4 inhibitor
(e.g. -gliptins)			     	
SGLT2 inhibitor (e.g. -flozins)			     	
GLP-1			     	
Pioglitazone			     	
Meglitinide			     	
Acarbose			     	
Ace inhibitor			     	
Angiotensin receptor blocker			     	
Calcium channel blocker	
Other Drug Name      		     	
Diuretic	
Other Drug Name      		     	
Beta-blocker			     	

Alpha-blocker			     	
Combination Antihypertensive			     	

Notes to referrers:  
Please give the patient a digital or paper copy of the Medications Adjustment form.
Please use secure NHSmail to send the completed Referral and Medication Adjustment Form or any questions to Momenta (the provider) at momenta.t2dr-bnssg@nhs.net  
Please code as ‘Referral to total diet replacement programme’ – SNOMED 1239571000000105
For more information about the programme please direct patients to 
www.momentanewcastle.com/t2dr-bnssg or they can call the Momenta Adviser team on 0117 203 2117.
QR code link to participant webpage, including downloadable patient leaflet: