BLMK REFERRAL PATHWAYS: DPP referrals via General Practice (primary route) with self-referral also available for GDM via maternity services. T2DR referrals solely via General Practice. BSOP referrals flow through the community weight management service (which also prescribes weight-management medicines). LTCP invitations to register sent by selected GP practices in NHSE time windows. All BLMK practices use SystmOne.

BLMK INCENTIVE: £90 per T2DR place taken up (not yet confirmed for 26/27).

C&P REFERRAL PATHWAYS: BSOP - GP reviews patient (or runs Ardens searches), refers to the 'Healthy You' Single Point of Contact which triages into the Community Intensive Weight Management Service (CIWMS) medication pathway; CIWMS provider refers to BSOP by email; once stable on highest tolerated tirzepatide dose, patient transfers to a place-based light-touch follow-up before returning to GP.

C&P INCENTIVES: T2DR £75 per TDR start; DPP £12.50 per patient; BSOP not incentivised.

HERTFORDSHIRE REFERRAL PATHWAYS: NDPP via GP online referral form plus GDM self-referral; T2DR GP-completed referrals; BSOP referrals made by primary care tirzepatide service providers.

HERTFORDSHIRE INCENTIVE: HWE primary care incentive includes a metric to review NDH patients (BMI check, referral to NDPP / weight management, lifestyle advice, social prescribing). KEY STAKEHOLDERS (all): General Practices, PCNs, maternity services for GDM, community weight management/CIWMS, Tier 2/3 weight management, public health & NHS Health Check providers, community lifestyle services, ICB and clinical leads, VCSE and faith groups, Healthwatch, neighbourhood teams (C&P North/South Place hubs).

REDUCING PRIMARY CARE BURDEN: Co-develop localised, pre-populated referral forms aligned to existing layouts; direct practice visits to demonstrate searches and referral forms; feedback to referrers on ineligible referrals; electronic clinical document transfer (Docman) and exploration of automated coding for outcomes (completion, weight). Explore extraction from GP lists for case-finding to reduce burden and inequalities.

F2F LOCATION PLANNING: Continue use of existing venues where possible; map utilisation, demand and waiting lists; meet ICB place-based teams, public health, faith and community leaders to find venues that engage high-risk/underrepresented groups; in C&P, work with Place neighbourhood teams (North/South) and neighbourhood hubs; in Hertfordshire, prioritise venues with good public transport to avoid widening inequalities.

BLMK ENGLISH PROFICIENCY: 20%+ of residents in Luton and Bedford Borough self-rate as 'cannot speak English well / cannot speak English'.

BLMK KEY LANGUAGES: Polish 2.1% (~20,061), Romanian 1.9% (~18,404), Urdu 1.2% (~11,260), Bengali 0.9% (~8,659), Punjabi 0.6% (~6,011).

BLMK ETHNICITY: Luton 55% ethnic minority - over 30% South Asian (Pakistani/Bangladeshi), much higher than rest of BLMK; Bedford Borough's largest minorities are Other White (Polish/Romanian) and Indian; Milton Keynes has greater Black African; Central Bedfordshire much less diverse.

BLMK PRIORITY: People of Asian ethnicity and people in the most deprived areas - referral, uptake, retention and 12-month weight change all lower for Asian ethnicity vs White on DPP/T2DR. Engagement to use Luton Council of Faiths, MK Equality Council, Bedford Faith Leaders Group.

C&P DEPRIVATION: Cambridgeshire IMD 13.9 vs Peterborough IMD 27.8; Fenland IMD 25.4. ~112,000 in Core20 = 13% of C&P, 18% of Fenland, 41% of Peterborough.

C&P HEALTHY LIFE EXPECTANCY: Peterborough 55.6 (M) / 55.2 (F) vs Cambridgeshire 62.6 / 62.4 vs England 61.5 / 61.9. C&P KEY LANGUAGES (Peterborough): Polish 18.1%, Lithuanian 16.2%, Portuguese 9.0%, Romanian 8.6%, Urdu 6.0%, Latvian 4.4%, Panjabi 4.1%, Russian 2.8%, Slovak 2.6%, Kurdish 2.2%. Fenland's main non-English language is Lithuanian (35.1% of those without English as main language). Cambridge: Spanish top (8.9%), high Chinese and Western European.

C&P ETHNICITY: Cambridge & Peterborough ~18% Asian, ~12% White Other, vs ~90% White elsewhere. Gypsy, Roma & Traveller populations 7,000+ across the ICS footprint.

C&P PRIORITY GROUPS: People with Learning Disabilities (39% of LD register also on obesity register in Peterborough; 43% in Fenland), Autism, SMI (45% / 42% obesity overlap), D/deaf people, physically disabled (access to weighing equipment).

HERTFORDSHIRE ETHNICITY: 71.8% White British; largest minorities Other White, Asian Indian, Black African. Most diverse: Watford (45.8% White British), Hertsmere (63.1%), Welwyn Hatfield (67.2%), Three Rivers (67.9%), Broxbourne (68.6%).

HERTFORDSHIRE LANGUAGES: 91.8% English as main language; top non-English: Romanian, Polish, Gujarati, Italian, Urdu.

HERTFORDSHIRE DEPRIVATION: 14 LSOAs in the most deprived national quintile - Stevenage, Broxbourne, Watford, Welwyn Hatfield, Hertsmere.

HERTFORDSHIRE PRIORITY GROUPS: Severe mental illness, learning disabilities, sensory impairments (deafness/blindness).