REFERRAL PATHWAYS: Continued use of digital routes including referrals via clinical systems aligned with current GP workflows. Patients identified opportunistically through routine appointments, NHS Health Checks, and NHS register invite letters/AccuRx text messaging from primary care to eligible patients via clinical searches. A standardised referral process to a single provider via the PCIT system will be implemented across all interventions, ensuring compliance with ICB and NHSE policies. Some variation in processes/policies currently exists between H&W and C&W - provider must be flexible during transition. Referral status and outcomes fed back to referring GP practice; clinical escalations flagged in a timely manner. STAKEHOLDERS: PCNs and GP practices; Local Medical Committee (LMC); primary care teams and social prescribers; Tier 3 specialist weight management services; Public Health teams; Voluntary, Community, Faith and Social Enterprise (VCFSE) organisations; social care and housing providers (where relevant).

REDUCING PRIMARY CARE BURDEN: Simple referral forms - automated/auto-populated and integrated into GP clinical systems and available on PCIT. Provider centralised case management using engagement leads/coordinators for onward allocation, programme enrolment and ongoing support. Work with ICB and place-based Health Inequalities team members/ambassadors to target greatest need. Compatible with Reasonable Adjustment Digital Flag (RADF). Concise communications with simple language, video and image content. Outcome data shared back into referring practice.

F2F LOCATIONS: Geographical location planning triangulating prevalence/need data with accessible familiar community settings; existing community assets (community hubs, leisure centres) where residents feel safe and travel is low cost; non-medical community-based venues meeting NHS standards; consider accessibility (disability, communication). Worcestershire >73% rural (JSNA 2023); Herefordshire 53% in 'rural village and dispersed' areas with limited public transport - smaller group sessions in rural villages required. Coventry's diversity drives cultural sensitivity and language barrier considerations.

PLUS GROUPS H&W: Rurally deprived populations and GP unregistered populations.

PLUS GROUPS C&W: Maternity, SMI, respiratory, early cancer diagnosis and hypertension. Focus on Priority Neighbourhoods aligning with highest unmet need and avoidable emergency admissions.

KEY LANGUAGES H&W: English 92.9%. Top non-English (Herefordshire / Worcestershire): Polish (3,005/1.61% / 8,115/1.34%), Romanian (1,548/0.83% / 3,994/0.66%), Bulgarian (471/0.25% / 1,068/0.18%), Portuguese (302/0.16% / 1,031/0.17%), Urdu (<100 / 939/0.16%), Punjabi (<100 / 896/0.15%), Malayalam (299 / 750), Hungarian (307 / 724), Lithuanian (572/0.31% / 625/0.1%).

KEY LANGUAGES C&W: English 82.5%. Coventry top non-English: Polish (2.3%), Panjabi (2.3%), Romanian (2.1%) - over 100 languages spoken. North Warwickshire: Polish, Punjabi, Gujarati. ETHNICITY: Coventry highly diverse - 45% from ethnic minority; significant/growing populations include Asian Indian 9%, Black African, Bangladeshi. Nuneaton most diverse in Warwickshire, followed by Rugby and Warwick.

COMMUNITIES NEEDING TAILORING H&W: Eastern European, Gypsy/Roma/Traveller, BAME including Pakistani and Bangladeshi (higher health inequalities/excess weight risk). DEPRIVATION: Worcestershire 11.2% (69,600 residents) in 20% most deprived; Herefordshire ~7.8% of neighbourhoods in 20% most deprived. Coventry's most deprived areas: Foleshill West, Willenhall, Hillfields, Bell Green, Foleshill East (life expectancy below regional/national averages, recently decreased). Healthy life expectancy Coventry: 64.0 years females, 61.1 males. Warwickshire most deprived areas (Atherstone, Dordon, Hartshill) - 8.3 years lower female life expectancy and 6.3 years lower male vs least deprived (Bishops Tachbrook, Barford, Hatton Park). Core20 in Warwickshire: North Warwickshire 16.72%, Rugby 3.77%, South Warwickshire 0.49%.

OBESITY/DIABETES PREVALENCE: Worcestershire 66.5% adults overweight/obese (Redditch 71%); Herefordshire 67%. T2D prevalence rising in 15-19 and 40-49 year olds since 2013. Diabetes prevalence: Herefordshire 7.7%, Worcestershire 8.2%. Obesity prevalence: Herefordshire 15.4%, Worcestershire 15.2%. ACCESSIBILITY: Resources in commonly used languages and alternative formats (videos, infographics) for lower health literacy; accommodate neurodiverse users; allow advocates/companions; accessible health-literate information.