FOOTPRINT: Essex population served by 3 local authorities, 3 Hospital Trusts, 10 community hospitals, community mental health and ambulance trusts, and over 200 GP practices.

KEY STAKEHOLDERS: GP practices and GP Federations; primary care providers including diabetes nurse leads and ARRS roles; Local Authorities (public health); Tier 2 and Tier 3 weight management providers; acute and community providers; community pharmacists; voluntary sector (e.g. Frontline); Healthwatch; Essex ICB staff; maternity services for GDM.

PROVIDER EXPECTATIONS: Understand geographical variation in service provision and referral pathways using local population data. Integrate with maternity (GDM), primary care including ARRS, public health, ICB medicines optimisation, Tier 2/3 weight management and diabetes services/specialists. Ensure communication and referral processes are clear across patients, referrers, primary care, weight management providers and diabetes providers (EPUT, NELFT, MSEFT, ESNEFT, PAHT, Provide, Everyone Health, Thurrock Health Trainer Service, Morelife, Second Nature, Big Picture Medical, GP Primary Choice, Suffolk GP Fed). NORTH EAST ESSEX SPoA: Integrate with the commissioned complex obesity Single Point of Access (SPoA), a digital referral management point for all weight management/obesity services in NE Essex. ESNEFT refers directly into BSOP - provider must enable 2-way communication, accept referrals from ESNEFT and communicate with ESNEFT and patient's GP. Provider also receives NDPP and potentially T2DR referrals via SPoA, which integrates with SystmOne and EMIS (with workarounds for EPIC).

REDUCING PRIMARY CARE BURDEN: Pre-populated referral form for each service; attend local primary care meetings to support promotion/uptake; work with practices to use existing data to identify eligible patients; innovative use of technology and clinical system links. INCENTIVES: Understand QOF and any local enhanced services variations across Essex.

F2F LOCATION PLANNING: Build on current face-to-face delivery locations to provide continuity; seek ICB approval for venue selection prior to service commencement; work within neighbourhood geography defined by the ICB. REPORTING: Provide ICB with data on referrals and outcomes by practice to support engagement and uptake.

POPULATION: ~2 million; older than national average (20% aged 65+). Younger profiles in Basildon, Harlow, Thurrock; older populations (23%+ aged 65+) in Castle Point, Maldon, Rochford, Tendring. ETHNICITY: 83% White British vs 74.4% nationally. Most diverse: Thurrock 66.2% White British, Harlow 72.8%. Largest minority Other White (Eastern European, Irish, Gypsy, Roma) 5.9%; Asian groups 4.2%; Black groups 3.4%.

KEY LANGUAGES: 95.6% English as main language. Top non-English: Romanian, Polish, Lithuanian. PRIORITY AREAS (greatest inequality, deprivation-driven): Clacton (Bluehouse, Cann Hall, Coppins, Jaywick Sands, Pier, St James, West Clacton); Harwich (Dovecourt All Saints, Harwich and Kingsway); Southend (Kursaal, Milton, Victoria); Basildon (Nethermayne, Pitsea North West, Pitsea South East, St Martins); Loughton (St Johns); Thurrock (Belhus, Tilbury Riverside, Tilbury St Chads); Walton-on-the-Naze (Homelands, Walton); Colchester (Greenstead). REPORTING: KPIs include referrals, activity, waiting lists, outcomes and milestone completion - reported by deprivation, age, sex, ethnicity, learning disabilities and SMI. APPROACH: Gain insight directly from communities via Healthwatch, VCSE organisations, community champions and Essex Frontline. Tailor services and make reasonable adjustments for additional needs; source accessible face-to-face venues with attention to transport links in rural areas.