REFERRAL PATHWAYS: Principal route is through primary care. Practice list searches and referral/bulk-referral templates are embedded on all GP practice systems across GM. The ICB has worked with the current provider to develop a referral toolkit; resources for patients/clinicians/providers are available via the GM MyWay Diabetes platform - successful bidder expected to dovetail into this. NDPP: Practice list searches with bulk referral following SMS consent; self-registration via online link/phone after text/email/letter; opportunistic referrals via @nhs.net inbox; GDM self-registration. T2DR: Patients invited by text/letter following list searches with practice contact to confirm eligibility and undertake medication review (in person or by phone); opportunistic referrals via @nhs.net; pre-programme info session option (in person/online) with provider engagement officer and practice staff. BSOP: Invitation/referral from primary care after list search; GP practice initiates tirzepatide and refers onto BSOP; in areas with a single-provider model (GP Federation or Tier 3 Specialist Weight Management), the practice refers to that single provider who refers onto BSOP. BSOP provider confirms eligibility/agreement and reports continued engagement back to the tirzepatide provider and the registered GP practice. LTCP: GP system search supplied by NHSE; direct invitations sent during NHSE referral windows (Jan-Mar 2026, 2027, 2028); patient self-registers via the link in the practice text.

KEY STAKEHOLDERS: ICB Healthier You lead and clinical lead; locality leads (using performance data for oversight); GP practices/PCNs; VCSE (outreach in deprived/diverse areas); GM clinical leads, NHS Health Check leads, maternity services, public health, Diabetes UK, ICB comms and prevention leads.

REDUCING PRIMARY CARE BURDEN: Maintain clear practice communication; enable interoperability with GP systems (e.g. via Docman); offer direct engagement support to clinical/non-clinical staff to raise awareness, discuss benefits, guide identification/referral, support pathways linked to blood-test results, and help practices implement pathways to grow referral volumes.

F2F LOCATION PLANNING: Practice mapping ensures F2F sites are local and accessible; ICB will support use of local intelligence/data to identify highest-need areas (high prevalence of NDH, T2D, obesity, hypertension), agree accessible venues aligned to PCN/practice boundaries (prioritising practice rooms and the ICB-approved venue list), and review referral/start data by demographic group, locality, practice and PCN. EXPECTATIONS: Build close relationships centrally and across all 10 localities; develop a mobilisation plan for quality referrals and equitable access; use locally available tools such as CVNeed analysis and the MyWay Diabetes platform; reduce unwanted variation; report to the ICB for oversight of referral and programme-start profiles.

DATA: GM has real-time data across localities, GP practices and PCNs - almost the entire primary care record (age, gender, deprivation, ethnicity, language). The GM Intelligence Hub includes Fairer Health for All and Core20PLUS5 dashboards; an NDH dashboard is being developed. Aligned to the Building Back Fairer 2022-2027 report. DEPRIVATION: 37.9% of the GM population live in the 20% most deprived areas nationally - significantly elevating risk of NDH, T2D, obesity and hypertension.

KEY LANGUAGES: One of the most linguistically diverse areas in the UK - Urdu 1.5% (~45,000), Polish 0.9%, Arabic 0.6%, Punjabi 0.6%, Bengali 0.5%, Portuguese 0.4%. Provider must translate written materials, use plain English, support visual/verbal/practical communication and develop easy-read materials; multi-lingual workforce welcomed across telephone, electronic and in-person support. ETHNICITY: Highly diverse - Pakistani 7.1%, African 2.8%, Bangladeshi 2.7%, Indian 2.3%, plus significant Eastern European and Middle Eastern communities - all experiencing disproportionately high rates of T2D, NDH, obesity and hypertension. Inequality example: only 60% of patients with recorded Black/African/Caribbean/Black British ethnicity are treated to HbA1c target vs 78.5% White British and 78.1% Asian/Asian British.

PRIORITY GROUPS: Ethnically diverse communities; non-English speakers; people with severe mental illness or learning disabilities; people with physical disabilities and multiple LTCs; older isolated/frail; people experiencing homelessness or insecure housing; unpaid carers; asylum seekers and refugees.

CVNEED VARIATION: Bolton, Manchester, Heywood/Middleton/Rochdale and Bury all have over 20% of diabetes patients in the High/Very High prioritisation categories vs 15-16% elsewhere. The CVNeed tool (built on the GM Analytics and Data Science Platform) is used to address inequities in access/experience/outcomes and enable population health management at individual, practice and population level.

INTERSECTIONAL BARRIERS: ~71% of GM adults aged 16-65 may struggle to understand health information that includes numbers (literacy/numeracy below national average); ~32% experience some form of digital exclusion; inflexible work, caring responsibilities, lack of transport, mobility/accessibility issues, low trust due to negative experiences, and cognitive/sensory/communication difficulties.