JOINED-UP PATHWAYS: Link NHS, local authority and third-sector services into seamless pathways; reduce duplication by integrating referral, assessment and follow-up across diabetes, obesity, hypertension and mental health; ensure pathways are coherent for professionals and patients.

INTEGRATION WITH LIFESTYLE SERVICES: NHS services complement LA/third-sector programmes (weight management, behavioural support); growing community pharmacy role in screening/prevention/management; behavioural support embedded in weight management and hypertension services. CO-DESIGN: Pathways co-designed with residents, lived experience groups and community organisations for cultural relevance; clear communication and education for professionals and patients.

NDPP/T2DR PROVIDER EXPECTATIONS: Proactively encourage referrals via regular comms; offer awareness webinars/Q&A and attend Place GP education sessions; engage low/no-engagement practices for an equitable offer; provide patient discussion/referral resources; work with the HNY Population Health Group to determine F2F locations and bespoke session needs; clarify content variations by referral pathway; support and encourage referrals from the most deprived areas and BAME communities. REFERRALS: GP-initiated via a standardised digital form with eligibility embedded; GDM self-referral portal also available.

KEY STAKEHOLDERS: ICB Healthy Weight & Treating Obesity Steering Group, LA weight management leads, community pharmacies, programme providers, NHSE weight management programme managers, people with lived experience, Local Prescribing Committees.

REDUCING PRIMARY CARE BURDEN: Digital referral forms with clear eligibility; provider app to reduce appointment demand.

F2F GEOGRAPHIC ACCESS: Service locations mapped using population health data and deprivation indices; collaborative steering group ensures equitable provision across urban, rural and coastal communities. BSOP: Delivered via a Community Pharmacy model in HNY (piloted via Pathfinder sites, designed for regional scalability); referrals via participating pharmacies with eligibility co-developed with primary care.

BSOP STAKEHOLDERS: BSOP lead, community pharmacies, ICB Steering Group, LA leads, NHSE programme managers, GP federation.

BSOP BURDEN: Pharmacy involvement reduces GP workload; pilots use feedback loops for continuous improvement.

BSOP ACCESS: Expansion guided by population health data and pharmacy accessibility.

POPULATION: ~1.8 million across six Places (Hull, East Riding, NE Lincolnshire, North Lincolnshire, York, North Yorkshire); higher proportion of older adults than national average, especially rural/coastal.

ETHNICITY & LANGUAGE: 95%+ White; minority populations concentrated in Hull, York, Grimsby and Scunthorpe. Common non-English languages: Polish, Urdu, Punjabi, Arabic, Romanian, Lithuanian.

DEPRIVATION & CORE20PLUS5: Nearly 20% live in the most deprived national quintile; Hull is among England's most deprived LAs; rural areas face transport/access challenges. Core20PLUS5 priorities include maternity, severe mental illness, chronic respiratory disease, cancer and hypertension; CYP priorities include oral health, mental health, asthma, epilepsy and diabetes.

HEALTH INEQUALITIES: Up to 10-year life expectancy gap between most and least deprived areas (CVD, cancer, respiratory disease drive the gap). High-risk groups: routine/manual workers, people with severe mental illness, pregnant women who smoke, children in deprived areas, older adults in rural/coastal communities, Gypsy/Roma/Traveller, refugees, people with disabilities.

LOCAL PREVALENCE: Adult obesity 11.7% (above national average) - Hull and coastal areas worst. Estimated 136,700 people with undiagnosed hypertension. Early-stage cancer diagnosis slightly below England average. Smoking highest in Hull and NE Lincs.

PLACE OVERVIEW: Hull most deprived (smoking 18.9%, obesity 70.5%, lowest life expectancy); East Riding rural deprivation, older population, high obesity; NE Lincs - high deprivation, smoking 16.6%; N Lincs - deprivation in Scunthorpe, smoking 15.4%; York least deprived (smoking 8.7%, obesity 6.7%, highest life expectancy); North Yorkshire - rural/coastal deprivation, obesity 25.3%, smoking 9.6%.

SYSTEM RESPONSE: Neighbourhood health teams and community pharmacies deliver integrated prevention with digital tools and behaviour-change campaigns; specialist services for obesity, diabetes and tobacco dependency; VCSE partnerships enable culturally relevant outreach. Provider expected to use local data to target high-need groups, ensure translation for key languages and co-design with lived experience groups.