REFERRAL PATHWAYS NDPP: GP identifies eligible adults, invites with consent and refers to local Healthier You service; self-referral for GDM and practice referral links maintained on ICB webpages and clinical systems. In 2025/26 N&W delivered a Population Health Management (PHM) scheme with targeted patient communications prompting patients to contact practice for referral/self-register.

REFERRAL PATHWAYS T2DR: Practices identify eligible adults, discuss and refer with consent and complete medication review; provider updates GP at key milestones. PHM scheme used in N&W to prompt patient engagement. REFERRAL PATHWAYS LTCP (N&W only): 15 pilot practices run searches to identify and invite eligible patients during NHSE-set windows (Jan-Mar 2026, 2027, 2028).

REFERRAL PATHWAYS BSOP: Where practices prescribe tirzepatide they refer for wrap-around behavioural support using BSOP referral process; SNEE is launching a Single Point of Access (SPoA) for weight management referrals from GPs and consultants - SPoA uses rules-based algorithms with ESNEFT Clinical Nurse Specialists reviewing recommendations and AI policy compliance. ESNEFT Community Outreach supports patients suitable for primary-care obesity medication. INCENTIVES: N&W - GPs claim referral fee under Diabetes LCS for those not meeting WMES criteria; 2025/26 fee for Quality Improvement and Patient Engagement Scheme funds case-finding, coding and proactive invitation; T2DR fee for training and medication reviews. SNEE - no local incentive scheme. STAKEHOLDERS: ICB LTC commissioning, transformation and clinical leads (Obesity, Diabetes, CVD); ICB Locality/Neighbourhood teams; PHM teams; LMCs; incumbent providers; County Council Public Health teams.

REDUCING PRIMARY CARE BURDEN: Successful provider must work with system and SPoA to streamline referral processes; clinical system searches (compatible across all platforms) to identify potentially eligible patients; clear accessible information for referrers.

F2F LOCATION PLANNING: Collaborate with ICB LTC, neighbourhood and BI leads to identify areas of significant need including high condition prevalence, Core20 populations, co/multi-morbidities, rural and coastal communities. Health literacy challenges from hidden deprivation.

ELIGIBLE POPULATION: NDPP ~60k Norfolk / ~50k Suffolk; T2DR ~18-24k Norfolk / ~12-16k Suffolk; BSOP ~60k Norfolk / ~44k Suffolk (104k combined; ~13.6k treated in primary care over 3 years leaving 90,164 gap).

POPULATION HEALTH APPROACH: Both ICBs adopt Core20PLUS5 - directing efforts at the most deprived 20% (Core20) and locally significant PLUS groups (ethnic minorities, inclusion health, LD/autism, rural/coastal). DEPRIVATION: ~10% of England's most deprived 100,000 people live in Norfolk & Suffolk; 28 LSOAs in Ipswich and 20 in Lowestoft are in the bottom 20% nationally. Most deprived areas: Great Yarmouth, Lowestoft, King's Lynn, Norwich, Ipswich.

KEY LANGUAGES: ~9,000 households in Suffolk where English is not the main language. Top non-English languages: Polish (~5,700), Romanian (~5,500), Portuguese (~3,345), Lithuanian (~2,500).

ETHNIC MINORITY COMMUNITIES: Ipswich and Norwich have growing Bangladeshi, South Asian and Black communities (higher T2D risk from age 25). GYPSY/ROMA/TRAVELLER: Estimated 1,000-2,000 individuals across Norfolk and Suffolk.

RURAL & COASTAL: Large parts of both counties rural/coastal with high coastal deprivation (Great Yarmouth, Lowestoft). OBESITY/LTC: ~460,000 adults eligible for obesity pathways; 104,000 eligible for obesity medications; Complex Obesity Service (COS) serves ~800 patients/year. SMI/LD: SMI prevalence ~0.9% of adults; LD prevalence ~2-3%.

OLDER POPULATIONS: Norfolk and Suffolk have some of the oldest populations in England with high LTC prevalence and digital exclusion - prioritise in-person delivery, printed materials, telephone support; partner with Age UK, community pharmacies and social prescribers.

YOUNG ADULTS: Young carers ~1,000+ each county; care leavers hundreds per year - partner with youth services, colleges, social care.