REFERRAL PATHWAYS NDPP: Three main routes - (1) NHS Health Checks: patients with HbA1c 42-47 mmol/mol or FPG 5.5-6.9 are referred directly after discussion (with consent); (2) Opportunistic interactions where last HbA1c/FPG meets NDH thresholds (retest if >12 months); women with current/previous GDM can be referred or self-refer (acute providers can also signpost); (3) Clinical system searches for eligible individuals invited by text/letter. The bulk of referrals are GP-initiated using a referral form available on Ardens/DXS.

REFERRAL PATHWAYS LTCP: Invitation-to-register sent by selected GP practices in time windows set by NHSE - eligible patients receive two texts ~6 weeks apart and self-register on the provider website. Referrals run January-March each year, with seven practices participating (continuing in subsequent years).

REFERRAL PATHWAYS T2DR: All referrals from General Practice using T2DR searches embedded on EMIS/Ardens; patients invited by text/letter after a clinical discussion. Self-referrals NOT accepted. INCENTIVES: LTCP - practices undertake searches/referrals directly and are remunerated for activity. BSOP: Primary care use Ardens to identify and grade patients into four categories; amber reviewed via joint assessment. Suitable patients referred to BSOP, which is delivered via a hub model using case-finding through GP Federations.

REDUCING PRIMARY CARE BURDEN: Standardise/simplify referrals across all Healthier You interventions using coded templates embedded in GP clinical systems with Docman workflows; use SNOMED codes; auto-populate demographic/clinical data; align with existing GP workflows. Subject to IG approvals, support bulk extraction and population-level identification of eligible cohorts (NDH, newly diagnosed T2D, BMI thresholds) for targeted outreach in higher-deprivation/lower-uptake areas. STAKEHOLDERS: General Practice (PCNs, practice managers, clinical leads, care coordinators); ICB and Place-Based Partnerships (public health, Central and Place commissioning leads); VCSE (especially those working with underserved groups); Local Authorities (public health, leisure, wellbeing); Secondary Care Diabetes Teams (T2D and GDM referrals).

F2F LOCATION PLANNING: Use ICB and LA data on deprivation, diabetes/NDH prevalence and transport links/travel times; prioritise venues within reasonable public transport time and supporting underserved populations; review distribution regularly against uptake, equality/access monitoring and service-user feedback.

POPULATION HEALTH APPROACH: Designed and delivered with place-based partners using a population health management approach, local intelligence and proportionate tailoring.

ETHNICITY & DIABETES RISK: Several SEL boroughs (Southwark, Lambeth, Lewisham) have a high Black ethnic minority population (East/West African and African-Caribbean) - up to 30% of the population - and are at higher risk of diabetes. Provider expected to collect/report data for demand and capacity analysis and use it to drive proactive outreach and case finding. ETHNICITY (numbers): White 1,032,000 | Asian 180,000 | Black 301,000 | Mixed/Other 186,000.

KEY LANGUAGES: Diverse South Asian population plus borough-specific groups - Tamil, Portuguese (Lambeth), Nepalese (Greenwich), Polish, women with GDM. Top non-English first languages by borough include: Bexley - Romanian, Panjabi, Polish, Tamil, Nepalese, Bulgarian; Greenwich - Nepalese, Romanian, Spanish, Portuguese, Polish, Italian; Lewisham - Spanish, Tamil, Portuguese, Romanian, Italian, French; Bromley - Portuguese, Polish, Romanian, Spanish, Italian, Tamil, Turkish, Russian, French, Chinese. Welcome a workforce that can engage linguistically and culturally; consider combining resources across boroughs (e.g. Tamil) to tailor courses for highest-risk groups.

WORKING-AGE ACCESS: South London has a high working-age population - Saturday and weekday-evening courses are essential.

DIGITAL EXCLUSION: The Digital Exclusion Index Tool highlights areas of higher digital deprivation across SEL - share of broadband exclusion varies by borough. PRIORITY GROUPS (Core20PLUS5): People living in the most deprived 20% of neighbourhoods; ethnic minority groups with higher diabetes risk and poorer outcomes; people with severe mental illness, learning disabilities or multiple long-term conditions; individuals facing digital exclusion, social isolation or transport barriers.