REFERRAL PATHWAYS: NDPP and T2DR referrals are made digitally by GPs/HCPs (with patient consent) using South Yorkshire referral forms; GDM also offers a self-referral option. For BSOP, the patient must attend session 1 before tirzepatide prescribing can commence - the BSOP provider then notifies the GP practice to begin prescribing. INCENTIVES: Barnsley operates a local quality incentive scheme paying practices for hitting NDPP and GDM referral targets.

PROVIDER EXPECTATIONS: Raise awareness via online webinars, Q&A sessions and Place GP education sessions; engage non-referring practices to understand barriers and share Accrux templates, leaflets and case studies; feed back clearly on rejected referrals; work with Maternity Diabetes Care for timely DPP referrals; offer programme summary content for patients with low literacy or additional needs.

REDUCING PRIMARY CARE BURDEN: Train VCSE, social prescribers and pharmacists to support assisted referrals; deliver in prevalent languages; simplify referral forms with clear eligibility.

KEY STAKEHOLDERS: Primary and secondary care, VCSE, social prescribers, pharmacists, public health/Local Authorities, and people with lived experience.

F2F VENUE MAPPING: Joint mapping exercise with the ICB during mobilisation using population health and deprivation data; venues must be culturally appropriate, trusted by communities, accessible by public transport, with parking, and offer evening/weekend sessions for working-age adults, shift workers and underserved groups. Venues to be reviewed routinely. Quarterly online HCP support sessions to be offered across SY.

DEPRIVATION (headline): ~37% (527,000) of South Yorkshire residents live in the 20% most deprived neighbourhoods nationally - Doncaster 41%, Barnsley 39%, Rotherham 36%, Sheffield 34%. Barnsley is the 30th most deprived LA in England, Doncaster 33rd, Rotherham 40th, Sheffield 60th.

ETHNICITY x DEPRIVATION: 55% of ethnic minority residents live in the most deprived areas, rising to 66% for Black/Black British/Caribbean/African residents.

KEY LANGUAGES: Polish (1.04%), Romanian (0.86%), Urdu (0.41%), Slovak (0.38%), Punjabi (0.23%), Spanish (0.13%), Bengali (0.11%); Arabic, Mandarin and Cantonese concentrated in Sheffield; Kurdish, Persian and Turkish in Doncaster; African languages including Somali, Tigrinya and Amharic.

COMMUNITIES NEEDING TAILORED OFFERS: South Asian; Eastern/Central European; Middle Eastern/North African/Kurdish; African; Chinese; Arabic-speaking; ~1,600 Gypsy/Roma/Traveller residents (high in Doncaster); shift workers; young people. DISABILITY/SENSORY: 2.5% have a learning disability; ~750 BSL users and ~27,000 adults with severe hearing loss - Doncaster has a large deaf community linked to the deaf school and would benefit from BSL support.

DIGITAL EXCLUSION: SY Digital Inclusion Programme (Citizens Advice) runs to 31 March 2026; only the Doncaster branch continues into FY26/27 - support for digitally excluded users is valued elsewhere.

INCLUSION HEALTH GROUPS: homelessness, drug/alcohol dependence, vulnerable migrants, Gypsy/Roma/Traveller (high in Doncaster), sex workers, people in contact with the justice system, victims of modern slavery.

PROVIDER EXPECTATIONS: Target Core20PLUS5 using local data; offer F2F interpreters; integrate with wider weight management pathways, mental health trusts, LD teams, VCSE, smoking cessation and alcohol support; provide quarterly PCN data packs with simple improvement guidance; consider pop-up prevention/remission clinics in non-clinical settings; offer adapted LD sessions (visual content, appropriate length, co-facilitated with LD VCSE where possible); train bilingual community workers to deliver sessions locally on a paid basis.