REFERRAL PATHWAYS STW: NDPP, T2DR and BSOP referrals are made via General Practice using EMIS Web with in-built alerts linked to trigger medications, blood results, BMI and weight to identify eligible patients. STW is implementing a direct referral route into NDPP from SaTH midwifery services to address a gap for women with gestational diabetes.

REFERRAL PATHWAYS STAFFS & STOKE: DPP managed by Staffs County Council (referral by primary care, appropriate professional or self-registration with HbA1c/FPG and NHS number); T2DR managed by ICB Community Transformation (primary care/GP referral only due to medication changes); BSOP managed by ICB Improving Population Health and offered only to selected patients invited to specialist hubs - referrals received from GP/prescribers via electronic referral form upon Tirzepatide prescribing and eligibility confirmation. INCENTIVES: Local incentive currently offered to primary care for DPP referrals in Staffs & Stoke (under review); no incentive for T2DR or BSOP. STAKEHOLDERS: 141 primary care practices and 25 PCNs (BSOP hubs); diabetes teams across acute and community settings; Staffs County Council and Stoke City Council; Weight Management Programme Senior Manager; ICB Health Inequalities, Service Redesign and Prevention workstreams; GP Board/PCNs; Training Hub/PLT leads; SaTH midwifery; community partners.

REDUCING PRIMARY CARE BURDEN: Provide clear referral guidance, eligibility prompts, short scripts and patient-friendly 'what happens next' information; keep data requirements minimal; offer a single clear route for practice queries; build engagement around Protected Learning Time (PLT) rather than lunchtime sessions; provide practical resources for time-efficient searches and outreach.

F2F LOCATION PLANNING: Venue planning must reflect both urban deprivation and rural access barriers - prioritise accessible community venues (market towns, community hubs, village venues) and offer session timing that works for rural and agricultural working patterns (early starts, seasonal peaks).

POPULATION HEALTH APPROACH: STW prioritises Core20PLUS to reduce inequalities in access, experience and outcomes.

KEY LANGUAGES STW: Polish, Romanian, South Asian languages (including Panjabi and Urdu), Bulgarian, Arabic and Akan. Telford & Wrekin top non-English: Polish (3,089/26%), Romanian (1,756/15%), Panjabi (1,075/9%), Urdu (574/5%), Akan (503/4%). Shropshire top non-English: Polish (1,385/17%), Bulgarian (1,270/15%), Romanian (966/12%), Arabic (355/4%), Panjabi (292/4%).

KEY LANGUAGES STAFFS & STOKE: Urdu, Panjabi, Polish and Romanian. ETHNICITY: In Stoke-on-Trent, Asian/Asian British forms 9.9% of population (predominantly Indian and Pakistani with smaller Bangladeshi communities); 3.3% in Staffordshire (concentrated in Burton-upon-Trent, Newcastle-under-Lyme and Stafford). Black/Black British forms 2.7% of Stoke and 0.57% of Staffordshire. DEPRIVATION: Telford ranked among 30% most deprived nationally - 45,400 of the 60,100 STW residents in the most deprived 20% nationally live in Telford & Wrekin. Shropshire is predominantly rural (101 people/sq km) with 14,700 in the 20% most deprived areas. Stoke-on-Trent has 53% of population in the most deprived IMD quintile; Staffordshire has 9.9%, localised in urban centres (Newcastle-under-Lyme, Cannock, Burton-upon-Trent, Tamworth, Stafford).

PRIORITY GROUPS: Eastern European, South Asian, Black British/African/Caribbean communities; people needing reasonable adjustments (physical/learning disability, autistic people); rural communities facing digital connectivity and transport barriers; migrant workers and agricultural/farming populations needing flexible session times and trusted local venues (e.g. farming events).