REFERRAL PATHWAYS DPP: Primary care via existing digital referral mechanisms supported by population health searches (EMIS, SystmOne), opportunistic identification during routine consultations, and signposting from community and prescribing services.

REFERRAL PATHWAYS T2DR: From general practice following system-wide searches for eligible patients, supported by clinical conversations and shared decision-making.

REFERRAL PATHWAYS BSOP: From primary care with clear eligibility criteria and referral prompts embedded within practice systems. INCENTIVES: Aligned with existing locally commissioned services or enhanced service arrangements that remain after the merger of Surrey and Sussex ICBs - provider must work with ICB to ensure clarity on eligibility, referral and incentive mechanisms and avoid duplication with other weight management or diabetes services. STAKEHOLDERS: General Practice, PCNs and neighbourhood teams; place-based partnerships; prescribing and medicines optimisation teams; community and VCSE partners including social prescribing networks; public health and population health management teams.

REDUCING PRIMARY CARE BURDEN: Clear, concise referral criteria and step-by-step guidance; centrally coordinated patient searches and data insights; referral systems fully integrated with existing clinical systems requiring minimal additional data entry; practice-level feedback rather than relying on individual clinicians; short, practical training aligned with existing workflows.

F2F LOCATION PLANNING: Locations accessible by public transport in areas of greatest need; reflect population density, deprivation and health inequality data; familiar trusted community venues (community hubs, health centres); account for digital exclusion, rurality and transport barriers; flexibility to adapt over time based on uptake, capacity and equity.

POPULATION HEALTH APPROACH: Diverse population including affluent communities, rural and coastal deprivation, large minority ethnic communities in urban centres, sizeable LGBTQ+ population in Brighton & Hove, and ageing population in parts of East Sussex. East Sussex healthy life expectancy gap ~20 years between most/least deprived; Brighton & Hove women in most deprived areas live 7.7 years fewer and 12.5 fewer years in good health. DEPRIVATION: Concentrated along the coast and in Hastings, Crawley, Arun (Bognor Regis, Littlehampton), Worthing, parts of Chichester. Surrey contains hidden deprivation in Spelthorne, Woking and Reigate & Banstead. OBESITY: Surrey 58.2% adults overweight/obese; West Sussex 63.8%; East Sussex 62.5%; Brighton & Hove 57-58%.

KEY LANGUAGES: Surrey - 93.1% English as main language; pockets of diversity in Woking and Spelthorne; top non-English: Polish, Romanian, Portuguese, Spanish plus South Asian, East Asian and European languages. West Sussex - ~49,850 (5.8%) do not speak English as main language; Polish and Romanian most common; Crawley has significant Asian communities (Gujarati, Urdu, Tamil). East Sussex - non-English speakers concentrated in Eastbourne and Hastings. Brighton & Hove - ~9% do not use English as first/preferred language.

ETHNIC COMMUNITIES: Surrey - substantial Indian, Pakistani and Nepalese communities plus Gypsy/Roma/Traveller. Crawley highly diverse with large South Asian and Eastern European communities. Hastings and Eastbourne most diverse in East Sussex. Brighton & Hove notable for diversity, large LGBTQ+ population, significant disabled population, growing Black and racially minoritised residents.

PRIORITY GROUPS: Most deprived neighbourhoods; ethnic minority communities; Gypsy/Roma/Traveller; refugees, asylum seekers, migrant workers; people with disabilities and learning difficulties; LGBTQ+ communities; unpaid carers; people experiencing multiple disadvantage.