REFERRAL PATHWAYS NCL DPP: Primary care referrals via embedded NCL EMIS form; patients with language needs may require telephone referral to be matched with appropriate language-supporting coach. Existing GDM self-registration pathway for women with historic gestational diabetes. Identification supported by EMIS searches with automated mailmerge letters/SMS invitations.

REFERRAL PATHWAYS NCL T2DR: Clinically structured pathway - GP submits referral following eligibility assessment and medication review; provider processes referral and completes initial assessment.

REFERRAL PATHWAYS NCL BSOP: Eligibility identified through EMIS/Ardens searches; pathways flow from primary care.

REFERRAL PATHWAYS NWL: Predominantly primary care. ICB wants the provider to improve access for populations least likely to engage with routine general practice (most deprived neighbourhoods, some ethnic minority communities, insecure employment, lower trust in statutory services). NWL operates an LTC Platform - platform insight shows Black/African/Caribbean/Black British currently have lowest uptake of platform accounts; South Asian communities are primary eligible audience for prevention/remission. STAKEHOLDERS: GPs, PCNs and practice staff (referrals, EMIS searches, medication reviews, early engagement); ICB digital, clinical, planned care and proactive care leads; community pharmacies and dentists; RCGP (CPD-accredited NDPP training); local digital training partners; PPV (Public & Patient Voice), VCSE, faith-based groups.

REDUCING PRIMARY CARE BURDEN: Maintain and enhance embedded DPP EMIS referral form and NDPP search suite; ensure completion/attendance notifications return to GP for coding; provide centrally supported outreach/communication models; provider manages onboarding, assessment and modality selection; support safe standardised T2DR referrals with structured medication adjustment tools.

CONTEXT & BURDEN (NCL): Over 1 in 20 registered patients in NCL live with diagnosed diabetes; ~8% of adults living with diagnosed + undiagnosed T2D; only 39% of T2D patients achieved all three treatment targets in 2023/24. ETHNICITY: South Asian and Black communities (Bangladeshi, Pakistani, Black African, Black Caribbean, Somali) have higher diabetes risk and/or poorer outcomes; several overrepresented in most deprived areas. Turkish/Kurdish and Eastern European (Romanian, Bulgarian, Polish) communities are locally numerous with sizeable lower-English-fluency proportions.

KEY LANGUAGE CLUSTERS: Turkish/Somali in Haringey/Enfield; Bengali in Camden/Islington; Romanian/Bulgarian/Polish in Barnet/Enfield. GENDER/AGE: Men have higher diabetes prevalence; risk increases sharply from midlife. Women have higher prevalence ages 20-35 and overall higher obesity prevalence (men more susceptible to visceral fat). Women more likely to seek obesity treatments.

PERINATAL RISK: GDM more prevalent in Black/Asian populations and deprived areas; historic GDM elevates lifetime T2D risk; women often missed once discharged from maternity.

PRIORITY GROUPS: Women with prior GDM; people across age spectrum; people with SMI; people with LD (greater obesity risk); people who experience weight stigma (training and specialist psychology required); deprived east NCL communities with earlier T2D onset and lower English proficiency.

NWL FOCUS: CORE20 PCNs, populations with greatest unmet need; multilingual culturally competent engagement; combine community-based F2F and digital/remote offers; track equity metrics with ICB to close gaps.