REFERRAL PATHWAYS - NDPP/T2DR: Opportunistic referrals via primary care and neighbourhood health teams using clinical system alerts/prompts, routine GP/HCP consultations (Make Every Contact Count), NHS Health Checks, Women's Health Hubs, community pharmacist referral, targeted outreach health checks and Work Well initiatives. Batch invitations supported by WY validated clinical searches (e.g. T2DR search suite) targeting subgroups such as Early Onset Type 2 Diabetes and people diagnosed within the last 12 months - delivered via practice-led mailouts/SMS or provider-led batch invitations where data sharing agreements exist. NDH register annual recall (incentivised in QOF) used as an NDPP referral opportunity.

INCENTIVE SCHEMES: There are currently NO local enhanced incentive schemes anywhere in WY for NDPP/T2DR/BSOP, though Bradford is exploring a potential NDPP referral incentive scheme.

COMMUNITY PHARMACY: Pharmacists to refer to BSOP where local arrangements exist for independent prescribing of tirzepatide; pharmacies to signpost the 'Know Your Risk' tool and the GDM self-referral route.

SECONDARY CARE: GDM referral mechanism built into the maternity pathway with individual opt-out - a successful Leeds maternity pilot referred 773 people since Jan 2025, with ambition to roll out WY-wide via Local Maternity Services. Secondary care referrals are NOT currently an option for BSOP.

BSOP PRIMARY CARE: Clinicians supported to access BSOP or other appropriate weight management per the WY Tirzepatide Clinical Guideline.

KEY STAKEHOLDERS: ICB integrator teams at Place, neighbourhood health leads/teams, public health teams - working with the provider to keep referral processes simple and avoid extra admin burden on general practice. The system commits to continuously adapting (e.g. tailoring DPP for busy young women from deprived/ethnic minority backgrounds juggling babies, families and work). Learning from Leeds Teaching Hospitals Trust (LTHT) Henry Programme will inform DPP optimisation for the GDM population.

REDUCING PRIMARY CARE BURDEN: A single WY provider will simplify information governance and admin. WYICB has a co-designed suite of SOPs ensuring consistency across WY (with Place adaptation) - to be updated to reflect Healthier You changes and made available via the WY Joined Up Care NHS Futures space. Where providers contact patients directly, signed data sharing agreements with practices are required; for secondary care referral pathways, DPIA and data sharing agreements with acute partners may also be needed.

F2F GEOGRAPHIC LOCATIONS: Joint identification with Place-based partners and continuous review of F2F sites; engage VCSE, community champions and social prescribing teams to identify trusted, familiar venues; use existing system/community assets including health centres, community/leisure centres, faith-based venues and neighbourhood hubs; venues to be well connected by public transport, within walking distance for deprived/low-mobility groups, non-stigmatising and welcoming for people in larger bodies and those with physical/mental disability or neurodiversity. WYICB will support primary and secondary care to code NDH and GDM accurately so searches can identify and target eligible populations in hot-spot localities.

DEPRIVATION (headline): WY has higher than average deprivation - 36% (883,888 people) live in the most deprived quintile, highest in Bradford (46%), rising to 55% for Bradford's Children and Young People (0-24).

ETHNICITY x DEPRIVATION: 232k of 550k (42%) ethnic minority residents live in the 10% most deprived neighbourhoods in WY, rising to 61% in the 20% most deprived. 44% of people in the 10% most deprived neighbourhoods are from an ethnic minority vs only 7% in the least deprived. ETHNICITY (overall): 23% of WY identifies as ethnic minority (up from 18% in 2011) vs 19% nationally. Bradford has the highest share at 39% (and is home to 39% of WY's ethnic minority population). The largest group is Asian/Asian British: Pakistani (38% of the ethnic minority population, +32% growth since 2011). Non-white ethnic minorities mostly live in major towns/cities; in Leeds the population is more spatially dispersed.

KEY LANGUAGES: 91.3% of WY residents (aged 3+) speak English as their main language; Calderdale highest (95.4%), Bradford lowest (88.6%). Around 1 in 10 Urdu and Panjabi speakers in England live in WY - translated and culturally appropriate delivery models and materials are essential. Urdu/Panjabi particularly prevalent in Bradford and Kirklees; Polish, Arabic, Romanian, Ukrainian and Russian more common in parts of Leeds, Wakefield and Kirklees.

ENGLISH PROFICIENCY: 8.7% of WY have a main language other than English; 0.4% (8.7k) cannot speak English at all. 44% of WY residents who cannot speak English live in Bradford (3.8k - 1 in every 136 Bradford residents, 2.5x the England average). Bradford also has double the England average for residents who cannot speak English well (3.4%).

OBESITY & ACTIVITY: ~1 in 4 reception children are overweight/obese; ~37.5% by Year 6 (higher in deprived areas). 2 in 3 adults are above a healthy weight; 29% (~656,000) live with obesity. A quarter of adults are physically inactive and over two-thirds do not eat 5-a-day.

INCLUSION HEALTH POPULATIONS: Gypsy and Traveller (2,314); Roma (3,984); Statutory Homeless Q4 2024/25 (2,943); alcohol dependent (~27,060); people using opiates and crack cocaine (17,392); resettled refugees (1,720); unaccompanied children seeking asylum (880); people seeking asylum (5,094); people in prison (3,150); sex workers (count unknown). Life-expectancy gap at birth between Irish Traveller/Romany Gypsy women and the general female population is 7.1 years (10.3 years for men); 90% of people in prison aged 50+ have at least one moderate/severe condition - WY is keen to deliver NDPP into the health and justice system. A health needs assessment for inclusion health populations is planned for 26/27.

ADDITIONAL STRATEGIES: Use community anchor organisations to reach groups where translation isn't available via primary care; offer gender-sensitive (women-only) and GDM-only sessions; tailor for LD, physical disabilities and mobility impairments; programme content must be on provider websites (NOT embedded PDFs) to allow translation. WYICB will offer the provider trauma-informed training to enable trauma-informed care.