Delivering responsive and joined up services

Primary care transformation

Primary Care services including general medical practice, dental, eye care and community pharmacy are central to bringing care closer to home, managing long term conditions, preventing unnecessary hospital admissions, and helping people stay well and healthy. We recognise to achieve these ambitions for Primary Care we will need to enable our services to work together across local communities (neighbourhoods). Integrating our services in this way is key to delivering joined up care for our residents but also supports our primary care services in maximising their capacity.

The Primary Care Joint Forward plan builds on the current primary care strategy Primary and Community Care Services Strategy 2019/2024 aiming to establish a new model of primary care, aiming to improve the health of the population and make better use of resource. Our plan aligns with previous approaches to primary care in West Yorkshire, emphasising collaboration, population health, reducing variation and empowering individuals and communities. Our strategic focus is on transforming primary and community-based care in accordance with the broader ambitions outlined in this document.

We recognise that to deliver on our ambitions we will need to work to prioritise our key enablers for integration, namely workforce, estates and digital. The importance of these key enablers are further emphasised through the Fuller Stocktake Report.

The Fuller Stocktake Report, “Next Steps for Integrating Primary Care,” published in 2022, outlined a new vision for primary care that reorientates the health and care system to a local population health approach through building integrated neighbourhood health and care teams. At the core of the Fuller Report is a neighbourhood-based model for integrated care, centred around streamlining access to urgent care, continuity of care for those with long-term conditions, and a proactive approach to prevention and tackling health inequalities, helping people to stay healthy. The implementation of this vision in West Yorkshire is discussed in subsequent sections of this plan.

Within the West Yorkshire Integrated Care Board (ICB) our approach to primary care is aligned to the operating model in West Yorkshire, guided by the “three tests” outlined in the Joint Forward Plan which are focussed on adding value to our five local places.

Primary Care within the West Yorkshire Integrated Care Board (ICB) area

We have developed specific objectives and priorities to contribute toward the strategic vision for primary care in West Yorkshire with the aim of fulfilling the recommendations of the Fuller Report. These objectives focus on

• General Practice Access transformation and improvement
• Estates development and transformation
• Workforce development, transformation and building capacity, and
• Commissioning and Integration of Community Pharmacy and Optometry services.

Our work on primary care connects with other areas, including urgent and emergency care, long-term conditions, personalised care, digital and workforce development. Arrangements through our West Yorkshire ICB programme structures and the Fuller Delivery Board support these connections.

Delegating responsibility for Community Pharmacy, Optometry and Dental (POD)Services to ICBs in April 2023 provides opportunities for transformation and integration to support service delivery and improvement. Aligning POD services with ICB level strategies, enables integrated care within local communities and neighbourhoods supporting our broader ambitions.

Our work and deliverables

The West Yorkshire Fuller Delivery Board will during 2023/24 agree a number of outcome measures to demonstrate the ICB’s progress in implementation of the vision set out in the Fuller report.

Delivery plan for recovering access to Primary Care

Improving Access to general practice continues to be a priority across West Yorkshire. We know that our residents have told us, through the local work that Healthwatch led to produce the Healthwatch Insight Report published in August 2022, as well as other engagement programmes across the partnership, that access to Primary Care remains a key area of concern for patients.

The recently published NHS England delivery plan for recovering access to primary care will help to address those concerns as the plan focuses on recovering access to general practice, supporting two key ambitions.

1. To tackle the 8am rush and reduce the number of people struggling to contact their practice.
2. For patients to know on the day they contact their practice how their request will be managed.

The plan sets out the ways it will support the overall recovery with a focus on four areas:

1. Empowering patients – Working locally to promote with patients the benefits when using the NHS App, self-referral pathways and better use of the services offered through Community Pharmacy
2. Implement modern general practice access – Providing rapid assessment and response to patients to avoid patients having to call back at on another day to book an appointment and improving some practices telephone systems
3. Build capacity – delivering more appointments from deploying different clinical staff roles, supporting recruitment and retention initiatives
4. Cut bureaucracy – looking primarily at the interface between primary and secondary care to reduce workload, releasing more clinical time for patients

In the first year:

Primary Care Access

We are not starting from a blank page in West Yorkshire and have already started to develop initiatives and programmes to improve patient experience when accessing primary care services. We will build on what we have done to date and use the aims and key deliverables described in the NHS England delivery plan for recovering access to primary care, to challenge us, guide and monitor our progress. We aim to deliver modern general practice access with improved experience of access for patients and better continuity of care where most needed. Working collaboratively, we will develop system delivery plans with clear alignment to local place plans which support access improvement across primary care. We will ensure our approach addresses inequalities in access and experience whilst encouraging integration across all primary care services.

A priority we will continue to focus on is how we use data and intelligence better to embed quality improvement. Data will enable us to better understand variation and share best practice working closely with the national requirements of the delivery plan for recovering access.

Primary Care Workforce

Effective recruitment, training and retention strategies are vital in achieving our ambitions for primary care including Improving access to care. Our delivery of support to primary care workforce at West Yorkshire level is driven through our West Yorkshire Primary Care Workforce Steering Group. The Steering Group will continue to work to enable an effective primary care response to the West Yorkshire People Plan by bringing together places and wider colleagues to take forward programmes of work at system level.

Our Steering Group is underpinned by a clear approach to prioritised actions which align to the three tests of the ICB. We will continue to work closely with our delivery partners on programmes of work which already support our workforce for example the offer of mentorship to General Practice staff, delivery of a General Practice Nurse Vocational Training Scheme and tailored Fellowship Programmes for General Practitioners and General Practice Nurses.

Primary Care Estates

Estates capacity is recognised as a key enabler to transformation and supports growth of the workforce. Our work at West Yorkshire will enable and support the development of system wide strategic estates plans. These plans will align to the delivery of services and support how we prioritise developments in the context of resources.

We will use the drivers within the NHS England delivery plan for recovering access to primary care to look at how we work collaboratively with local authorities in estates developments. Our work to ensure we have strengthened primary care estates plans is interdependent with our digital transformation strategies and we will ensure that our programmes of work recognise these interdependencies.

Community Pharmacy and Optometry

We will work within our direct commissioning responsibilities for Community Pharmacy and Optometry to ensure continued access to high quality services maximising the opportunities to integrate services in local communities.

At West Yorkshire level we will look to the offer of wider services through Community Pharmacy as part of their national Community Pharmacy Contractual Framework and improve uptake and access to these services, for example the NHS Community Pharmacist Consultation Service (NHS CPCS). Strategies to maximise and embed these referral pathways will complement our work to improve access and ensure a more resilient primary care.

In years two to five:

We will continue to refresh and adapt our primary care plan to ensure that we can respond to any changes to the national strategic direction for primary care. We will aim to build on our year one plans by taking the following steps;

• We will maintain focus on our system delivery plan for recovering access to primary care, reflecting on building on initial successes and quality improvement approaches.
• We will strengthen integration of community pharmacy using what we know will be commissioned through the Community Pharmacy Contractual Framework including the introduction of the Pharmacy First Service.
• We will support the development of clear estates plans that are informed by and enable PCN strategic service requirements build around populations.
• We will further develop and learn from our approaches to workforce development and transformation broadening our reach to Community Pharmacy, Dental and Optometry.
• We will develop approaches to how we will include community pharmacy and optometry in the ICB plans for sustainability.
• We will review how our plans ensure a focus on a trauma informed approach building on initial actions in year one.

All these aims will be developed into tangible actions to help us measure our impact against our ambitions and additionally, will be further reviewed following confirmation of the outcome measures to be determined by the Fuller Delivery Board.

Integrated health and care neighbourhoods

Our Integrated Care Strategy aims to improve the overall health and well-being of our populations. Neighbourhoods are at the heart of this strategy as collaboration starts here. The health and care context for neighbourhoods includes various wider factors such as employment, housing, green spaces, and transport – and ensuring and understanding how these wider determinants interrelate with the health and care needs of our populations is a key focus for local health and wellbeing boards.

Helping people to stay healthy at home, providing access to tailored treatment and care in their communities, and addressing the needs of individuals and local communities in a way that is holistic and joined-up are central to our ambitions for how health and care services wrap around neighbourhoods. Integrated health and care neighbourhood teams play a vital role in achieving these goals. The capacity and capability of these teams to meet community needs are crucial in improving outcomes and reducing inequalities.

The Fuller Stocktake Report outlined a vision for integrating care and improving access and outcomes for communities through further development of Integrated health and care neighbourhood teams (INTs). These include general practices, primary care networks, primary care services (such as community pharmacy, dentistry, and eye care), community health services, social care, and the voluntary, community, and social enterprise sector (VCSE). Across West Yorkshire, we will develop INTs in a way that suits the specific contexts of neighbourhoods. As the Fuller Stocktake Report sets out, there is unlikely to a single INT working to support a local population, but a ‘team of teams’ based approach, where different groups of health and care staff are able to come together depending on the particular needs of individuals and communities. Enabling this collaboration, workforce development, digital and data integration, and sufficient resources are key to their success. Each of the local West Yorkshire place plans that form part of this JFP set out in more detail the specific steps being taken locally to develop integrated neighbourhood-based care models. Supporting this overall evolution across the West Yorkshire system will be part of the remit of the Fuller Delivery Board described above.

Our ambition for dental services

The ICB taking on responsibility for the commissioning of dental services across West Yorkshire brings a range of opportunities to improve access and quality for our population. To date, much of this work has happened on a regional Yorkshire and Humber footprint, and we remain committed to both getting things right for West Yorkshire and collaborating across our region.

We know that access to dental services is important to our population. Recognising this, we have already acted and demonstrated the scale of our ambition, with the NHS West Yorkshire ICB Board agreeing to:

• Improve access to dental services through the continuation of Flexible Commissioning, and extending the scope of it, and additional investment of £4.5m this financial year to enhance access for those most in need of dental care
• Develop a long-term dental workforce plan that enables us to ensure sufficient capacity to meet needs both in the nearer term and future
• Support working closely with local authority partners to ensure a joint approach to oral health improvement, promotion, and prevention across West Yorkshire, including through water fluoridation.

Our ICB Board commitment is being driven through a programme that collaborates with partners including the regional commissioning team, our five places, the dental profession (e.g., through Local Dental Committees and the Local Dental Network), local authorities, and public health professionals, to deliver our priorities. Working in this way, we will build upon work already underway, including:

• The Flexible Commissioning Programme that has operated to improve access by utilising a percentage of current contract value differently
• The delivery of access schemes, funded through reclaimed contract value
• An approach to dental commissioning that is evidence based, using the Oral Health Needs Assessment and other insights, working toward more preventative care
• Waiting list validation work, to understand the number of patients and types of need in several practices
• Workforce retention initiatives, including a ‘golden hello’ scheme, establishment of a Tier 2 Paediatric Accredited Scheme which will support more skills mix and community-based care and continued professional development training for dental teams to support General Dental Council registration

Our ambition is bold and must be to improve services and meet public need, but we must recognise that improving access and quality for the long-term takes time and requires a sustained collaborative effort. We will adopt a phased approach that works through areas at pace, with plans to develop and delivery to evolve over the course of this financial year and the wider life cycle of the Joint Forward Plan.

• In the short term we will work at pace to improve access through investing the additional £4.5m of in-year underspent funding in areas where need and impact is greatest, and explore the extension of a flexible commissioning approach
• In the mid-term we will work on developing a dental workforce plan, strengthening our connectivity with our local authority partners on oral health improvement, promotion, and prevention, and progress discussions on fluoridising water in West Yorkshire (delivering this in the long term)
• Over the longer term we will be ambitious about continuous transformation, improving access and quality improvement in dental care, and ensuring that dentistry is integrated within the wider system, with clear plans on how to execute this, and operate nationally to influence decisions and policy.

It is important to both patients and the profession for the ICB to maximise the opportunities in front of us. This will require judgement and precision given the financial limitations and contextual constraints, but we remain committed to being ambitious and improving dental services, and doing so in collaboration with the profession, our people, and other partners now and in the future.

Our ambition for integrated urgent and emergency care

As West Yorkshire is a large and diverse system, a considerable amount of work happens within our local places through place based Urgent and Emergency Care Boards, or equivalent. There is a well-established West Yorkshire Urgent and Emergency Care (WY UEC) Programme Board with representation from our five places, provider organisations, West Yorkshire Association of Acute Trusts (WYAAT), clinical quality, and the voluntary and community sector. The Board’s role is to lead and oversee transformational priorities where they meet one of the three tests of partnership working.

Due to the substantial interdependencies, the Programme Board also promotes the objectives of urgent and emergency care across the wider partnership whilst simultaneously complimenting the various place based UEC Boards and their priorities.

The ‘Delivery plan for the recovery of urgent and emergency services’ sets out ambitions to develop a system that provides more, and better, care in people’s homes, gets ambulances to people more quickly, sees people faster when they go to hospital and helps people safely leave hospital having received the care they need.

Our vision for urgent and emergency care is:

• for those people with urgent but non-life-threatening needs - providing highly responsive and effective integrated urgent care services in the community, where more care is delivered either at home or close to where people live, reducing the need to travel to hospital, and disruption and inconvenience for people
• for those people with more serious or life-threatening emergency care needs - supporting people in the most optimal settings (such as a hospital’s A&E Department) with the appropriate expertise, processes, and facilities to maximise a good recovery.

Our three ambitions

Access to urgent health and care services

We know that people understandably often present at the service they are most familiar with, which may not necessarily be the service that could most appropriately meet their needs. Whilst we have made significant improvements supporting people to access services and in ensuring consistency in messaging, we need to continually improve our communication of what is available, to who, and when.

Calls to NHS 111 and accessing NHS 111 online will be instrumental in achieving this ambition. We will continue to invest in call handling and clinical advisors within NHS 111 to ensure people get a prompt response and work with partners to make sure that services are available accessible for patients and healthcare professionals alike. We will work with the Yorkshire Ambulance Service, our regional provider of NHS 111, to maximise integration with urgent care services, directing patients to the right service or care advice both across West Yorkshire and through place-based initiatives.

Our messages remain consistent across West Yorkshire as we highlight the alternative methods of accessing health and care support and to only use A&E Departments for serious injury or a life-threatening situation. We have reframed communications so people consider alternative options rather than the first option of ‘call your GP’ this includes prompts and reminders of how community pharmacy can help, avoiding people calling already busy telephone lines. Promoting digital alternatives allows people to see what self-help support is available and the alternative ways there are of using and contacting health services.

The winter period is always challenging as demand for services tends to increase significantly with the onset of cold weather, flu, and other seasonal illnesses. The “Together We Can” campaign promotes simple, consistent messaging in a variety of languages and formats. It encourages people to “choose well” and to opt for convenient self-care, where safe to do so during the winter months and ensures people understand which service to use, for example when they should use NHS 111 or go to their local pharmacy or GP practice.

Urgent and emergency care communications

‘Together We Can’ (TWC) is West Yorkshire’s long term campaign to minimise pressures on urgent and emergency services. This is the second year the campaign has been rolled out as an area wide winter campaign. The signposting campaign has been built on data, insight, and user testing. Campaign creatives were updated to reflect the current climate and learning from the previous year. The aim of the campaign was to encourage people to use health services responsibly during what was expected to be another challenging winter for NHS services.

The Together We Can winter 2022/23 campaign evaluation is available to view here.

Integrated same day urgent care response

Delivering the ambitions of the national UEC Recovery Plan will mean supporting more patient-centred personalised care, accessed closer to, or at, home – as part of better integrated urgent care services, working together across organisational and team boundaries. This is about ensuring that an individual’s urgent care needs can be met in a timely way from the most appropriate service – ranging from lower acuity episodes that could safely be handled same day within primary care (including through enhanced access), through various models of urgent community response and urgent treatment centres, virtual wards, to (where most appropriate) hospital- based and ambulance services.

Acute emergency care

Reforming acute emergency care helps improve good patient flows, which is central to patient experience, clinical safety and reducing the pressure on staff. Whilst most of this work happens in our five places and through A&E Departments in our main hospitals (supported by the ambulance service), our collaborative work on same day emergency care aims to align with local initiatives through place based urgent and emergency care boards and local provider relationships and partnerships. Although our ambulance service is regionally provided, they are embedded in our places and work with providers to integrate patient pathways, care and treat people in the community and signpost patients to other appropriate services to meet their needs.

Each of our five places has their own programme of recovery and transformation work and are responsible for identifying clear trajectories for delivery against the national plan. During 2023/24 across West Yorkshire, we will:

• Improve A&E waiting times so that no less than 76% of patients are seen within 4 hours by March 2024 with further improvement in 2024/25
• Improve category 2 ambulance response times to an average of 30 mins across 2023/24, with further improvement towards pre-pandemic levels in 2024/25
• Monitor our collective adult general and acute bed occupancy to move us towards the operational planning target of 95.2%
• Consistently meet or exceed the 70% 2-hour urgent community response standard.

West Yorkshire Urgent and Emergency Care Programme Board priorities

The Programme Board has agreed three key areas it will focus on over the next two years, with a focus on those things that will have the biggest impact to enable patients to access care first time and in the right place.

West Yorkshire urgent care services review

We will be reviewing service provision and commissioning of out of hospital urgent care to ensure that:

• The Primary Care Out of Hours service is fit and future proof and that a sustainable West Yorkshire Clinical Assessment model which support NHS 111 is incorporated within the service
• Local provision provided at place delivers local need.

Same day emergency care

As all Same Day Emergency Care services are being implemented in each of our places, we are taking a coordinated approach to Same Day Emergency Care pathways across West Yorkshire. This is to ensure we develop and expand services with direct referral pathways to ensure patients get the right care in the right place first time and to reduce avoidable ambulance conveyance to A&E departments and reduce hospital handover delays.

Supporting Yorkshire Ambulance Service NHS Trust transformation

We are taking a coordinated approach to working with our colleagues in both the 999 and NHS 111 services to produce:

• Integrated work plans to ensure joined up delivery of initiatives and projects both across West Yorkshire and at place in line with strategic direction, local priorities, and planning
• Scoping work with wider partners and places with a focus on key initiatives which aim to improve Category 2 ambulance call out times
• Focus on urgent care pathways and services such as Urgent Community Response to avoid conveyance to A&E Departments
• Implement urgent and emergency mental health response programme for NHS 111 and 999 service in partnership with the Mental Health, Learning Disabilities and Autism programme.

Supporting people leaving hospitals and developing integrated step-up and step-down intermediate care services

To meet the health and care needs of the population of West Yorkshire, it is essential we proactively support people to stay healthy and well at home and in the communities where they live wherever possible, and that we organise services in a way so that people receive care at the right time and in the right setting for their needs. Our approaches to integrated neighbourhood teams and integrated urgent care are major components of this. It is also essential that there are seamless transfers (or transitions) of care when someone moves between care settings (such following a hospital stay back to their own home). Although we have made considerable progress over recent years, we know that there are many instances where across West Yorkshire we could, both improve these transitions – so the care experience feels more seamless to patients and service users – but also ensure if someone does require additional health and care support, it happens in the optimum setting.

Both unnecessary emergency admissions into hospital and unnecessary delays in being discharged from hospital does not result in the best outcomes for people.

Evidence shows that it is better for people, and more cost effective, where clinically appropriate, to spend as short a time as possible in hospital, and to avoid going into hospital when healthcare can be delivered safely in the home environment. To support developments in this area across our Partnership, complementing the wider developments on urgent and emergency care described in the previous section, we have established multi-sector arrangements to explore the next steps in developing the strategic aims and vision for discharge and intermediate care, with a focus on provision of care in communities including social care.

The workstreams and working groups we have for this at system level complement similar arrangements that exist in our five places. A significant amount of development and investment in these areas also happens through the Better Care Fund, for which each ICB place develops a local plan jointly with their local authority partners.

Our ambition is that we ensure the right care at the right time in the right place with a focus on improving the outcomes and experience of discharge and looking more holistically at integrated models of intermediate care. Our challenge in this work is to develop models of care that support people to be discharged to the right place, at the right time, and with the right support that maximises their independence and leads to the best possible sustainable outcomes and experience. It does not just involve our hospitals, but all elements of primary, community and social care.

Our approach includes:

• A clear recognition by all stakeholders of the safety benefits to both people, staff, and organisations of a timely and sustainable discharge
• Despite significant operational pressures, there is strong commitment and wide engagement across ICS, systems, providers, and a focus on the prioritisation of resources to support areas of most need embedding the 'Home First' approach
• Our proposed approach is to support improved outcomes, experience and performance across health and care services.
• This will be based on verified outcomes using data, evidence, input from across the system striking a balance between place, ICS, and region.

The conditions for success for us to achieve our ambition will centre on a focus on an end-to-end pathway, looking at the patient holistically at the centre. Part of this involves considering our future models of integrated intermediate care. This often refers to a short-term, multidisciplinary service that provides support to people who have been in hospital or who are at risk of hospital admission - helping people to recover or rehabilitate at home, or in the community. They are usually provided by a range of NHS, local authority and independent care sector services and should be underpinned by the “home first” principle.

We need to continue the ‘home first’ approach, ensuring that we have both the capacity and capability in communities to facilitate this, this will need to be resourced in financial and workforce terms. To support this work, we will need to rebalance our investment across the system (including in social care) so that we have sustainable community capacity that supports people to live well in their own homes (such as virtual wards as described further below). A number of places in West Yorkshire are already considering their long term economic and workforce models for reshaping intermediate care services, which are described in more detail in the local place plans within the overall JFP.

A relatively recent development within intermediate care has been the growth of virtual ward models of care. These support patients who would otherwise be in hospital to receive care, monitoring and treatment at home or place of residence. This is intended to help prevent avoidable admissions, support earlier discharge, and potentially help contribute to freeing hospital bed capacity for other purposes such as elective recovery. National guidance from NHS England states that “a virtual ward is a safe and efficient alternative to NHS bedded care that is enabled by technology.”

There are two main types of virtual ward

1. Remote: based on technology-enabled remote monitoring and self-management.
2. Face-to-face (‘Hospital at Home’): based on a blended model of technology solutions and in-person care from health professionals, delivering sub-acute level interventions at home. Although these are community models, these are hospital consultant-led ‘virtual wards.’

In 22/23, NHS England set out that all integrated care systems in England should develop and increase virtual ward capacity, with an initial focus on care for those with frailty and with respiratory conditions. National support funding was provided to all ICSs to help with workforce costs and also for additional enabling technology. As per our ICB’s delegated operating model, the development and implementation of virtual wards is led in our five places.

We know that we will need to have continued focus and momentum on the delivery of operational and longer-term transformational change, with a willingness to challenge, be challenged and share good practice. This will require our plans to be co-owned with the support of senior leadership and engaged staff on the ground to drive forward and embed change

Whilst this work will evolve over the coming months, we have an initial ten-point plan for 2023 which includes:

• Exploring the use of our resources across the system differently
• Exploring new approaches to our workforce
• Seven-day discharge
• Looking at the work and resources in the context of capacity and demand of the whole pathway
• Building a strong approach to data quality and understanding variation
• Considering work based on a population approach, looking at specific groups
• Maximising virtual care/wards
• Maximising anticipatory care
• Building work into our place-based plans
• Sharing good practice, developing a resource catalogue

Our ambitions to recover and transform planned care services

The planned care programme encompasses elective recovery, the programme of work to tackle the backlog of planned care appointments and procedures following the coronavirus pandemic; transformation of planned care pathways and services; and clinical threshold policy harmonisation to remove variation in access to services that exists as a result of different policies which existed in the five places of the ICB prior to its establishment on 1 July 2022. The services that are covered by the planned care programme for transformation are those which are identified by the five places of the ICB, the West Yorkshire Association of Acute Trusts (WYAAT) and wider partners from the integrated care system (ICS). Governance of the programme is through the WYAAT programme board, with elements being governed through the Transformation Committee of the ICB where they relate entirely to commissioning decisions.

Elective recovery

Elective recovery meets all three of the criteria for working at West Yorkshire-wide level. Recovery of constitutional targets for waiting is a wicked issue and requires collaboration between our acute providers and places in order that we can achieve our ambitions, and sharing of good practice in ways of working within the trusts enables change and improvement to happen more quickly. The flexibility in use of resources across trusts and the independent sector has supported patients to be offered treatment at alternative providers. It is this collaboration which has enabled West Yorkshire to perform so well in reducing the waiting times for people who had been waiting more than 104 weeks by December 2022, and then 78 weeks by March 2023.

We have established clinical networks through which we will: drive our work to implement the Getting It Right First Time (GIRFT) recommendations for theatre productivity; drive clinical specialty transformation through rapid adoption of best practice across all our acute hospital providers; and support collaboration in our most pressured medical specialties across West Yorkshire to ensure people in all of our places receive treatment in the timeliest way possible. These actions will help us to ensure patients see the right clinician the first time so no appointments are ‘wasted,’ and we can see and treat more people with the existing teams and resources that we have.

Our outpatient transformation work is based on sharing best practice between places and providers to deliver improvements at pace. Each acute provider has its own, well defined projects which address the core priorities in the way that is best for that place, but all are working towards the same core ambitions of: ensuring no one is waiting for outpatient care for more than 65 weeks by the end of March 2024; that where clinically appropriate patients initiate their own follow up if they have concerns, rather than being routinely expected to attend for follow up; and that routine follow up appointments are significantly reduced (by approximately 25%), freeing up these appointments to be used to see people who are still waiting to be seen for the first time.

All places are working on approaches to supporting people who are waiting for elective care, tailored to the needs of the local population. These approaches will be targeted to address the needs of those who need them most, and to help reduce health inequalities or prevent the inequality growing through the long waiting period. These include schemes for waiting well and preparing for surgery including initiatives with the voluntary sector in Leeds and a pilot for a cohort of cancer patients to have remote health coaching and support as they prepare for surgery. Shared decision making and personalisation of care are embedded across the all the work at place and in the programmes.

In 2023-24 our ambition is to continue to increase productivity and treat more people, so that by the end of March 2024 no-one in West Yorkshire will have been waiting for treatment for more than 65 weeks following referral. We will also continue to work to develop and grow the planned care workforce, so we have sufficient, skilled clinical staff to deliver the care required by our population.

Eye care services transformation

With an aging population the demand for eye care is rising faster than many other specialities, and a national shortfall in the number of ophthalmologists meant that a different approach to managing care was required. Our West Yorkshire work programme will draw to a close during 2023-24 as the final objectives are achieved including: complete implementation of electronic referrals in eye care services; final proposals to provide a greater range of assessment and monitoring of eye conditions in the community; and public facing tools and resources to help people look after their own eyes.

Policy harmonisation

Harmonising policy removes unwarranted variation, improves health outcomes by ensuring care is evidence based, and improves patient experience. Work will continue throughout the year and into 2024-25 to harmonise any remaining policies where geographical variation exists within West Yorkshire.

Pathway and service transformation

The planned care programme board will identify future priorities for transformation, based on those challenges which meet one or more of the three tests for working together across West Yorkshire. Over the period of the Joint Forward Plan, we would anticipate delivering two further programme of clinical speciality transformation.

Deliverables

• No patients waiting more than 65 weeks from referral to treatment by March 2024.
• Outpatient follow up activity reduced by 25% by March 2024.

How we will embed personalised care

As a Partnership we continue to embed personalised care into all our services and plans. We already have a long history in delivering personalised care in West Yorkshire, having already achieved the following over the last four years:

• 416,000 personalised care interventions;
• 114,000 patients have had shared decision making conversations;
• 191,000 personalised care and support plans developed; and
• 4800 people trained in personalised care.

We know however there is much more we can do to give people choice and control over their mental and physical health. Our vision is that everyone in West Yorkshire to be able to access high-quality health and care services that have been codesigned to take account of lived experiences and personalised through shared decision-making. The care will be responsive to health inequalities, trauma informed, and respectfully delivered, resonating with what matters most to the individual, their family and unpaid carers, and in support of the community connecting them.

A one size fits all health and care system cannot meet the increasing complexities of people’s needs and expectations and personalised care provides the opportunity to better meet those needs. We also know that training in personalised care approaches, builds confidence in the workforce.

That training supports the development of Personalised Care and Support Plans (PCSP), which must meet these five criteria:

1. People are central in developing and agreeing their plan and who is involved in their care
2. People have proactive, personalised conversations which focus on what matters to them
3. People agree the health and wellbeing outcomes they want to achieve, in partnership with the relevant professionals.
4. Each person has a sharable, personalised care and support plan which records what matters to them, their outcomes and how they will be achieved
5. People are able to formally and informally review their plan

Personalised care in practice with an all age, whole population approach, can be seen illustrated in the diagram on the personalised care section of our Partnership website.

Social prescribing is a key component of universal personalised care. It is an approach that connects people to activities, groups, and services in their community to meet the practical, social, and emotional needs that affect their health and wellbeing.

Social prescribing is an all-age, whole population approach that works particularly well for people who:

• have one or more long term conditions
• who need support with low level mental health issues
• who are lonely or isolated
• who have complex social needs which affect their wellbeing.

In the NHS Long Term Plan, NHS England committed to building the infrastructure for social prescribing in primary care and embed social prescribing and community- based approaches across the NHS.

Unpaid carers

We are committed to continue to support unpaid carers across West Yorkshire with an aspiration to be a region where carers are recognised, given the support they need to both manage their caring role and remain in work and education.

Increasing awareness and support for young carers

We will continue to support young carers being identified especially those who come into contact with NHS 111 and Yorkshire Ambulance Service. We will continue to build awareness of young carers through training resources for staff in education sectors alongside develop young carer champions in schools. We will continue to promote digital app resource created for young carers to enable them to access resources to support them in their caring role and focus on supporting young carers transitioning into adulthood.

Improving the lives of working carers

We will support health and care organisations in West Yorkshire ICS to sign up to Carers Accreditation alongside embedding developed managers guidance to support local policy around supporting working carers. We will continue to promote the health and wellbeing of working carers including those from diverse backgrounds. We will continue to develop targeted communications and resources to increase our reach and identify more working carers.

Better recognition and support in primary and community care

We will improve how we identify unpaid carers and strengthen support for them to address their individual health needs. We will do this by embedding our developed primary care resource packs to increase identification including consistent clinical coding. This work will be further promoted locally by a network of carer champions. We will continue to work with our vaccinations group to champion and ensure carers maintain priority status for vaccinations across the region.

Working with our hospitals

We will develop an offline and digital contingency plan which links to Yorkshire & Humber Care Record to ensure contingency plans can be recorded and accessed in the event of unplanned situations requiring urgent care replacement. We will develop a West Yorkshire toolkit to support unpaid carers being involved in discharge pathways across NHS Trusts to support timely discharges for the people they care, being involved, and prepared for meeting their needs.

Recognising carers as experts in care

We want our workforce to continue to recognise the expertise of carers. Through training and resources to encourage better conversations with carers and their loved ones, acknowledging their role in the triangle of care.

Supporting the mental health/wellbeing of carers

We want to enable patients and their carers to better manage their health and wellbeing. Working with Mental health Trusts and VCSE organisations, we will develop a suite of resources focusing on mental wellbeing support for carers. We will engage with communities to better understand the impact of caring on mental health with a focus on learning disabilities and ethnic minorities to improve outcomes for carers.

This work will be measured in a variety of ways, the number of staff trained, registered working passports, organisations signed up to Carers Accreditation, carer champions within schools, coded carers within primary care, registered contingency plans, engagement statistics of digital app, alongside case studies of carers sharing their lived experiences.

Working in Partnership with the VCSE (Voluntary, Community and Social Enterprise Sector)

One of West Yorkshire Health and Care Partnership’s key strengths is having a vibrant, diverse, and dynamic VCSE sector. Recent research by Durham University estimates that there are:

• 13,930 VCSE sector organisations (registered and unregistered)
• 31,767 full time equivalent employees delivering 52.4 million working hours a year
• 132,214 volunteers giving at least 9.5 million hours of work valued at between £94 million and £132 million a year
• An economic value of £1.4 billion and estimated value of £5.18 billion when considering added and social value.

Nationally, the West Yorkshire Health and Care Partnership is recognised as leading the way in our work with the VCSE, delivered through the Harnessing the Power of Communities Programme (HPoC), including how we have embedded the sector within our governance and decision-making structures, our plans, and strategies, and in how we work together to tackle health inequalities and improve the health and well-being of our population.

Our approach in Harnessing the Power of Communities (HPoC)

• We reflect the VCSE sector through being flexible and adaptable.
• We promote the authentic, community-based nature of the VCSE and share best practice, innovation, and ideas from the sector with health and care colleagues.
• We communicate openly with all stakeholders at ICB and place levels and do our best to engage the wider VCSE, including smaller community organisations
• We respond to changing population health needs and priorities and work to ensure continued and increasing collaboration between the VCSE and health and care
• We build on community assets and place-based development and delivery and ensure the diversity of communities in WY is represented in all we do.

Our vision: For vibrant, sustainable, and resilient communities across West Yorkshire where citizens, the VCSE sector and partners come together to plan, develop, and deliver innovative solutions to improve population health and well-being and reduce inequalities.

Our ambition: To establish the VCSE sector as an equal health and care partner in co-creating and shaping strategies, plans and services and delivering improved health and wellbeing for our populations enabled by long-term joined up investment to deliver consistent, sustainable solutions to reducing health inequalities.

Throughout everything we do, we work alongside our health and care partners to ensure the VCSE sector are fully part of our approach to tackling rising poverty, the cost-of-living crisis and climate change.

As part of the West Yorkshire Integrated Care Strategy and development of the Joint Forward Plan, HPoC has worked with stakeholders to identify 4 key priority areas for specific focus over the next 5 years, to add value and maximise impact. These are:

1. Acute & Specialist Provision
2. Community & Neighbourhoods
3. Access, inclusion, and working with diverse communities
4. Workforce

See our HPoC priorities on a page.

Priority 1: Acute and specialist provision

Across the Partnership, there is a range of strong VCSE activity with a clear evidence base for delivering specialist work including preadmission and those on waiting lists, supporting discharge, and rehabilitation, specialist services and support including for specific long-term conditions. These complement statutory provision often easing pressure on acute and specialist services whilst providing support and care for patients. This includes communities with protected characteristics and those least likely to access statutory services. HPoC will work with the appropriate System level programmes and with Places to build on existing good practice, harness innovation and strengthen collaboration to positively impact on patient health and well-being, specific system pressures and support alternative (often non-clinical, community-based approaches) or provide solutions in the face of growing workforce pressures and system demands.

Priority 2: Community and neighbourhoods

Our local VCSE are often rooted in communities and trusted by them, and much of their work is at a community and neighbourhood level, often focused on minoritised communities. They deliver a diverse range of early help and prevention activity, close to where people live which crucially helps people to stay well for longer and builds resilience. This work builds on the assets in our community and shifts power in a way which emboldens people and communities to take ownership for their own health and wellbeing. It is the work that creates health and wellbeing and addresses the wider determinants of health rather than solely providing services to those who are unwell.

Priority 3: Access, inclusion, and working with diverse communities

Our grass roots organisations reflect the diversity of the communities they serve, helping our ICB reach those least likely to access statutory services. Their voice and influence are critical in ensuring we shape and deliver accessible, inclusive services and support to those who often experience the greatest health inequalities.

In HPoC we use co-production as a key aspect of our approach to ensure community and VCSE voices are heard and help shape services. We are committed to embedding this across the WY system as part of building a community powered health and care system.

Priority 4: Workforce

Current workforce challenges across our Partnership and nationally, including recruitment and retention, and staff health and well-being are shared by the VCSE, but the sector also faces challenges due to short term funding leading to fixed term contracts, low pay, and high demand for services.

Inclusion of the VCSE workforce – including volunteers – is critical in identifying ways forward to tackle current workforce challenges. There are opportunities to create different pathways to employment, to enable movement across sectors, to align our work with volunteers across the Partnership and to ensure when we commission the VCSE, we pay a fair wage and support our VCSE colleagues with access to training and development and well-being support.

How we support delivery of our plans – creating the conditions for success

HPoC have also identified key enablers which create the conditions for a strong and sustainable VCSE sector in West Yorkshire enabling it to maximise its contribution and impact towards our Integrated Care Board ambitions for our population.

These enablers include:

• Joined up, accessible funding for the VCSE
• A shift of investment to prevention
• Strengthening VCSE involvement across the ICB governance structures
• Developing, testing, and sharing a set of measurement tools
• Contributing to VCSE research and data analysis to inform decision making

We will measure and report on the following metrics:

1. Monitor and report on the number of VCSE organisations in West Yorkshire
2. Monitor and report on economic value of the VCSE
3. Monitor and report on NHS investment in the VCSE
4. Monitor ethnic diversity of VCSE advocates on decision making boards at place and at West Yorkshire level.