Priority areas for improving health outcomes for people

Priority areas for improving outcomes

Maternity services

The West Yorkshire and Harrogate Local Maternity and Neonatal System (LMNS) has an ambition to continually ensure maternity and neonatal care is personalised, safe and delivered by kind, competent staff across the whole maternity and neonatal pathway including prevention. The LMNS plan has been developed by women and staff across West Yorkshire and Harrogate and outlines how we will deliver transformation set nationally and by our Partnership.

The LMNS plan describes how we intend to transform and commission services in order to:

• Reduce stillbirth, maternal death, neonatal deaths, and neonatal brain injuries that happens when a baby’s brain doesn’t receive enough oxygen during delivery by 50% by 2025
• Reduce the rates of pre-term birth to below 6 per cent by March 2024
• Ensure that every woman has an individual care plan that is co-created by March 2024

Prior to the pandemic progress was being made against the ambitions, the LMNS has seen a 17% reduction in stillbirths since 2016 which did not meet the target for March 2023 and is not on track to meet the 50% reduction by 2025. Preterm births in West Yorkshire have continued to rise throughout the pandemic, up to 8% of all births are born before 37 weeks gestation. Everyone working in the LMNS is striving to meet the targets set out.

One of the first actions to be taken in year one of this Joint Forward Plan will be a refresh of the LMNS plan now that the Three Year Plan for Maternity and Neonatal Services has been published. The four themes addressed in the guidance are:

• Listening to women and families with compassion which promotes safer care;
• Supporting our workforce to develop their skills and capacity to provide high- quality care;
• Developing and sustaining a culture of safety to benefit everyone; and
• Meeting and improving standards and structures that underpin the national ambition.

Many of the recommendations in the guidance are already being addressed in our current LMNS plan, however this will be reviewed in collaboration with our Maternity and Neonatal Voices Partnerships, Clinical Staff and Stakeholders. Working more closely with neonatal colleagues is a key to improving the outcomes of mothers and infants, the LMNS will work with Specialised Commissioning and the Yorkshire and Humber Neonatal Operational Delivery Network to improve outcomes

Central to all our LMNS transformation and quality oversight is the Maternity and Neonatal Voice. Women as experts by experience will have an equal role in the process of understanding local need and developing innovative solutions to address them and importantly quality oversight of services. We intend to undertake further work to ensure appropriate funding and training is in place for women to undertake this important role. Collaboration with the VCSE will ensure the voice of the seldom reached is embedded in this co production process. The LMNS are also partaking in the new Maternity and Neonatal Independent Advocate role, this helps women and families to be listened to and heard by their maternity and neonatal care providers following a death or where a brain injury is suspected or diagnosed.

Central to the delivery of the transformation to provide the best care for all is personalised care, care is centred on the woman, baby, and her family, based around their needs and their decisions, where they have genuine choice, informed by unbiased information. A key to delivering personalisation is the implementation of midwifery continuity of carer particularly for those at greatest need.

Our biggest challenge is workforce, the newly developed Maternity Workforce Strategy outlines the LMNS plans in order to become the place of choice for maternity staff to work, ensuring maternity and neonatal staff are listened to and supported to deliver the best possible care. Central to the implementation of the plan is compassionate leadership to ensure psychologically safe cultures,

To support the Maternity Workforce Strategy and Personalisation agenda the LMNS will become a trauma informed system. Adversity and Trauma are more prevalent amongst those in our society who already suffer from poorer health, poverty, inequalities, and other disadvantages. This strengths-based, trauma informed, and responsive approach will embed the trauma informed principles (safety, trust, choice, collaboration, empowerment, and cultural consideration) which will ensure maternity services across West Yorkshire are physically and psychologically safe for all who work in them and women and families in their care. A trauma informed approach will empower women to re-establish control of their lives during their pregnancy and beyond.

Addressing inequalities and focusing on prevention is core to our work. The LMNS needs assessment and Equity and Equality Plan published in 2022 sets out our plans and priorities for the next three years to reduce inequalities Our priorities include ensuring data has a deprivation and ethnicity lens to understand performance and inform transformation priorities, a new inequalities dashboard has been developed to support this action. Delivery of the LMNS Public Health Recommendations is key to the success of the programme.

The impact of poverty is already evident in the LMNS, having been seen in reviews undertaken of serious incidents. To address this, we are working closely with the VCSE, linking with food banks, ensuring access to freephone numbers, working with local transport services, and delivering care close to home to try and mitigate these challenges, ensuring that we continue to evaluate these approaches as we develop.

The LMNS will continue to address clinical variation, share best practice, and learn from incidents. The Perinatal Quality Surveillance Model is embedded at Place and System.

The LMNS will support trusts to implement their digital strategies and develop the system interoperability plan. Giving access to all information available means healthcare professionals will be able to provide more focused, individualised care and therefore improve the experience for the woman and her family.

Throughout our work we will align to the West Yorkshire Climate Change Strategy, supporting sustainable practice.

Supporting our children, young people, and families

Supporting children, young people, and families in West Yorkshire is a top priority. Unfortunately, the Covid-19 pandemic and rising living costs have led to widening health inequalities among children and young people in the region. The Child of the North Report 2021 revealed the stark reality of these inequalities, including higher rates of obesity, poverty, low-income households, infant mortality, missed schooling, mental health challenges, and increasing numbers of children in care.

In West Yorkshire, children and young people are more than twice as likely to live in the most deprived areas compared to the national average. For those aged 18 and under, the odds increase to almost three times higher. A significant portion (28.7%) of our 0-18 population resides in the most deprived areas. Various factors intersect to impact our communities, with a notable percentage of children and young people from Black, Asian, and Minority Ethnic backgrounds living in deprived areas. This exacerbates educational inequality, poor health outcomes, limited access to services, and an increased sense of loneliness among affected populations.

Furthermore, domestic violence, food instability, access to health and care services, especially for complex needs and long-term conditions, varies across the West Yorkshire region and seasonal pressures pose additional challenges especially during unprecedented workforce gaps. Data from National Health Service England (NHSE) also highlights the growing backlog for elective care, and a review of data for Children and Adolescents Mental Health Services (CAMHS) in West Yorkshire shows an increasing demand for support.

Diagnosis waiting times for autism spectrum disorder and attention deficit hyperactivity disorder in children and young people are a concern and the gap between initial assessments and follow-up plans is a challenge. We recognise the further opportunities for integrated working the Health and Care Bill 2022 brings across all sectors in West Yorkshire to address these challenges.

Existing priorities

To address these outlined challenges, we have an ambition to close the gaps in health and wellbeing outcomes for all children and young people across West Yorkshire no matter where they were born, where they live or where they go to school. The vision to realise this ambition across West Yorkshire is ‘All children and young people will have the best start in life and the support to be safe from harm, enjoy healthy lifestyles, do well in learning and have skills for life.’ Which is in keeping with the West Yorkshire Health and Care Partnership’s 10 Big Ambitions.

Design conversations with key stakeholders including the mental health, learning disability and autism teams, and young people themselves have helped further define the priorities for children and young people across West Yorkshire. National policy, statutory requirements and local data for West Yorkshire have further informed the strategic priorities which include: Best Start and Healthy Weight, Family Resilience and Early Help, Children’s Healthcare in the community, Complex Needs and special educational needs and disabilities (SEND) and Long Term Conditions.

An overarching strategic ambition to ensure the voice of children, young people and their families influences decision making remains a golden thread for the work.

Strategic objectives

To meet our goals for children and young people in West Yorkshire, we have several strategic objectives which are delivered through integrated working and co- production with communities:

1. Focus on providing the best start and promoting healthy weight. This includes working together across West Yorkshire to share knowledge on pre-conception and early years, reducing variations in outcomes. We will focus on areas such as maternity and neonatal care, health and nutrition, oral health, language and communication, social and emotional development, and addressing issues related to excess weight and obesity.
2. Build family resilience and provide early help. We will connect with various sectors in West Yorkshire to align our approaches and share good practices in prevention, assessments, and early intervention. We aim to support looked after children, reduce variations in early interventions, provide collaborative training opportunities, and help families and communities develop skills to support one another.
3. Improve children's healthcare in the community. We will collaborate on designing and influencing new models of care to reduce unplanned admissions to hospital care. Emphasis will be placed on using digital devices and technology to provide care closer to home, developing a future-ready workforce, designing specialist palliative care services, and learning from ambulatory pathways.
4. Develop equitable services for complex needs and SEND. We aim to create a coordinated approach across West Yorkshire, reduce variations in outcomes, and ensure statutory requirements are met. We will support a collective approach to early diagnosis of complex needs and SEND, working with the Mental Health, Learning Disabilities and Autism (MHLDA) service.
5. Deliver improvements for children and young people with long-term conditions. We will collaborate to share best practices across West Yorkshire, reduce variations in outcomes, provide equal access to technology and services, focus on transition periods, and learn from audits.

These strategic objectives align with the principles of subsidiarity, which involve sharing best practices, working at scale for better outcomes, and addressing complex problems collectively. Additionally, we have strategic objectives related to the mental health of children and young people. These objectives are carried out in collaboration with the West Yorkshire Mental Health, Learning Disabilities and Autism Provider Collaborative and West Yorkshire ICB MHLDA Programme.

This ensures parity of esteem between physical and mental health. Initiatives include supporting the mental health needs of children and young people in acute settings and enhancing experiences through a youth worker function for CYP and their families.

There is clear alignment to the 10 Big Ambitions across West Yorkshire as we aim to address health inequalities in deprived communities by providing comprehensive support services for families from conception to early adulthood. Collectively in West Yorkshire we are using an integrated working approach, we focus on poverty- proofing and collaboration with the Improving Population Health Programme. The goal is to become trauma-informed by 2030, supporting children, young people, and families. Efforts include the "Project Hope" career development initiative for care experienced young people and addressing asthma-related challenges by improving air quality through working in collaboration with housing.

Delivery plan

To achieve our ambitions, we need to continue to work together with various partners and adopt a collaborative approach. The children, young people and families function will play a key role in delivering our plan. In the first year, we will continue our ongoing work in alignment with our strategic priorities. Some of the deliverables for Year One include:

• Providing a specialised services for 100 patients a year with weight-related complications
• Running a career development project call ‘Project Hope’ to help we care experienced young people find employment in the health and care sector
• Launching an online parenting support research initiative and supporting implementation across health and care sectors
• Development of a ‘Healthier Together’ website that offers digital information on access to health and care services, including promoting physical activity
• Developing an outcomes framework to reduce variation in SEND
• Continuing delivery against the asthma care bundle for children and young people, with a focus on health and housing connections and asthma-friendly schools
• Launch of digital platform ‘vCreate Neuro’ for children and young people with epilepsy across West Yorkshire’s Acute NHS Trusts
• Harmonisation for the continuous glucose monitoring (CGM) policy for diabetic patients.

In Years Two to Three, we will build on our existing work in alignment with our strategic priorities. Some of the deliverables for this period include:

• Reviewing oral health provision, mapping prevention activity and support joint commissioning opportunities of the epidemiology survey
• Establishing a 24/7 palliative care service for children and young people
• Supporting the design of virtual ward pathways by sharing best practice
• Improving pathways for children and young people by sharing best practice
• Support implementation of harmonised policy for CGM devices
• Support increase access to epilepsy and diabetes specialist nurses and clinical pathology services.

Tackling antimicrobial resistance

Antimicrobial resistance or AMR for short, happens when microbes (bacteria, fungi, or viruses) find ways to stop medicines like antibiotics working, making infections harder to treat. Many lives are lost to drug-resistant infections with potential to spread to other people; and this is happening more often. The World Health Organisation has declared AMR to be one of the top 10 most urgent global public health threats facing humanity.

Governments, scientists, and clinicians around the world are acting to tackle this issue. The first five-year UK AMR National Action Plan (NAP) launched in 2019, to help move towards the 20-year vision of containing and controlling antimicrobial resistance by 2040.

Here in West Yorkshire, our health and care partnership recognised the importance of AMR prevention and selected it as one of its 10 big ambitions.

Our action plan sets out how we will contribute to the national plan, and our strategy will follow the next set of national priorities - and show what we hope to do to tackle AMR locally over the next five years.

We will deliver our strategy with a steering group made up of front-line healthcare workers, managers, and academics from our five partnerships, working on challenges and issues related to AMR. Members also work together in small groups, transforming ambitions into actions across subjects like Antimicrobial Stewardship (using medicines like antibiotics better), Infection Prevention Control, data, and environment and sustainability.

Our action plan has four themes:

1. Reducing human infections

Drug resistant microbes spread between humans, animals, and the environment. We know that there is a link between deprivation and the number of infections. Many people are at increased risk of infections, particularly from bacteria called E. coli that can cause infections of the bloodstream. As urinary tract infections can cause E. coli bloodstream infections, preventing these is important.

In recent years, we have produced information to support unpaid or social care carers to recognise signs of E. coli infection and sepsis - a life-threatening condition that requires emergency hospital admission. We share resources within the regional Hydration Network and have developed a series of AMR animation videos; each providing education about AMR and outlining steps we can take to keep healthy, prevent infection and reduce drug-resistant infections.

We will continue to take collective action to minimise rates of bloodstream infections, and other healthcare associated infections, across West Yorkshire.

2. Appropriate antibiotic prescribing

We want to improve people’s lives by supporting healthcare professionals to prescribe the most appropriate antibiotic (the right antibiotic, delivered in the correct way, within the correct time, for the correct duration – and only when required). We will continue to produce guidance like a remote prescribing pathway and improve access to appropriate antibiotics and alternatives. We will report on the percentage of prescriptions supported by a diagnostic test or decision support tool by 2024; and by 2025, will set targets to provide a vision for improvement. And to encourage this, we will work in collaboration with the Academic Health Science Network (AHSN) to use point of care testing better. We will work with primary care partners to improve prescribing, provide education, and support general practice. We will also regularly review prescribing tools and support WY Research and Development group in delivery of the Lowering Antimicrobial Prescribing (LAMP) programme of a clinical audit and feedback.

In addition, the Pharmacy Quality Scheme (PQS) effectively promotes our work in community pharmacies, with many in West Yorkshire participating and producing antibiotic action plans, with a workforce committed to be Antibiotic Guardians. We have also celebrated the success of the Leeds Seriously campaign and promoted its messaging in other areas; to create awareness and a shift in understanding so that antibiotics are viewed as an advanced treatment for serious and not self-limiting illnesses and not an everyday option. We will deliver annual activity to raise awareness and understanding of infection prevention, educate about AMR, promote appropriate antibiotic use, and encourage alternative treatments.

3. Increasing Workforce Capacity

A clear understanding and plan of the current workforce is required for infection teams to maximise workforce capacity. In social care settings, there needs to be sufficient time for care staff to provide for patient’s needs, including those around prevention and antimicrobial stewardship. Without this, there is a risk that infection management won’t happen. Over the next 5 years, we will work together with providers to put the National Infection Prevention manual into action and increase workforce capacity.

4. Learning from Covid-19

The Covid-19 pandemic has changed the landscape of healthcare, presenting consistent challenge and demand. As we continue to support recovery, we gain more understanding of changes in healthcare delivery and management of suspected infections. Over the next 5 years, we will continue to review and mitigate the impact of the pandemic and other external factors on antibiotic prescribing.

Our system

We will build relationships and networks, so we can do more joined-up working on AMR between primary care and providers in public health, acute care, community services, mental health, out-of-hour GP collaboratives and out of hours dental providers, and education. The AMR group will work with existing medical, dental, pharmacy, nursing, health informatics and other professional networks across the system. This is likely to include further exploration into the wider determinants of health and embedding action to ensure that our citizens and healthcare professionals recognise the environmental impact of antimicrobials and take action to reduce carbon footprint.

Mental health, learning disabilities and autism

Across West Yorkshire everything that our providers do contributes to our ambition to reduce the gap in life expectancy between people with mental health conditions, learning disabilities and/or autism and the rest of the population. Strong family and friendship connections, good quality employment and safe, healthy accommodation are vital. Our work across West Yorkshire covers– service delivery and improvement, alongside the culture change needed so that all partners focus on the holistic mental and physical needs of people and communities.

We remain committed as a system to ensuring parity of investment in mental health, delivering the Mental Health Investment Standard as a minimum but continually seeking ways to ensure that support for mental health, learning disability, autism, and attention deficit hyperactivity disorder (ADHD) is prioritised; particularly to reduce inequalities and unwarranted variation in access to care and outcomes.

Each of our five places has their own programme of local transformation work and are responsible for identifying clear trajectories for delivery against the national priorities. As such during 2023/2024 across West Yorkshire we will:

• reduce our use of inappropriate out of area placements towards the national ambition of ‘0’
• increase our use of NHS Talking Therapies so that at least 69,000 people access services
• increase the number of women accessing specialist Perinatal Mental Health services to over 2,300
• deliver a Dementia Diagnosis Rate of over 67%
• delivery at least 75% of Learning Disability Annual Health Checks
• deliver at over 27,000 occasions where people received two or more contacts from Community Mental Health Teams
• deliver at least 34,000 occasions where Children & Young People receive at least one contact from CYP Mental Health services
• ensuring for those people who are autistic, have a learning disability or both that:
  • no more than 30 adults are in inpatient beds commissioned by the ICB
  • no more than 19 adults and in inpatient beds by NHSE or the provider collaborative
  • no more than 8 children and young people are in inpatient beds commissioned by NHSE or the provider collaborative.

In addition to the above, our West Yorkshire Mental Health Learning Disabilities and Autism (MHLDA) Provider Collaborative is accountable for delivering services across West Yorkshire and beyond, ensuring the quality of all services provided. This includes for:

• Adult eating disorders – improving management of complex needs in inpatient and community settings, treating more people at home and ensuring safe and effective monitoring of physical health within the community
• Adult secure services – developing a consistent community offer, reducing placements outside of natural clinical flow and better awareness of West Yorkshire wide capacity and demand
• Tier 4 children and young people’s mental health – further reducing the number of young people receiving hospital treatment outside of West Yorkshire and reducing length of stay
• Forensic child and adolescent mental health services (CAHMS) – ensuring the smooth transition of the Yorkshire and Humber Community Forensic CAMHS Service into provider collaborative arrangements and developing the service to include enhanced training offers, improving feedback mechanisms and reviewing the current workforce composition
• Assessment and treatment units for learning disability – strengthening clarity on clinical decision making and escalation processes and reviewing assumptions about the existing inpatient model.

Through our West Yorkshire MHLDA Partnership Board, we also have several agreed transformation priorities for the whole system, agreed by all of our five places. These are:

• Learning disabilities – delivering our health inequalities challenge to raise awareness of the inequalities faced, supporting the roll-out of Autism friendly wards, the development of keyworker roles for Children and Young People and reviewing our current approaches to LeDeR (Learning from Deaths of People with a Learning Disability)
• Children and young people’s mental health – developing services, training, and pathways for eating disorders/disordered eating, improving the regularity of effective transition to adult services, access to 24/7 crisis support, implementing risk registers in line with Dynamic Support Registers and benchmarking our self- harm pathways against National Confidential Inquiry into Suicide and Safety in Mental Health recommendations
• Adult mental health pathways – establishing a system mindset for our Psychiatric Intensive Care Units to help reduce out of area placements, delivering the requirement for people to be able to dial NHS111 in mental health crisis and support quality and enhancing quality & safety within adult acute inpatient units
• Community mental health transformation – developing new and integrated models of primary and community mental health care, developing our approach to eating disorders/disordered eating in the community and meeting the needs of older people and young people transitioning into adult services
• Neurodiversity – improving consistency in neurodevelopmental service provision including how we collect and use data, improving the availability of needs led, holistic support, implementing the right to choose consistently and ensuring that co-production is at the heart of all the work we do
• Older people’s mental health – improving support following a dementia diagnosis, improving access to talking therapies for older adults and networking the system together to promote equity for the older adult population
• Complex rehabilitation – to develop a complex emotional needs pathway, continue the roll-out of the Complex Rehabilitation Enhanced Support Team (CREST) and develop a collaborative approach to the commissioning of inpatient beds in WY for people with complex rehabilitation needs
• Perinatal mental health (PMH) – to improve the understanding and awareness of Perinatal Mental Health in specific communities, reducing barriers to access and support, taking learning from the Maternal Mental Health Services pilots into a finalised model and mobilising the PMH provider collaborative for Yorkshire & Humber
• Workforce – Increasing diversity in the workforce across the Mental Health Trusts, establishing an ethnical migratory pathway for Mental Health Nursing and Consultant Psychiatrists and establishing a non-medical collaborative bank across the Trusts
• Data and intelligence - improving collaboration between Trust BI teams, places, and the system, mapping current capabilities and capacity and linking this to the national strategic direction
• Wider determinants and inequalities – increasing collaboration across specialist MH services, local authorities, and physical healthcare, supporting Mental Health Trusts to implement the objectives of the Patient and Carer Race Equality Framework, and enhancing support to health promoting activities.

Creativity and health

Finding new and innovative ways to support our population to have happier healthier lives is important to us in West Yorkshire and we want to have an active, vibrant, creative health sector. Our work to use creativity to support this is an important element of our work. It is proven to:

• Keep us well, aid our recovery and support longer lives better lived
• Meet major challenges facing health and social care: ageing, long-term conditions, loneliness, and mental health
• Save money in the health service and in social care through building health producing and better-connected communities.

As a national leader in creativity and health, we already have good examples of where we have made a real difference through using a creativity and health approach, for example our Calderdale Creativity and Health Programme working with South West Yorkshire Partnership Foundation Trust and Creative Minds. We know that expanding this learning could help us create stronger, healthier, more resilient communities through working at a population health level. We know that it will support us in delivering targeted interventions addressing the greatest health disparities and importantly, be part of a transformation in the way health and care services look and work for everyone.

We will continue to work with the National Centre for Creative Health (NCCH) who are working in partnership with NHS England on a programme of developing a programme of Creative Health Hubs, of which West Yorkshire is one of four nationally. We have been working with NCCH to:

• Capture the stories and learning from Creativity and Health in West Yorkshire, pulling together networks in each of our places and across West Yorkshire; articulating these so that they and their wider partnership groups can effectively advocate at a national level
• Map and evaluate the level of health and care sector investment in arts/ creativity/ cultural projects across the ICS to inform future funding/ commissioning opportunities and to frame future investment discussions with Arts Council England
• Develop a plan of how the learning and successes of how Creativity and Health work could be scaled or replicated. With many successful cultural events already having been held there are still many others to come, including Kirklees Year of Music 2023, Leeds 2023, Calderdale Year of Culture 2024, Wakefield Year of Culture 2024, and Bradford 2025. This alongside strong strategic interest from the Arts Council, there is a significant opportunity to advance this work to the benefit of all of our communities and with tangible benefits for our health and care system.

Our position as one of these four Arts and Health hubs in the country reflects the pioneering work of (among others) Creative Minds, HOOT, Leeds Arts Health, and Wellbeing Network (LAHWN) over the last ten years alongside the support, passion and dedication of our system leadership including a national role on Creative Health.

The acknowledgement also reflects the outstanding, diverse work in each of our places we have been supporting and sponsoring work across West Yorkshire utilising creative approaches to addressing health inequalities. We have been working with the National Centre for Creative Health, Arts and Humanities Research Council and the University of Huddersfield to mobilise and connect creative health networks in place and across West Yorkshire and are working with Arts Council and the WY Mayor’s Office to develop a new, sustainable infrastructure for Creative Health in West Yorkshire bringing together the academic, health and cultural sectors.

This cross-sector approach will help us:

• Create a sustainable creative health sector that helps our health and care systems to address some of our trickiest issues and is equitable, accessible and co-produced with our communities
• Produce better supported, developed and healthier, happier workforces in our health and cultural sectors
• Design a system driven by innovation where creative solutions are used to reduce health inequalities, lead system change, improve how our spaces look and feel and how we communicate and ultimately save the health and care system money
• Work with systems and communities to ensure arts, culture and creativity are embedded by our citizens in their everyday lives and incorporated into health sector approaches results in longer lives better lived and stronger, more connected communities.

Examples of where this work is having significant success:

• Six-month trial of a creative workforce (8FTE) working across SWYPFT acute wards, providing an expanded workforce, more creative opportunities, 1:1 work, creative care planning and an integrated approach linking to Social Prescribing and cultural assets for people approaching discharge
• the Lullaby Project in Calderdale, creating unique lullabies for those suffering or at risk of suffering post-natal depression.
• work with care homes, providing opportunities and Music in Care accreditations for staff.
• the development of a creativity app to provide everyday creativity opportunities for everybody in our population.
• working with the acute hospital to explore how storytelling, theatre and advocacy for staff and patients might lead to system change
• working with people with lived experience and artists to re-design the health check process for people living with serious mental illness

Living with long term health conditions

The NHS define a long-term condition ‘as a condition that cannot at present be cured but can be controlled by medication and therapies.’ These conditions require ongoing management over a period of years.

Our programme’s aim is to support people with long-term conditions and their unpaid carers to live well.

Diabetes

We deliver across West Yorkshire the national programmes to prevent both the onset of, and improve the lives of people living with, diabetes. Whilst type 1 diabetes cannot be prevented, type 2 diabetes is largely preventable through lifestyle changes.

Prevention

The Healthier You: NHS Diabetes Prevention Programme supports patients identified as at high risk of developing Type 2 diabetes through a behaviour change programme. Over the course of 9-12 months, group sessions help patients achieve a healthy weight, improve nutrition, and increase their levels of physical activity. We will work to continue to support our places to increase referrals to the Programme.

The NHS Type 2 Diabetes Path to Remission Programme, is a programme that provides a low calorie, total diet replacement treatment for people who are living with type 2 diabetes. Eligible participants will be offered low calorie total diet replacement products for 12 weeks, during this time all meals are replaced with this product.

Alongside this, participants will receive support and monitoring for 12 months. We will work to continue to support our places to increase referrals to the Programme.

Treatment and care - We are working to ensure that the treatment patients receive follows National Institute for Health and Care Excellence (NICE), best practice guidelines.

Monitoring and management – We will work to implement NICE guidance to ensure wider access to Flash (a glucose monitor) and continuous glucose monitoring for people living with diabetes. These work by enabling patients to check sugar levels without having to prick their fingers. We will prioritise this monitoring to vulnerable populations and those at risk of health inequalities. We will continue to invest in workforce training in personalised care. Personalised care will involve using personalised health budgets where appropriate to support individuals to manage their condition.

Digital and innovation – ‘Healthy Living’ is a free, online NHS ‘app’ that support people to live well with type 2 diabetes. The resource is also available for those who care for someone living with type 2 diabetes. We are working to increase uptake of the app.

Staff training – we are working to increase usage of the Cambridge Education Programme This provides training for health and social care workers to improve knowledge and promote patient care.

We recognise the importance of data to monitor our work and progress. We will continue to use local and national dashboards to ensure we target our resources to have the greatest impact.

We will continue to raise awareness to support people to understand their risk of developing diabetes and other long-term conditions. We will build on success of previous West Yorkshire diabetes awareness campaigns to bring easy to understand health information to local communities.

Our aim is that patients are involved in discussions about their care and management, as evidence shows that managing care in this way can lead to the most appropriate use of limited resources.

Stroke

The NHS Long Term Plan (2019) identified stroke as a clinical priority for the next 10 years.

Integrated Stroke Delivery Networks (ISDNs) are the vehicle for transforming stroke care across the country. Their aim is to

• Prevent patients suffering a stroke through improved diagnosis and access to treatments in 24/7 specialist stroke units
• Increase the availability of high-quality rehabilitation and ongoing community care to rebuild patients’ lives after a stroke.

The ISDN will do this by bringing together key stakeholders to facilitate a collaborative approach to improving the entire stroke pathway and ensure a patient centred, evidence-based approach to delivering transformational change.

Health inequalities – We will use data to aid the completion of a stroke specific health needs assessment. A programme of work will follow, designed in collaboration with places to address the priorities identified, and using co-creation workshops to progress developments.

Prevention - We will work with local primary care networks to ensure strategies are in place to identify those at risk of stroke, and work to prioritise assessments for patients with cardiovascular disease (CVD) risk factors.

Diagnosis - We will collaborate with partner organisations across the network to raise awareness of stroke symptoms and to standardise triage tools and pre-alert processes. Our aim is to increase access to imaging within one hour. We will work with the Yorkshire Ambulance Service and our acute trust colleagues to trial stroke telemedicine, and we will collaborate with partners to understand current Transient Ischaemic Attack pathways and services, identifying areas for improvement in pre and post hospital settings.

Treatment - We will work with our local acute trusts to improve access to thrombectomy services across West Yorkshire, ensuring a regional mutual aid agreement is in place and working towards the delivery of the National Optimal Stroke Imaging Pathway. We will collaborate with our partners to improve the entire acute stroke pathway, ensuring parity of access to assessment and treatment for everyone within our local places.

Rehabilitation and life after stroke - We will collaborate with partner organisations across the NHS, social care, and the voluntary sector to ensure equity of service and access across the entire stroke pathway, providing a seamless experience for people affected by stroke, irrespective of their locale or social background. We will continue to work in coproduction with people affected by stroke, using their lived experience to codesign the optimal recovery journey, personalised to individual need.

Workforce, education, and training - We will employ an integrated approach to workforce development, merging stroke-specific and professional practice education with training opportunities that encompass all staff involved in the delivery of effective, safe, and compassionate stroke care, including those from the voluntary sector.

Cardiovascular Disease (CVD)

CVD causes a quarter of all deaths in the UK and is the largest cause of premature mortality in deprived areas. The NHS Long Term Plan identified CVD as the single biggest area where the NHS can save lives over the next 10 years.

CVD can often be prevented by leading a healthy lifestyle. Spotting risk factors early reduces the chance of developing potentially life threatening conditions including heart attacks, stroke, and dementia.

We are working to increase both the number of annual health checks and their quality; people aged over 40 years should have their estimate of CVD risk reviewed every five years. We will focus on high-risk groups such as those living with learning disabilities/severe mental health.

We are working to ensure that the treatment patients receive follows National Institute for Health and Care Excellence (NICE), best practice guidelines.

High blood pressure rarely has noticeable symptoms, but if untreated increases risk of serious conditions such as a heart attack or stroke. The only way to find out if your blood pressure is high is to have your blood pressure checked. Through approaches such as ‘making every contact count’ we are working to reduce the number of people with undiagnosed/untreated high blood pressure to pre-pandemic levels. We intend to undertake targeted work to reduce variation.

We are aiming to increase the availability of workforce training on CVD and embed a personalised care approach.

Work in this area will involve proactive case management to target specific groups e.g., working aged men, Familial Hypercholesterolaemia and undertake the West Yorkshire targeted health check project driven by Core20Plus5.

Atrial Fibrillation (AF) is a condition that caused an irregular and often fast heartbeat. We are working to increase the number of people identified with AF and subsequently treated.

We will work to support implementation of national guidance for cholesterol management for primary and secondary prevention of CVD.

We will work to educate communities about CVD prevention and empower them to take action. We will support national campaigns e.g. Know your numbers, Blood Pressure UK to encourage patients to check their blood pressure.

Cancer

As an ICB ambition, we are committed to ensuring that by 2024, 1,000 more people should have the opportunity for curative cancer treatment than was the case when the strategy was originally set. Working together, we are making good progress towards achieving our ambition, which sets the context for our Joint Forward Plan covering the period up to and including 2028.

Cancer continues to be a major population health priority for the ICB because 1 in 2 people are expected to have cancer at some stage of their lifetimes, with outcomes continuing to be worse than international comparisons and strongly affected by health inequalities. Almost every family locally will have been touched by this condition. For an increasing number of people affected by cancer, the disease will become a chronic condition, which will significantly affect the type, range, and duration of support they will need to care for them as individuals. It is vital that our focus as an ICB reflects the ongoing needs of people affected by cancer as new, innovative, and more personalised, forms of care and treatment increasingly become available.

This means that our vision for cancer care in West Yorkshire is that we transform services so that cancer care, treatment and support is wrapped around each individual patient throughout their entire care journey – from awaiting diagnosis, to treatment options, to discharge where appropriate, end of life care where needed, including living with and beyond cancer.

The West Yorkshire and Harrogate Cancer Alliance is a hosted, non-statutory body which sets system-level strategy and oversees transformation work in this area towards achieving this vision, reflecting both national priorities and responding to local need. As a body, its purpose is to bring partners together to transform outcomes, with specific areas of work focussing on improving patient and carer experience of cancer care improving patient and carer experience; reducing health inequalities; harnessing networks for better treatment outcomes; adopting innovation and new models of care; and developing our people .

You can find out more about our work with the Cancer Alliance via their website or by checking out social media. These social media feeds also includes details of information for patients about cancer signs and symptoms and links to other trusted sources of information.

• Twitter
• Facebook
• LinkedIn
• YouTube

Financial resources are provided to the Cancer Alliance by the National Cancer Programme of NHS England. The Cancer Alliance determines how these financial resources are used, via an annual delivery plan and a programme board, comprised of partners from primary care; secondary care; the academic health science network; the voluntary, community and social enterprise (VCSE) sector; and lay representatives. This plan is agreed with the ICB each year and details of achievements are published in its Annual Report.

Linked to the above, the ICB has set two main strategic goals for the Joint Forward Plan for cancer in West Yorkshire. Both strategic goals require the ICB to work collaboratively with other linked programmes and other colleague organisations within the broader Health and Care Partnership.

Strategic Goal 1: Reduce the incidence of avoidable cancer by acting with our partners to change population behaviours1.

Strategic Goal 2: Increase one-year survival from cancer from 70 to 75%, and early- stage diagnosis to 62%, as a first step towards the goal set out in the NHS Long- Term Plan2.

Our Joint Forward Plan for 2027/28: Achieving success

By the end of the 2027/28 financial year (year 5) and the end point of the Joint Forward Plan, the Cancer Alliance will have supported the West Yorkshire Integrated Care Board, and its constituent members and partners to have achieved the following improvements for people affected by cancer in West Yorkshire.

For clarity, each of the following priorities has been adopted into the five West Yorkshire Place based strategies for cancer. The implementation timeline for each goal, in each Place, commences in either year 1 (2023/24) or year 2 (2024/25) of the plan – details of which are covered in the Delivery Plan for the Cancer Alliance – all priorities are referenced against the strategic goals.

1. Lung health checks: All residents in West Yorkshire and Harrogate who have either ever smoked, or smoke currently, will have been invited to undertake a lung health check if aged between 55 and 74 (Strategic Goal 1).

Why is this important?   Lung Health Checks will reduce avoidable cancer mortality in the medium and longer term.

2. Smoking cessation: The adult smoking rate in West Yorkshire and Harrogate will be 13% or less (Strategic Goal 1).

Why is this important? By supporting the efforts of our population health and local colleagues, we will be able to reduce avoidable cancer mortality in the medium to longer term. We will specifically support this goal through incorporating this focus into lung health checks and secondary influencing opportunities; supporting all tobacco control boards locally; encouraging local teams to invest in this area via Core20Plus5 recurrent funding and other commissioning opportunities; and by undertaking specific promotional campaigns highlighting the benefits of smoking cessation.

3. Earlier presentation: We will have met and exceeded the ICB ambition for 1,000 more patients to have access to curative treatment; improved population awareness of cancer signs and symptoms; and be continuing to close the health inequalities gaps in our system (Strategic Goals 1 & 2).

• Nearly 4 out of every 10 cancers are preventable via simple changes to lifestyle such as stopping smoking; eating more healthily; becoming more physically active; avoiding excessive alcohol intake and substance misuse; adopting safe sun-care; and working to improve air quality.
• There are a range of measures being developed to seek further acceleration of this early-stage goal. For more information.

Why is this important? The sooner patients present, the more likely we are to be able to diagnose their cancers at an earlier stage. This directly relates to improving survival.

4. Faster diagnosis: At least 4 in 5 people receiving either a diagnosis of cancer, or an exclusion of cancer, within one month of being referred with cancer symptoms (Strategic Goal 2).

Why is this important? Avoiding unnecessary delays in cancer diagnosis is essential to improved patient experience. The vast majority of people referred to cancer services do not have cancer, so we must reassure those people at the earliest possible stage.

5. Best treatment, sooner: At least 95% of people receive cancer treatment within one month of a decision to treat being made. No more than 1 in 20 people on our cancer patient tracking list are waiting more than two months in total for a first definitive cancer treatment to take place after being referred for urgent cancer symptoms by their GP (Strategic Goal 2).

Why is this important? When people are diagnosed with cancer, it is essential that the right treatment plan for that person, agreed with them, is initiated at the earliest possible stage.

6. Personalised care: We have a fully embedded system for genomics testing in West Yorkshire and Harrogate, reflecting national strategy aims; all suitable patients have a personalised care support plan (PCSP) and benefit fully from the living with and beyond cancer programme (Strategic Goal 2).

Why is this important? Cancer care in the future will become more personalised around the needs of the individual and what we know around what types of treatment are most likely to be effective. It is essential that we care for the whole person affected by cancer, not just treat the disease itself.

7. Innovation: Alongside an enabling innovation pipeline, we will have transformed cancer diagnostic management by introducing asymptomatic and symptomatic blood test screening for the local population, based on service evaluation and clinical trial evidence (Strategic Goal 2).

Why is this important? This type of innovation will help those people who may not realise that they have cancer enter care services sooner, improving outcomes as a result.

8. Highly effective collaboration: We will bring patient experience to the heart of what we do by developing and extending our partnership working. We will expand our reach and connection across the Partnership, further expanding opportunities to work with primary care, research and the VCSE sectors as priorities (Strategic Goals 1 and 2).

Why is this important? Working together as a system, breaking down silos, means that we can act on the barriers which prevent people from getting the best possible cancer care and treatment.

The ICB has also set metrics to allow progress towards the delivery of the headline ambition, the two main strategic goals and the linked priorities, to be tracked effectively. These metrics are as follows:

Planned Performance (%) by Year
Metric	Current	2023	2024	2025	2026	2027	2028
TLHC*: Population roll out (Target 100%)	55.0%	62.5%	70.0%	77.5%	85.0%	92.5%	100%
Early Stage at Diagnosis**: (Target 62%)	54%	55.3%	56.7%	58.0%	59.3%	60.7%	62.0%
Faster Diagnosis Standard*** (Target 75%)	75.0%	76.0%	76.0%	77.0%	78.0%	79.0%	80.0%

 

*TLHC = Targeted Lung Health Check (TLHC). This involves inviting people with a smoking history (either current or historical) to have an assessment and low dose CT scan to check for signs of early-stage lung cancer, which they may be unaware of.

**Cancers are staged at four levels – 1 to 4. The lower the number, the more localised the tumour is. This often means that the cancer is more susceptible to active treatment.

***The Faster Diagnosis Standard looks at how quickly a patient with suspected cancer symptoms is either given a diagnosis of cancer, or an “all clear” for cancer, following referral by their general practitioner (GP). The NHS aims to complete the tests and investigations necessary to inform the patient within 28 days of being referred, in at least three quarters of cases.

ICB required reporting metrics for cancer

This year (2023/24), the ICB is also required to report on delivery of specific trajectories for cancer linked to the operational planning process, alongside programme level measures in 17 further areas of activity. These relate to making progress on cancer stage, the Faster Diagnosis Standard, the proportion of patients waiting for cancer treatment and the rollout of a specific diagnostic test (Faecal Immunochemical Test (FIT)) on the lower gastrointestinal pathway. This process will be refreshed in each year covered by this Joint Forward Plan.

Palliative and end of life care (PEoLC)

We are committed to ensuring that people of all ages with end-of-life care needs are identified and those that require specialist services can access these seven days a week in all settings. Our vision is for people to die in a place of their choice, with their loved ones, and with their end of life wishes in place. Our programme delivery will be focused on the following areas:

Choice and control supported through personalised care and honest conversations – This includes supporting our local places to offer a shareable advance care plan (ACP) to those in the last year of their life. A toolkit of advance care plan and bereavement resources has been recently published to support personalised conversations. We will work with the Cancer Alliance and Ageing Well Programmes to ask for feedback about how advanced care planning and shared decision making relating to NICE guidance on is being implemented. We will support development of personal health budget approaches in palliative and end of life care (PEoLC), and we will develop resources to support our diverse populations to understand the legal requirements relating to death certificates.

Fair access to PEoLC is driven through early identification and reduction in inequalities – We will develop a consistent approach for identification of patients in the last year of their life, using data from completed GP records to understand those numbers of people identified early. A key priority is to complete an all-age health needs assessment (HNA) across West Yorkshire focusing on health inequalities. The core purpose of the HNA is to guide the future development of equitable PEoLC services across the WYHCP footprint. The HNA will also ensure West Yorkshire’s services is compliant with PEoLC statutory guidance. Outcomes from the HNA will be used to implement an equitable all age vision of PEoLC across West Yorkshire, working with people with lived experience and their carers, the public, the voluntary sector, place colleagues and WYHCP programmes. We will also support place led research opportunities relating to PEoLC health inequalities.

Comfort and wellbeing are maximised - We have asked Healthwatch to speak with adults, children and young people experiencing PEoLC, and their families and carers, ensuring there is a focus on engaging with people experiencing health inequalities. Healthwatch will be asking people about the quality of their care and the responses they receive will inform the Health Needs Assessment. We will build a West Yorkshire wide approach to reviewing availability and access to bereavement support. Working in partnership with West Yorkshire Hospice Collaborative, Living and Ageing Well and MHLDA Programmes we will evaluate how people with complex communication difficulties are being supported when they may be experiencing distress.

Access to coordinated 24/7 care across all services is improved – We are working across the Partnership to collate information about the number of emergency admissions people experience in the last three months of life. We are also working with colleagues from the digital team to widen the information sharing of PEoLC records and recommended summary plan for emergency care and treatment (ReSPECT) records through the Yorkshire and Humber shared record. We will ensure across West Yorkshire people having access to 24/7 coordinated support for PEoLC from health, social care and community services and we will co- ordinate a working group to focus on the transition from children to adults’ services.

Staff are skilled to be compassionate and person-centred – We will support the development of the NHS England PEoLC workforce strategy for West Yorkshire and the delivery of the ECHO programme specialist palliative care clinical nurse specialist development programme. We will deliver advanced care planning and bereavement training for health, social care, VCSE staff and volunteers. We will develop an approach to involving people with lived experience to evaluate staff training courses, to coproduce resources to support any gaps they identify and to support the delivery of personalised care training. We will work across West Yorkshire to share personalised care training and good practice.

Communities are compassionate and resilient – We will work with the NHSE lived experience team and peer leaders in PEoLC to develop a coproduction group to

• Identify what it means to be part of a compassionate and resilient community experiencing PEoLC
• Identify how unpaid carers supporting someone at end of life are supported to access local services using NICE QS13 End of life care, quality statement five.

We will support conversations about advance care planning end of life care with our local communities across West Yorkshire. We will implement , Tell three people what matters to you’ NHS Lancashire and South Cumbria :: Tell 3 people introduction. (healthierlsc.co.uk)  communication and working with voluntary sector colleagues to hold a West Yorkshire Good Grief festival.