Delivering responsive and joined up services

Improving primary care

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.

Delivering responsive and joined up services Building on our current Primary and Community Care Services Strategy 2019/2024 we aim to establish a new model of primary care that improves the health of the population and makes better use of resource. Our plan aligns with previous approaches to primary care in WY, emphasising collaboration, population health, reducing variation and empowering individuals and communities.

Key enablers such as workforce, estates and digital are emphasised through the Fuller Stocktake Report outling a new vision for primary care with a neighbourhood based model for integrated care at the core, streamlining access to urgent care, continuity of care for those living 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 WY is discussed in subsequent sections of this plan guided by the “three tests” and will focus on:

General Practice access, transformation and improvement
Estates development and transformation
Workforce development, transformation and building capacity
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.

Delegating responsibility for community pharmacy, optometry and dental (POD) Services to ICBs in April 2023 provided 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.

Delivery plan for recovering access to primary care

Improving access to general practice continues to be a priority across WY. The NHS England delivery plan for recovering access to primary care published in May 2023, continues to address those concerns as the plan focuses on recovering access to general practice, supporting two key ambitions:

To tackle the 8am rush and reduce the number of people struggling to contact their practice.
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:

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

We are making strong progress against the requirements of the delivery plan. For example In 23/24 we have:

Delivered 17m General Practice appointments – this is more than ever before and ahead of trajectory. Of these, 72% are face-to-face and 44% are on the same day.
Maximized Additional Roles in General Practice with 1400 Whole Time Equivalent new roles in General Practice.
Adopted the joint standards in the Royal College GP guidance, supporting Primary and Secondary Care Interface. This work is being progressed through place Clinical and Professional Committees.
Enabled Cloud-Based Telephony systems in 86 practices.
Delivered over 110,000 blood pressure checks in community pharmacy – 40,000 more than last year.

We will continue to prioritise improving access to general practice. Our focus in 24/25 will include:

Further embedding the pharmacy first approach, with further roll out of blood pressure checks, oral contraception provision and clinical pathway consultations
Further implementation of the RCGP guidance to cut bureaucracy at the primary care secondary care interface.

Integrating 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 WY level we will look to get the best value and fully reach the potential for our population from community pharmacy programmes and services. As part of the National Community Pharmacy Contractual Framework and the requirements set out in the NHS England delivery plan for recovering access to primary care we will co-design strategies and plans to improve uptake and access to services.

Our immediate priority will be to strengthen community pharmacy and general practice integration, supporting the implementation of the national Pharmacy First Advanced Service launched on the 31st January 2024. An example is increasing the volume of referrals to Pharmacy First.

Working in partnership with WYAAT collaborative colleagues, we will work to better understand potential gaps in primary care optometry, maximizing opportunities through pathway redesign, delivering care closer to home.

Primary care estates

Estates capacity and configuration is a key enabler to transformation and supports growth of the workforce. Our Partnership will enable and support the development of system wide strategic estates plans, together with the development of the ICB’s Infrastructure Strategy. These plans will align to the future delivery of integrated services and support how we prioritise developments in the context of available 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.

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 continue to strengthen integration of community pharmacy and support the transition into an increasingly clinical future, working more closely with general practices as part of the integrated NHS primary care team.
We will support the development of clear estates plans that are informed by and enable PCN strategic service requirements built around populations.
We will further develop and learn from our approaches to workforce development and transformation, enhancing our reach to POD.
We will develop approaches to how we will include community pharmacy and optometry in the ICB plans for sustainability.
We will work collaboratively with programmes and the People Directorate to explore the creation of educational opportunities to support the development of the community pharmacy and optometry workforce.
We will review how our plans ensure a focus on a trauma-informed approach, building on initial actions in year one.
We will consider outputs from PCN and place strategies (e.g., estates and digital) and identify any key risks and gaps and help define solutions, working with wider partners as required. This will support defining the specific primary care requirements to help inform the ICB's wider infrastructure strategy.

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 wellbeing of our populations. Our priorities for primary care and delivering improved access are an important part of that, but we know that the solution is broader.

This year we have identified the further development of Integrated Neighbourhood Teams (INTs) as one of our transformation priorities. INTs will be designed and delivered locally, but there are things we can do together as one WY system. We are doing this through an Integrated Neighbourhoods Blueprint.

The Blueprint will make clear our strategic vision for developing INTs and the enabling infrastructure that supports integrated working at neighbourhood level. It will prioritise reducing variation in quality, access and outcomes, have a specific focus on health inequalities, and seek to ensure that we provide high quality services in communities that meet peoples physical, psychological and social health and wellbeing needs.

There are several important components to delivering this. We will ensure that people and their carers are involved as partners in their care. A focus on embedding population health management approaches will consider the skills, data and digital requirements to deliver this across WY. The integration of services and workforce spanning primary care, community services, mental health, the VCSE, and local authority teams to provide the most appropriate and seamless care at community level is key.

Complete detail of the blueprint vision and how we will deliver it will be finalised this year. It is being developed based on what the public have told us they want from services, with matrix leadership from our five places and WY teams, and strong clinical leadership and engagement.

Going forwards, it will provide a guiding framework for action across system partners to deliver joined up health and care in neighbourhoods, to support people to live healthy and thriving lives.

Our ambition for dental services

The ICB took on responsibility for the commissioning of dental services across WY in April 2023. When we accepted the delegation of commissioning responsibility we did so to harness the opportunity to improve access and quality for our population, and integrate dentistry alongside other health and care services. We know that access to dental services continues to be a key concern for the public. The commitment set out in this Board paper, which recognises the public need and opportunities, continues to guide our priorities.

We are over 12 months into a long-term commitment to improve dental services across WY. We will continue to do this by working across the Yorkshire and Humber region with our partner ICBs, maximising the opportunities of at-scale working, working in collaboration with the dental profession, for example through our Local Dental Committees, and engaging with local people.

To improve access to services, outcomes for patients, and the experience of our workforce, our plan takes a methodical approach of stabilisation, improvement, and transformation. We have already started to stabilise and improve services including through a £6.5m investment plan, enabling 110% contract delivery, and establishing strong relationships with the profession.

These initiatives have undoubtedly made a difference:

Our urgent access scheme delivered 7551 additional sessions throughout the year, meaning that up to 52,857 people received urgent dental care.
Our homeless scheme has provided access to 265 patients
Our people seeking refuge and asylum scheme (which began only in January 2024) has provided 60 patients with treatment. This means we are meeting urgent dental needs, which we know are heightened given dental access issues, and the needs of those experiencing the highest inequalities.

Since becoming the commissioner in April 2023, we have also seen improvements in our core activity. The percentage of adults accessing NHS dentistry in 24 months has increased by 5.5%, to 48.2%. Children accessing NHS dentistry in 12 months has also grown by 9.9%, to 60.8%. This is above the national averages of 43% and 56% respectively.

Looking into next year, our priorities will be to:

Continue to maximize the use of the dental budget toward dental service delivery, including on a multi-year basis, through re-investment of underspent funds and further work on flexible commissioning. We plan to achieve a minimum of 3% further improvement on the adult and children access figures.
Continue working with dental service providers to maximize delivery through a supportive and collaborative approach.
Develop a dental workforce plan.
Deliver improvements to specific dental service areas, including Community Dental Services through a co-designed, improved service specification and model, and the development of commissioning strategies for other priority areas.
Deliver the requirements of the recently published dental recovery plan to maximize its impact in WY, alongside our other work and progress to date, which collectively aim to improve access to services.
Better align dental commissioning with local authority public health teams, to ensure a joint approach to oral health improvement, promotion, and prevention across WY, including through water fluoridation.
Continue to deliver through strong collaborative relationships with experts, the dental profession, and the public.
Robustly evaluate the impact of the schemes we have commissioned to date, to ensure our resources are used efficiently.

Several issues within dentistry require change at the national level – including on contract reform, workforce planning and fairer funding. We will continue to influence the national discourse on these matters, but believe that with a clear plan, intent and precision that we can make substantial progress locally.

Our ambition for integrated urgent and emergency care

Our vision for urgent and emergency care (UEC) is for patients to have access to the right care, in the right place, as close to home as possible. This means:

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 accident and emergency (A&E) department with the appropriate expertise, processes, and facilities to maximise a good recovery.

We want to ensure 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 the 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.

The plan for urgent and emergency care recovery

In January 2023, NHS England published a ‘Delivery plan for the recovery of urgent and emergency services’; an ambitious two-year plan to deliver improvements for patients across the integrated UEC pathway, with an update published in 2024. The plan identified five key areas:

Increasing capacity – investing in more hospital beds and ambulances, but also making better use of existing capacity by improving flow.
Growing the workforce – increasing the size of the workforce and supporting staff to work flexibly for patients.
Improving discharge – working jointly with all system partners to strengthen discharge processes, backed up by more investment in step-up, step-down, and social care.
Expanding and better joining up health and care outside hospital – stepping up capacity in out-of-hospital care, including virtual wards, better supporting people at home for their physical and mental health needs, preventing avoidable admissions to hospital.
Making it easier to access the right care – ensuring healthcare works more effectively for the public, so people can more easily access the care they need, when they need it.

The plan set the following metrics:

Patients being seen more quickly in emergency departments: with the ambition to improve to 76% of patients being admitted, transferred, or discharged within four hours by March 2024, with further improvement in 2024/25.
Ambulances getting to patients more quickly: with improved ambulance response times for Category 2 incidents to 30 minutes on average over 2023/24, with further improvement in 2024/25 towards pre-pandemic levels.
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.

The aim of the plan is 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.

In July 2023 NHSE launched a universal support offer aligned to the UEC recovery plan. Within the offer NHSE identified 10 evidence-based high-impact interventions: same day emergency care (SDEC), frailty, inpatient flow, community beds, intermediate care, care transfer hubs, urgent community response (UCR), single point of access, acute respiratory infection hubs, virtual wards. Although this work is being led within our places, we are reviewing any opportunities to work across WY.

Working across the Partnership to deliver urgent and emergency care recovery

We understand that the ambitions of the national UEC recovery plan are broad, and therefore to deliver effective improvement, we must work together across organisational and team boundaries. At WY we work closely with other ICB functions, our provider organisations including Acute Trusts and the Yorkshire Ambulance Service (YAS), and our five places to deliver joined up care for our patients.

We recognise the fundamental role of the VCSE sector. Across the Partnership, there is a range of strong VCSE activity delivering specialist work, which compliments statutory provision often easing pressure on acute and specialist services whilst providing support and personalised care for patients. This includes communities with protected characteristics and those least likely to access statutory services.

We also understand the importance of primacy of place and the need for local variation when it is in our patients’ best interest. As WY covers a large geography with diverse populations, a considerable amount of work happens within our local places through place based Urgent and Emergency Care Boards, or equivalent. 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.

Supporting people to ‘choose well’

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.

Our messages remain consistent across WY as we highlight the alternative methods of accessing health and care support and to only use emergency departments (also known as A&E) for serious injury or a life-threatening situation. 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.

“Together We Can” is West Yorkshire’s long-term campaign to minimise pressures on urgent and emergency care services. The campaign promotes simple, consistent messaging in a variety of languages and formats. It encourages people to “choose well” in order to use health services responsibly and to opt for convenient self-care, where safe to do so 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.

This is the third year the campaign has been rolled out as an area wide winter campaign, but it is also used throughout the year to deliver seasonal messages such as during holiday/bank holiday periods and at times of exceptional demand. The campaign is built on data and insight, learning from previous years and user testing, ensuring that a targeted approach is taken to reach the intended audience. A campaign evaluation report will be available in spring 2024.

Community Health Services

Community Health Services (CHS) provide all age care and a key role in keeping people well and supporting them to live independently in their own home. The NHS’s Long-Term Plan makes clear the centrality of CHS to the health and care system, describing an ambition to boost out of hospital care and a trend towards integrated neighborhood based, close to home care. The WY ICB endorsed the ambition to keep people well, closer to where they live at their Board meeting in July 2023 and support the shift to more care in the community.

The importance and impact of CHS via the outcomes they deliver are recognised by the ICB and are critical via intermediate care services to alleviate system pressures, reduce health inequalities and improve population health and wellbeing outcomes for WY to provide support for a short period of time to assist recovery and increase independence. The support can help people to remain at home, recover after a fall, acute illness or an operation, or avoid going to hospital unnecessarily. 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 meet the health and care needs of the population of WY, 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, ensuring a ‘Home First’ philosophy.

Ensuring that we have both the capacity and capability in communities to facilitate this (finance and workforce), requires a 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. Work is being undertaken to review investment at place level into community services to understand trends and to consider whether across West Yorkshire a minimum investment standard for community could be adopted, similar to the Mental health approach. 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.

Consistent with NHS England Priorities, to enable people to live healthier, more independent lives in their communities, by supporting provision of proactive, personalised, and integrated care for population groups that would benefit most, our approach includes:

A commitment on the prioritisation of resources to support areas of most need embedding the 'Home First' approach, moving more care into the community. The financial position and support for the case for change to refocus resource to CHS has been recognised by the ICB board.
Responding to the growth in demand on CHS, supporting the system in improving timely access to quality community services, responding to increases in elective activity, pre and post rehabilitation, waits and transformation of new models of care and consistency of standards when required.
Ensuring intermediate care services such as virtual wards and UCR forms part of the blueprint model described above for UEC and Primary Care to support consistency, clarify the optimal operating models and scalability, and trust.
Collaborative working across sectors, places and organisation to share best practice and prioirtise efforts, ensuring consistent approaches and understanding.
A clear recognition by all stakeholders of the safety benefits to both people, staff, and organisations of a timely and sustainable discharge.
Verifing outcomes using data, evidence, input from across the system striking a balance between place, ICS, and region
Maximising anticipatory care and enabling the delivery of more proactive care to keep people as well as possible in their home.
Building a strong approach to data quality, working towards a single version of the truth, and understanding variation through quality improvement and standardisation.

Most CHS functions are delegated to the five places. This enables joined up planning and delivery in response to local need, often multidisciplinary and multi organisational at place and neighbourhood level and is inclusive of acute, social, 3rd sector and social care, primary care including community pharmacy, hospitals, professional in care, social and domiciliary care home, and hospice settings. Where partners involved in transformation across WY and are all within the Community Provider Collaborative, the lead will be taken from here.

The five areas of community development led by the Community Provider Collaborative include:

Optimising community based urgent care – working with YAS services to navigate to appropriate home based services.
Proactive Care – More personalised approaches mean individuals receive the right care, in the right place at the right time for more positive outcomes and experiences of the health and care system.
Intermediate Care – to further shape and develop the clarity of wider intermediate care pathways and create a stronger messaging and evidence base around the importance of ’HomeFirst’ and Reablement pathways.
Community Dental Services – create a community dental service model that enables equitable access and outcomes across West Yorkshire.
Develop a set of relevant community KPI’s – and support targeted towards proactive care; avoidable conveyance and admissions; intermediate care and early supported discharge. Deploy improved community data to benchmark and continuously support business improvement.

Alongside and through these work areas, the collaborative remain committed to supporting the ICB transformation priorities.

Virtual wards

Maximising VWs is part of the ICB ten point plan to support people leaving hospitals and forms part of the Urgent and Emergency Care Delivery Plan to support people to remain in their own home. VW’s are also significantly more environmentally friendly than traditional hospital care. Although the initial focus was on care for those with frailty and with respiratory conditions, there is now more flexibility in the model as virtual wards for all ages is considered providing a more flexible approach in other clinical areas.

As per our ICB’s delegated operating model, the development and implementation of virtual wards continues to be led in our five places. Places are aligning wider integrated approaches with neighbourhood teams including YAS to step-up and step-down intermediate care, inclusive of VWs, Urgent Community Response (UCR), and unscheduled care with an emphasis on ‘home first’ approaches.

Where it makes sense to do so, as per the ICBs “three tests” across West Yorkshire into 24/25, we will:

Strengthen evaluation, and benchmark to understand how VWs represent a viable, strategic opportunity to help people stay at home and live more independently.
Support an approach that retains a long term view of what is of strategic importance for WY and Places.
Focus on equitable access and application of Core20plus5 will help to ensure there is no population group that is disproportionately disadvantaged or excluded, supporting people who face the greatest health inequalities. We’re keen to input and learn from the INCLUDE study that aims to develop methods to identify digitally excluded older people, to develop interventions to meet their digital needs.
Understand sustainability of virtual wards including the impact made on the greener agenda.
Consider referral source and discharge destinations, to understand potential opportunities to increase referrals alongside local intermediate care models such as UCR, Same Day Emergency Care (SDEC), Anticipatory Care Planning (ACP), social care and discharge processes.
Embed and raise awareness of VWs as part of a culture so that VWs is a service that everyone thinks of immediately and trusts.

Urgent Community Response

UCR is another example that forms part of a joined-up approach to intermediate care, considering access points, across the breadth of step-up and step-down services and is one of our 10 high impact interventions to support UEC recovery.

There was continued progress in delivery of the national UCR requirements during 23/24 and as reported on CSDS, WY is in a positive position against the 2 hour UCR standard. Beyond the 70% standard, source of referral forms part of local quality improvement work and data quality issues will be understood as part of a newly established WY Community Services BI group that nests within the Community Collaborative. A better understanding of, for example, source of referral and reason will help identify any improvement at place or at scale.

Part of the Community Collaborative programme of work includes a focus on:

Reviewing alternative community based pathways across the five WY places to identify best practice, gaps and demand/capacity, with view to increasing/standardising capacity (particularly in Urgent Community response and falls services).
Considering options to reduce 'points of access' at scale or at place into community based services to support YAS identify alternative pathways – at both telephone triage and on site.

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 and transformation of planned care pathways to remove variation in access to services 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, WYAAT and wider partners from the ICS. The programme is delivered through WYAAT.

Elective recovery

Elective recovery meets all three of the criteria for working at a WY 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. Sharing good practice and new 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 WY to perform 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 which 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 specialties across WY 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, 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 support 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 all the work at place and in the programmes.

Our ambition is to continue to align workstreams to the national themes (expansion, prioritisation, transformation and empowering patients), to increase productivity and treat more people. We will also continue to work to develop, grow and retain 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 WY work programme will draw to a close during 2024/25 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.

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 WY. Over the period of the Joint Forward Plan, we would anticipate delivering two further programme of clinical speciality transformation.

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 WY, 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.

Our vision is that everyone in WY to will 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.

Training in personalised care approaches, builds confidence in the workforce and can support the development of Personalised Care and Support Plans (PCSP), which must meet the five criteria below:

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

We are working to develop a WY Personal Health Budget (PHB) policy to ensure everyone with the legal ‘right to have’ is offered a PHB. The work involves collaborating together across the system to reduce variation.

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 in a way which is more effective and more environmentally friendly than pharmaceutical based interventions.

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

have one or more long term conditions.
need support with low level mental health issues.
are lonely or isolated.
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 WY 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 YAS. We will continue to build awareness of young carers through training resources for staff in education sectors alongside developing 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.

We continue to provide ‘micro grants’ to organisations working with young carers. These grants will help to support young carers remain in education and pursue employment opportunities.

Improving the lives of working carers

We will support health and care organisations in WY 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

Work is progressing to 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 have developed and will shortly be launching, a WY toolkit to support unpaid carers being involved in discharge pathways across NHS Trusts to support timely discharges for the people they care for, 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.

Working in partnership with the Voluntary, Community and Social Enterprise (VCSE) 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 in WY 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 WYHCP is recognised as leading the way in our work with the VCSE, delivered through the Power of Communities Programme (PoC), 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 wellbeing of our population.

Our approach in the Power of Communities (PoC)

We will 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 WY 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 WY Integrated Care Strategy and development of the Joint Forward Plan, PoC has worked with stakeholders to identify four key priority areas for specific focus over the next five years, to add value and maximise impact. These are:

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. PoC 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 wellbeing, 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.

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.

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.

4. Workforce

Current workforce challenges across our Partnership and nationally, including recruitment and retention, and staff health and wellbeing 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

PoC have also identified key enablers which create the conditions for a strong and sustainable VCSE sector in WY enabling it to maximise its contribution and impact towards our ICB 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:

Monitor and report on the number of VCSE organisations in WY.
Monitor and report on economic value of the VCSE.
Monitor and report on NHS investment in the VCSE.
Monitor ethnic diversity of VCSE advocates on decision making boards at place and at WY level.