Priority areas for improving outcomes for people

Maternity services

Our plan may use the terms women, pregnant people, service users and mothers; understanding that practitioners will modify their language in accordance with the preferences of individuals within their care. The plan available here describes how we intend to transform and commission services in order to:

• Reduce stillbirth, maternal death, neonatal deaths, and neonatal brain injuries that occur during birth by 50% by 2025.
• Reduce the rates of pre-term birth to below 6 per cent by 2025.
• Ensure that every woman has an individual care plan that is co-produced by March 2024.
• By March 2024 all pregnant women will have access to smoking cessation services.
• Implement a perinatal pelvic health service by end of 2024.

The Saving Babies Lives Care Bundle version 3 is being implemented across the system with monitoring of progress overseen by the LMNS. This is a key enabler to meeting the ambitions.

Actions to be taken in year two 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. Work has commenced to ensure appropriate funding and training is in place for service users to undertake this important role in line with the national Maternity and Neonatal Voices Partnership guidance. 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 an adverse outcome.

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 care 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. We will ensure maternity services across WY 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 wedevelop.

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 level.

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.

Supporting our children, young people, and families

Supporting children, young people, and families in WY is a top priority. As outlined earlier in the plan, as an ICS we are concerned about the impact financial settlements for local authorities and NHS organisations are having on our ability to support our children and young people. Unfortunately, the Covid-19 pandemic and rising living costs have led to widening health inequalities among children and young people in the region.

In WY, 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 overlap 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 WY region and seasonal pressures pose additional challenges especially during unprecedented workforce gaps. Data from NHS England also highlights the growing backlog for elective care, and a review of data for Children and Adolescents Mental Health Services (CAMHS) in WY 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 Health and Care Bill 2022 brings further opportunities for integrated working across all children’s services in WY to address these challenges.

We have an ambition to close the gaps in health and wellbeing outcomes for all children and young people across WY, no matter where they were born, where they live or where they go to school. The vision to realise this ambition across WY 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 WYHCP 10 Big Ambitions.

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.

A Healthier Together digital platform has been designed to provide children, young people, and families across West Yorkshire with high quality clinically informed and widely accessible source of advice about health and care needs through digital means.

This means our communities are now empowered and better able to access reliable, standardised and clinically sound information to make decisions about self-managing their health conditions. The impact of this innovation means people are accessing the right information, in the right place at the right time

To meet our goals for children and young people in WY, consistent with principles of subsidiarity, we have several strategic objectives which are delivered through integrated working and co-production with communities. We will:

• Focus on providing the best start and promoting healthy weight. This includes working together across WY 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.
• Build family resilience and provide early help. We will connect with partners across WY to align our approaches and share good practice for prevention, assessments, and early intervention. We aim to support looked after children, those with complex needs, reduce variations in early interventions, provide collaborative training opportunities, and help families and communities develop skills to support one another.
• 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 24/7 specialist palliative care services, and learning from ambulatory care pathways.
• Develop equitable services for complex needs and special educational needs and disabilities (SEND). We aim to create a coordinated approach for improvement across WY that reduces variations in access, experiences and outcomes, whilst ensuring statutory requirements are met. We will also support a collective approach to early diagnosis of complex needs and SEND, working with the Mental Health, Learning Disabilities and Autism (MHLDA) service.
• Deliver improvements for children and young people with long-term conditions. We will collaborate to share best practices across WY, reduce variations in outcomes, provide equal access to technology and services, focus on transition periods to improve experiences, and learn from evidence based practice including audits.
• There is clear alignment to the 10 Big Ambitions across WY as we aim to address health inequalities in deprived communities by providing comprehensive support services for families from conception to early adulthood. Collectively in WY 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.

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 called ‘Project Hope’ to help 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 focusing on quality to reduce variation in SEND services.
• 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 WY Acute Trusts.
• Harmonisation policy for continuous glucose monitoring (CGM) 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:
• Review oral health provision, mapping prevention activity and support joint commissioning opportunities of the epidemiology survey.
• Establish a 24/7 palliative care service for children and young people.
• Support the design of virtual ward pathways by sharing best practice.
• Delivery of the children and young people epilepsy care bundle including shared learning across clinical pathways.
• Support implementation of harmonised policy for CGM devices.
• Support increased access to epilepsy and diabetes specialist nurses and clinical pathology services.
• Improve the quality of educational and health care plans for children with complex needs and SEND through partnership working.
• New workforce models that reduce the need for specialist referrals to speech and language therapy due to earlier intervention.
• Continue to strengthen partnership working including in education settings focusing on the needs of children with complex needs and those that are neurodivergent.
• Continue to work with young people to co-produce and co-design service transformation initiatives.

Tackling antimicrobial resistance

Antimicrobial resistance (AMR) 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. Our WYHCP 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. It is driven through a steering group consisting of front-line healthcare workers, managers and academics from our five places.

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 WY.

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. To encourage this, we will work in collaboration with Hospital In Your Home (HIYH) 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 WY 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 five 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 five 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 WY, 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 WY 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 2024/25 across WY we will:

• Reduce our use of inappropriate out of area placements towards the national ambition of ‘0’.
• Increase our reliable recovery and improvement rates for service users of NHS Talking Therapies so that it is at least 48%.
• Ensure that our reliable improvement rates for service users of NHS Talking Therapies is at least 67%.
• Deliver at leat 25,000 completed courses of treatment within NHS Talking Therapies.
• Increase the number of women accessing specialist perinatal mental health services to over 2,400.
• Deliver a dementia diagnosis rate of over 69%.
• Deliver learning disability annual health checks to at least 79% of the eligible population.
• Deliver severe mental illness annual health checks to at least 69% of the eligible population.
• Deliver at least 25,000 occasions where people received two or more contacts from community mental health teams in transformed services.
• Deliver at least 33,000 occasions where Children & Young People (CYP) receive at least one contact from CYP mental health services.
• Ensure for those people who are autistic, have a learning disability, or both that:
  • No more than 57 adults are in inpatient beds.
  • No more than 4 children and young people are in inpatient beds.

In addition to the above, our WY Mental Health Learning Disabilities and Autism (MHLDA) Provider Collaborative is accountable for delivering services across WY 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 WY 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 WY and reducing length of stay.
• Forensic child and adolescent mental health services (CAHMS) – continued delivery of the Yorkshire and Humber Community Forensic CAMHS Service to include enhanced training offers, improving feedback mechanisms and implementing a revised workforce model.
• Assessment and treatment units for learning disability – strengthening clarity on clinical decision making and escalation processes and undertaking a strategic review of assumptions about the inpatient and community offer.

As part of our collaborative work across WY, we also support quality improvement in our MHLDA Trusts, this includes focused work on inpatient quality and actions to grow the future workforce through dedicated work on careers awareness and inclusive recruitment.

Through our WY MHLDA Partnership Board, we 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, connecting our CYP keyworker services across the ICB, delivering LeDeR (learning from lives and deaths of people with a learning disability and autistic people) focus reviews and enhancing the offer to autistic people and people with ADHD by connecting with our Neurodiversity work.
• Children and young people’s mental health – delivering increased numbers of mental health support teams, actions to improve crisis and self-harm support, considering alternatives to inpatient provision, reviewing published guidance for CYP on ARFID (Avoidant Restrictive Food Intake Disorder) and piloting consultant psychologist roles within the Dynamic Support Register process.
• Adult mental health pathways – delivering ongoing monitoring and improvement to ‘NHS111 for Mental Health’, supporting the move away from the Care Programme Approach to a more holistic model of personalised care and delivering NHSE expectations on inpatient quality.
• Community mental health transformation – developing new and integrated models of primary and community mental health care, developing our approach to adults with 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 process 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 – developing 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) – improving the understanding and awareness of Perinatal Mental Health in specific communities, reducing barriers to access and support, supporting the implementation of the agreed model for maternal mental health services and mobilising the PMH provider collaborative for Yorkshire & Humber.
• Workforce – evaluating the implementation of the Trusts’ Collaborative Bank project to prepare it for business as usual operation, delivering pilots into self-rostering and transfer schemes and exploring opportunities for joint training and/or commissioning of workforce systems.
• Data and intelligence - improving collaboration between Trust BI teams, places, and the system, and delivering improved arrangements for data sharing between providers, providers and the ICB, and providers and the wider WY system.
• Wider determinants and inequalities – increasing collaboration across specialist mental health 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

In December 2023, the WY Yorkshire ICB, Mayor of West Yorkshire & West Yorkshire Combined Authority announced our region as a Creative Health System. To our knowledge, this is the first such announcement in the country.

The mission of this work is: to bring alignment, amplification and connection across our system to enable people to engage in creative approaches so that they can live well in their community and achieve their potential. This will take us toward our vision: that arts, culture and creativity are embraced by our citizens in their everyday lives and incorporated into health sector approaches resulting in longer lives better lived and stronger, more connected communities.

Finding new and innovative ways to support our population to have happier healthier lives is important to us in WY 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 (SWYPFT) 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 transforming 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 WY is one of four nationally. We have been working with NCCH to:

• Capture the stories and learning from Creativity and Health in WY, pulling together networks in each of our places and across WY; 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. 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, with tangible benefits for our health and care system.

Our 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.

Our work to date has focused on diabetes, cardiovascular (CVD) prevention and stroke, however our priorities are adaptive in response to the needs of those living in our communities and to ensure our work as a system reduces the impact of the long-term conditions which have the greatest impact on the gap in health inequalities between the most and least deprived populations, including the impact of co-existing multiple long-term conditions.

For example, this year we are delivering an exciting campaign, ‘Find Out How You Really Are’ in partnership with rugby league clubs across each of our five places and Yorkshire County Cricket. We will be attending games in the 2024 season to raise health awareness relating to risk factors for developing long-term conditions and to call individuals to action using quality conversations and health screens so help those in local communities know their risk factors and understand what they can do to improve their own health and wellbeing.

Additionally, working with the Y&H Renal Network, we are undertaking work to inform a co-produced WY approach to improving kidney health for our population. We have secured Health Technology Adoption and Acceleration Funding (HTAAF) to use innovative digital technology (Minuteful Kidney) to increase access to home urine testing to improve detection of patients at risk of kidney damage caused by high blood pressure. In 2024/25 we propose to screen 30,000 patients with diagnosis of hypertension who have not had their urine albuminuria tested in the preceding year.

Diabetes

We deliver across WY 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: National Diabetes Prevention Programme supports those identified as at high risk of developing type 2 diabetes through behaviour change. Over the course of 9-12 months, group sessions help participants 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, with a particular focus on communities more at risk of health inequalities.

The NHS Type 2 Diabetes Path to Remission Programme 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 continue to support our places to increase referrals to the programme. For example, throughout 2023 and 2024 we are working with GP practices and our provider (Xyla Wellbeing) to deliver locally hosted group patient information sessions for those who are registered with the practice and are eligible - to introduce the programme and to allow for the sampling of the diet replacement products

From November 2023, we rolled out a new WY T2DAY initiative funded by NHS England to 100% of people between 18 and 39 years living with type 2 diabetes across our five places. The T2DAY population are offered additional holistic reviews in primary care to help optimise their health and wellbeing and prevent diabetes related complications. This programme will extend at least until March 2025. WY ICB will be a local evaluation site for T2DAY working closely with NHSE to evaluate the programme and consider sustainability.

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 continue to work to implement NICE technical appraisal guidance and ensure wider access to continuous glucose monitoring (CGM) and hybrid closed loop (HCL) technology for people living with diabetes who are eligible. A WY CGM and HCL Commissioning Policy describes our five-year implementation strategy which priorities access to vulnerable populations and those at risk of health inequalities. We will continue to invest in workforce training to enable health and care teams to gain the knowledge and skills required to provide the technology and support individuals using it through personalised care approaches.

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 and uptake of structured education for people living with diabetes in general. Bulk text messages to eligible patients from their GP practice, raising the profile of the Digibete and YoungType 2 innovations, and working with the Y&H Diabetes Clinical Network to understand barriers to uptake of structured education are a few of the ways we are striving to improve self-management ability of those living with diabetes.

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. Working in a more integrated way with our CYP Diabetes system leaders we are enabling access to Seamless Diabetes Training for specialist adult and paediatric diabetes teams in secondary care to ensure young adults are optimally supported to transition between children and adults diabetes services. We hope to adapt and spread access to this training to primary care clinical teams in the next year.

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 continue to work with business intelligence and data quality colleagues to ensure a consistent approach to diabetes reporting for WY; and are scoping ways to optimise the data we have to support implementation, care quality and financial oversight of diabetes novel interventions, including CGM and HCL.

We will continue to raise awareness to support people to understand their risk of developing diabetes and other long-term conditions, demonstrated by our ‘Find Out How You Really Are’ campaign; and our partnership working with local VCSE colleagues at Diabetes UK and public health colleagues to increase access to risk screening, for example through uptake of NHS Health Checks, to bridge the gap between the estimated and actual prevalence of diabetes in WY.

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. Shared decision making is core to our work to ensure those living with diabetes are partners in care that is person centred and tailored to need.

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; and
• 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. This year we have progressed our co-production group, bringing together stroke survivors, VCSE partners and healthcare professionals to work on projects focusing on ‘Life after stroke’ elements of the pathway. They have successfully developed a stroke specific website/directory which will provide information and resources to stroke survivors, their carers and relatives across WY.

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. In the coming years, we will work with YAS 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 WY. We have successfully implemented a regional mutual aid agreement and are now 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 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 local or social background. We will continue to work in co-production 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 our efforts on those most at risk of health inequalities, for example, those from more deprived communities and health inclusion groups. Complementary work as part of the WY MHLDA programme aims to increase access to physical health checks for those with learning disabilities/severe mental health.

During 2023/24 we successfully secured funding from NHSE to support CVD prevention. The initiative aims to prevent and identify risks for undiagnosed CVD among individuals living in communities ranked most deprived and/or health inclusion groups in Calderdale, Kirklees and Wakefield. Targeted community outreach initiatives aim to improve the health literacy of those living in these communities and engage them in being checked for risk for CVD and where risks are identified, engage them in treatment and care with the aim of improving clinical outcomes and reducing health inequalities for those most at risk.

We are working to ensure that the treatment patients receive follows 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 prevention and embed a personalised care approach. Work in this area will involve proactive case management to target specific groups e.g., working age men, those with/at risk of familial hypercholesterolaemia and undertaking outreach CVD prevention health checks in communities most at risk of health inequalities including those from health inclusion groups.

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. This year we have started work on a new project to advance the objectives of the WY Healthy Hearts 2023/24 initiative, specifically focusing on lipids management and the improvement of AF targets.

For Atrial Fibrillation:

• Our objective is to help achieve the target of having 95% of the anticipated number of people with atrial fibrillation diagnosed by 2029.
• For Lipids Optimisation:
• We aim to raise the percentage of patients aged 25-84 years, with a CVD risk score over 20%, on lipid-lowering therapies to a 65% (5% greater than nationally set target).

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 committed to 1,000 more people having the opportunity for curative cancer treatment by 2024 then was the case in 2018/19. Even with the impacts of the pandemic, the Rapid Cancer Registration Dataset (RCRD) shows that 1,382 more people in West Yorkshire have been diagnosed at early cancer stages one and two, which make curative treatment more possible. This means that our Joint Forward Plan looks to go further, showing how we can progress towards three in four people being diagnosed with cancer at an early stage, as described in the NHS Long Term Plan, with an initial goal of 62%. We are also increasing the profile of our work to prevent more cancers where we can, by encouraging positive changes to lifestyle choices and behaviours.

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. We listen to our patients as part of this, a good example recently being through our non-surgical oncology work.

Non-surgical oncology (NSO) services are those that provide treatment and care for cancer patients other than surgery. The NSO programme involvement work during 2023 included 14 face to face and 2 virtual sessions, plus a 500 resident research survey, which aimed to cover all postcodes and protected groups as part of the plans. Clear messages and themes include:

• A fast, responsive service is important.
• Services should be accessible and provided as close to patients homes as possible.
• People are (generally) willing to travel beyond their local hospital but only expect to do so to receive specialised care or for an enhanced patient experience.
• The were happy to have remote assessments/use digital tools as long as the option for face to face was also in place for those that needed it.
• That cost, duration and availability of transport to hospital was an issue.
• Patients reported that their GP often had difficulty accessing information on NSO treatments provided by hospitals.

As a result, the Cancer Alliance has refocussed their programme to include the much larger gains from providing more out patients, chemotherapy and research access closer to the patients’ home, including the consistent use of oral chemotherapy and out of hospital (e.g. chemotherapy bus) reviews and treatment. They are also working to ensure there are consistent levels of expert access available out of hours through a more robust 24-hour helpline and more standardised first line acute oncology support in local hospitals. There is a recognition that transport, and transport costs have been a long-standing issue.

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.

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; Health Innovation Yorkshire and Humber https://www.yhahsn.org.uk/; 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.

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).

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

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.

Earlier presentation: We will continue to ensure that more patients to have access to curative treatment; improve population awareness of cancer signs and symptoms; and continue to close the health inequalities gaps in our system (Strategic Goals 1 & 2).

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).

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).

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).

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).

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).

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%	75.0%	76.0%	77.5%	80.0%	80.0%	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.

1 - 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.

2 - There are a range of measures being developed to seek further acceleration of this early-stage goal. For more information.

Palliative and end of life care

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.

This year we will host our first West Yorkshire, Palliative and end of life care conference, which will have a health inequalities focus.  This will bring together health and care professionals to share learning and support delivery of best practice.

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 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 commissioned Healthwatch to speak with adults, children and young people who had experienced PEoLC, and their families and carers, ensuring there was a focus on engagement with people experiencing health inequalities. Healthwatch have collected this feedback about the quality of their care, these responses will form part of 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 communication and working with voluntary sector colleagues to hold a West Yorkshire Good Grief festival.