5. Identifying our strategic initatives

Measurable improvement toward our goals will be driven by the people of Leeds, clinicians, professionals and the third sector. We will use population health management approaches and local insight (at a Local Care Partnership and city level) to identify, design and implement interventions and service changes that will have the biggest impact on people’s health and wellbeing. In line with the Health and Wellbeing Strategy ethos of starting with people and communities, co-production will run through all aspects of change.

Following identification of our system goals to reduce unplanned utilisation and increase early identification, the Office of Data Analytics has developed an initial methodology to identify areas of opportunity to improve health and wellbeing, drawing on the capability of our Leeds Data Model.

Using data from the most recent financial year 2022 / 2023 and focusing on unplanned emergency admission to acute and mental health services, in Leeds or nearby, for those in IMD1, the Office of Data Analytics (ODA) identified the presenting conditions that resulted in the highest rate of unplanned care activity per capita. The age, gender, ethnicity, and location profiles of these groups were then investigated in further detail to identify themes and potential relationships to population segments. For example, identifying a high rate of unplanned care due to injury and falls (as a presenting condition) led to the identification of a cluster of need within the frailty and cancer population segment. This initial methodology (and the assumptions made) were tested within an iterative process, with assurance, validation and challenge from clinicians and subject matter experts at each step.

This methodology will be improved and refined over the next year, including a broader range of metrics from Goal 1 and drawing on more powerful analytical techniques to identify further areas of opportunity. However, the data analysis has indicated several areas for Leeds to consider during 2023 / 2024 as potential areas of focus where we can make a difference and improve outcomes for our population.

These are summarised below:

Children and Young People Population: Diseases of the Respiratory System

The data analysis identified that a significant number of children and young people and their families were impacted by respiratory disease, with a higher prevalence in areas of deprivation. For people living in areas of deprivation the average length of stay, for non-elective bed days, was 2.5 days longer compared to the Leeds average. Through the work of the Children and Young People’s Population Board and in developing our health economic approach in Leeds, we know that people under the age of 18 are demonstrating the fastest population growth within IMD 1 areas in Leeds. Therefore, investment in prevention for this population group is important to support them in leading healthy lives in the future.

People with three or more Long Term Conditions and Serious Mental Illness

We know, through data analysis, that this cohort of people utilise a high number of non-elective bed days, coupled with a high prevalence of known risk factors. For example, we know that 60% of this cohort are obese and 32% smoke. We also know, through evidence-based methodologies, that these conditions area amenable to improvement via person centred proactive care.

Serious mental illness and multiple Long-Term Conditions (LTCs) are plus groups, as defined within the national Core20PLUS5 Programme. Three of the five clinical areas identified within the Core20PLUS5 programme that require accelerated improvements are workstreams within the Serious Mental Illness Population Board and the Long-Term Conditions Population Board.

Frailty and Cancer Populations: Injury / Fracture

Despite significant focus and investment in this area as a city, data demonstrates that injuries and fractures remain a challenge for the older population in Leeds even though improvements have been seen. Data analysis indicated that a large proportion of unplanned bed days were occupied by older people with an estimated average length of stay at nine days. For people living within areas within IMD 1, our most deprived areas, the average length of stay, following an injury or fall, was 5.5 days longer than people living in other areas of Leeds.

This analysis is also replicated within the population of people living with cancer, where we know that a significantly high proportion, 79%, are living with cancer and frailty and have experienced non-elective admission as a result of an injury / fracture. It is therefore proposed that the Cancer Population Board and the Frailty Population Board work together on this strategic initiative.

End of Life Population: Diseases of the Respiratory System

The End-of-Life population segment is our smallest population segment in size but represents the fourth highest number of bed days in total with the highest rate of bed days per 1,000 population. The rate of bed days per 1,000 population is higher for the people living within the more deprived areas of Leeds. With the projected growth in the population of Leeds who are over 80 years it is important that we understand and address this utilisation. This strategic initiative will be taken forward through the End of Life Population Board with input from the Long Term Conditions and Frailty Population Boards.

Intermediate Care Provision: HomeFirst Programme

Alongside the strategic initiatives, the partnership has agreed an area of focus on improving wider system flow, which directly links to achieving goal one. Every day in Leeds thousands of people receive great care and support from dedicated health and care staff, volunteers, and unpaid carers. However, there are opportunities for us to improve people’s outcomes. We know:

• Too many people spend more time in hospital than they need to.
• Our short-term care in the community is provided across many different services.
• Outcomes for people can vary depending on where, when, and how they are supported.
• We have a high use of bed-based care.
• Many older people could reduce or avoid deconditioning that has an impact on their interdependence and long-term care needs.

The HomeFirst Programme represents our fifth strategic initiative for the partnership. This programme is developing and implementing a new model of intermediate care services to address the challenges described above, achieving more independent and safe outcomes for people, unpaid carers and staff. By delivering improvements in five project areas (Active recovery at home, Enhanced care at home, Rehab and recovery beds, Transfers of care and System visibility and active leadership) it is expected to create real change for the people of Leeds, within measurable improvements in the following areas:

• 1,700 fewer adults admitted to hospital.
• 800 fewer people spending days in hospital.
• 400 more people going directly home after their stay in hospital.
• 1,200 people benefitting from a more rehabilitative offer in their own home.
• 400 people able to get home sooner form a short-term bed.
• 100 more people able to go home after their time in intermediate care (all year vs. a 2022 baseline)

Through the initial work of the HomeFirst Programme we know that 30% of the most deprived areas within Leeds account for 42% of intermediate care patients. On average, those patients living in IMD 1 are typically more frail and younger than the users living within other areas. People living with dementia are at least twice as likely to access intermediate care as the average person over 80 years or the frailty population. Patients living with dementia have a higher re-admittance rate to hospital following discharge from the Neighbourhood Teams or Community Care beds. We also know that in Leeds people living with dementia have a disproportionate use of unplanned utilisation, particularly non-elective bed days and this is higher for those people living in IMD 1.

Financial Sustainability

Leeds health and care partners will be unable to achieve its goals and deliver on the Health and Wellbeing vision if it doesn’t also maintain financial stability. Our financial plans for 2023 / 2024 are built on the premise that the city can achieve substantial in-year savings. The Leeds Integrated Care Board budget has grown over recent years by 34.5%, however spending on provision has grown even more – between 42% and 58% with our three main NHS providers in Leeds. Much of this spending has been on a recurrent basis and as such this has created an underlying deficit to the system that needs addressing. This change has three root causes:

1. Through COVID-19 the NHS rightly received a lot of additional funding, and this has now been withdrawn at a faster pace than the services (and staff) that were put in place.
2. The pandemic has driven up demand for health services in most areas above that which we saw before COVID-19 along with significant backlogs.
3. The cost of living whether in the cost of utilities or indeed well-deserved staff pay rises has also impacted as these have not been fully covered nationally.

Therefore, a focus on our priorities as described above must not only improve outcomes and experience for people but it must also lead to a better use of resources and contribute towards closing the financial gap within the NHS, as well as considering the considerable pressures within our wider partnership such as social care and other non-statutory providers. Responsibility for closing the financial gap is owned by the Leeds Health and Care Partnership. It is important that financial decisions are made in line with our system strategy and that a collective feeling of financial stewardship is fostered within the system, particularly within our Population and Care Delivery Boards, to support Leeds in reaching financial sustainability.

With this aim, our Population and Care Boards will play an important role in identifying, evaluating, and overseeing the implementation of the savings that need to be made. The people on these boards and their colleagues are the people closest to the services and their population. These boards have the knowledge and insight to drive better value for our Leeds pound.

Annual Priority Cycle

Ensuring success of a focussed approach, as demonstrated by Staten Island model, is not just about the goals themselves but the behaviours that focussing on a goal has led to. Within Leeds we have developed a partnership approach to an annual cycle based on the Staten Island model.

A small number of data-informed priorities, which link to our system goals, will be identified, and reviewed each year by our partnership and will be informed by data, insight and evidence. For each priority area identified we will collaborate with people, communities, and staff to really understand the root cause of the problem and work together to identify the solutions, whether these are health based or linked to the wider determinants. Solutions may be at a system level, population level or within our local communities. We will work together to monitor the impact of interventions and actively respond if the anticipated impacts are not being realised. In undertaking this planning approach, we will always:

1. Plan care by understanding the clinical and financial risk profile of specific population groups to inform interventions and investment priorities, particularly in prevention.
2. Improve equity of access and reduce unwarranted variations in health and care services.
3. Target interventions to those who need it most by identifying people at risk of poor outcomes earlier.
4. Design and deliver how and where people receive health and care services, ensuring care is closer to their home, their family or community and that people remain in Leeds, by embedding a ‘home first’ approach and ensuring people have the tools, knowledge, and skills to self-care.
5. Connect and integrate care and information across pathways, services, and teams, where it makes sense, through new hospitals, redesigned intermediate care offer and improved community and primary care offer.

Contents – Explore the Healthy Leeds Plan

1. Introduction
2. Our city and vision
3. Our goals
4. Population Health infrastructure
5. Identifying our strategic initiatives
6. Our plans
7. Enablers
8. Summary and next steps
9. Appendix One: Leeds Operational Plan – Anticipated trajectories
10. Appendix Two: Leeds Operational Plan Implementation