6. Our plans

Our Population and Care Delivery Boards are the focal point for delivery of the priorities identified above. They are also responsible for supporting the local delivery of West Yorkshire and National NHS priorities. These come together within the individual board plans, included below.

Each plan describes the vision, outcomes, and priority work programmes for each board (e.g., by population segment), and how these will drive improvements in our city’s goals, support West Yorkshire ambitions and ensure delivery of Long-Term Plan priorities, including COVID-19 recovery plans across Urgent and Emergency Care Recovery; Elective Recovery; and Primary Care Recovery.

There are two programmes of work that link to the West Yorkshire 10 Big Ambitions but are not aligned to a specific Population or Care Delivery Board and these are Suicide Reduction and Antibiotic Resistance and are described first.

The appendices provide the detailed operational plan for how the partnership will meet the 31 national objectives and locally defined population through a wide range of individual projects.

Suicide Reduction

Our Suicide Prevention Plan.

With the responsibility of suicide prevention resting with local authorities, Leeds City Council’s public health team leads our multi-agency citywide suicide prevention strategic group, which contributes to suicide prevention work across West Yorkshire, supported and guided by real time surveillance of suspected suicides from West Yorkshire Police. It is a working document, used as framework to guide local action and activity, and is informed by local and national policy and evidence for suicide prevention, including:

• Audit of Suicides in Leeds (2014 – 2016)
• Preventing Suicide in England reports

The local plan brings strategic partners across healthcare and wider settings to ensure the best use of limited resources, and is being delivered through six workstreams:

1. Citywide leadership for suicide prevention.
2. Reduce the risk of suicide in high-risk groups.
3. Develop and support effective suicide prevention activity in local primary care services.
4. Provide better information and support to those bereaved or affected by suicide.
5. Support the media in delivering sensitive approaches to suicide and suicidal behaviour; and
6. Improve local intelligence on suicide in Leeds to inform suicide prevention activity.

The latest Leeds Suicide Audit (due for completion summer 2023), using data from the coroner’s office, will provide details on demographics, risk factors and details of access to services for all Leeds residents of suicides between 2019 and 2021 and will help further target interventions to reduce risk. The audit will also support the development of new, co-produced recommendations for actions and a new Suicide Prevention Action Plan for the city. The Suicide Prevention Action Plan sits within the context of the wider public mental health programme. Other priorities in this programme include mental health promotion and wellbeing; reducing stigma and discrimination; and effective, equitable mental healthcare services.

Antibiotic Resistance

Leeds is part of the wider West Yorkshire Health and Care Partnership Integrated Care System Antimicrobial Resistance Steering Group, with a place-based stewardship group. The Leeds Antimicrobial Stewardship Group was developed in 2016 with a range of partners from across the Leeds Health and Care System. We have also developed a local, place based, collaborative and system wide approach to address antibiotic resistance in Leeds with a clear action plan which is monitored through the Leeds Antimicrobial Stewardship Group. The plan has three key priorities and aligns to the National Action Plan on Antibiotic Resistance and the West Yorkshire Antimicrobial Strategy:

• Reducing the need for and unintentional exposure to antibiotics.
• Optimising use of antibiotics.
• Investing in innovation supply and access.

Children and Young People (CYP) Population

Population size: 177,712 people, includes all Leeds residents under the age of 18.

Children and Young People Population Outcomes:

• Children are safe from harm.
• Children do well at all levels of learning and have skills for life.
• Children in Leeds are healthy.
• Children are happy and have fun.
• Children and young people in Leeds are active citizens who feel they have a voice and influence.

Key workstreams:

• Keeping children safe from harm
  • Compassionate Leeds supports the most vulnerable and addresses impact of trauma and adverse life experiences.
• Children with complex needs
  • Neurodiversity identification, assessment and support review
• Addressing health inequalities in children and young people
  • Core20PLUS5 action plan
• Children’s Mental Health
  • Crisis offer for CYP from prevention to inpatient stays.
• Children’s system flow
  • Develop proactive and reactive model to ensure children are seen at the right time in the right.

Link to NHS National Priorities

Improve access to mental health support for children and young people (0-25 years).

Link to Core20PLUS5

Focus on the most deprived communities and plus groups asthma, diabetes, epilepsy, oral health, and mental health.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

• Address the health inequality gap for children living in households with the lowest income, including halting the trend in childhood obesity.
• Reduce the gap in life expectancy between people with mental health conditions, learning disabilities, and / or autism, and the rest of the population. In doing this we will focus on early support for children and young people.

Link to West Yorkshire Programmes

Supporting our children, young people and families

Link to Leeds Health and Wellbeing Strategy (2023-2030):

• A Child Friendly and Age Friendly City where people have the best start and age well.
• Safe and sustainable places that protect and promote health and wellbeing.
• A mentally healthy city for everyone

Link to local strategies and plans

• The Future In Mind Strategy
• Compassionate Leeds Strategy
• Child Friendly Leeds
• Leeds Children and Young People’s Plan
• Best Start Strategy
• Early Help Strategy
• Nesta partnership
• Attainment Achievement and Attendance strategy
• Thriving strategy
• Leeds Play Strategy
• Leeds Food Strategy

Maternity Population

Population size: 12,777 people includes people over 18 and pregnant, or within two years of a pregnancy.

Maternity Population Outcomes:

• Families and babies are supported to achieve optimal physical health.
• Families and babies are supported to achieve optimal emotional health.
• People receive personalised maternity care safely.
• People feel prepared for parenthood.

Key workstreams:

• Maternity dashboard quality surveillance
  • Review utilisation, safety and risks.
  • Monitor workforce and retention.
  • Bookings before ten weeks.
• Maternity and Neonatal Voices Partnership
  • Accessible and close to home care service user engagement.
  • Staff satisfaction and feedback
• Gestational diabetes and maternal healthy weight
  • Targeted healthy eating and physical activity interventions.
  • Infant feeding support.
  • Future pregnancy planning education.
  • Community based peer support sessions for diabetes and unhealthy weight.
• Health inequalities
  • Review of interpreter service within maternity including digital access.
  • Accessible and closer to home care.
  • Young parents and doula service offer and support.
• Perinatal and maternal mental health
  • Service offer to combine maternity, reproductive health, and psychological therapy.
  • Increase access to perinatal and maternal mental health services.
• People feel prepared for parenthood
  • Perinatal parenting programmes.
  • Baby steps.
  • Infant mental health.

Link to NHS National Priorities:

• Make progress towards the national safety ambition to reduce still birth rate, neonatal mortality, maternal morality, and serious intrapartum injury.
• The NHS will continue to contribute towards levelling-up, through its work to tackle health inequalities showing a continued reduction in the difference in the stillbirth and neonatal mortality rate between that for Black, Asian, and Minority Ethnic women and the national average.
• Listening to and working with women and families with compassion.
• Growing, retaining, and supporting our workforce.
• Developing and sustaining a culture of safety, learning and support.
• Standards and structures that underpin safer, more personalised, and more equitable care.

Link to Core20PLUS5:

• Focus on the most deprived communities and plus groups.
• Maternity: Ensuring continuity of care for women from Black, Asian, and minority ethnic communities and from the most deprived groups. This model of care requires appropriate staffing levels to be implemented safely.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions

Reduction in stillbirths, neonatal deaths, brain injuries

Link to West Yorkshire Programmes

Maternity services

Link to Leeds Health and Wellbeing Strategy

Promoting prevention and improving health outcomes through an integrated health and care system

Link to local strategies and plans

• Leeds Maternity Strategy
• Child Friendly Leeds
• Ockenden Review
• Maternity Transformation Programme

Healthy Adults Population

Population size: 343,243 people includes people, aged 18 and over with no diagnosed long-term condition and not pregnant.

Healthy Adults Population Outcomes:

• People in Leeds are mentally healthier for longer.
• People in Leeds are physically healthier for longer.
• People in Leeds are supported to live well and have a standard of living which supports their health and wellbeing.

Key workstreams:

• Healthy Mind –
  • Data led approach to targeted interventions for those at greatest risk of developing anxiety, depression, and risk of suicide.
• Healthy Body
  • Data led approach to targeted interventions for those at greatest risk of developing hypertension, diabetes, liver disease and osteoarthritis.
• System Flow
  • Out of hospital project for those with no fixed abode / multiple complex disadvantages.
  • Social prescribing in A&E.
  • Home Plus service.
• People supported to live well
  • Social prescribing for non-clinical health and wellbeing needs.
  • Social prescribing in A&E.
  • Digital health hubs.
• Tackling Health Inequalities (Core20PLUS5)
  • Community grants schemes via Local Care Partnerships (LCPs).
  • Development of Core20PLUS5 data lenses for all boards.
  • Development of models best practice to design and implement interventions to tackle inequalities.
• Health Inclusion
  • Outreach, advocacy, and access – focussed support and intervention for the most vulnerable and at risk cohorts (sex workers, Gypsy and Travellers, refugee and asylum seekers, homelessness, offenders).

Link to NHS National Priorities:

• Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals (specifically weight management for this population)
• The NHS will invest in prevention to improve health outcomes.

Link to Core20PLUS5:

Focus on the most deprived communities and plus groups.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

• We will increase the years of life that people live in good health.
• Address the health inequality gap for children in poverty, including halting the trend of childhood obesity.
• Increased early cancer diagnosis rates.
• Reduce suicide by 10%.

Link to Leeds Health and Wellbeing Strategy:

• A city where everyone can be more active, more often.
• Improving housing for better health.
• A mentally healthy city for everyone.
• Promoting prevention and improving health outcomes through an integrated health and care system.

Link to local strategies and plans

• Leeds Drug and Alcohol strategy
• Leeds Best City Ambition
• Inclusive Growth Strategy
• Marmot City Ambition

People with a Learning Disability and / or Neurodiversity Population

Population size: 5180 people, includes all people with a diagnosis of a learning disability and / or autism.

People with a Learning Disability and or Neurodiversity Population Outcomes:

• Appropriate early identification of a Learning Disability and / or neurodivergence
• Prevention of LTC within this population through a focus on keeping healthy.
• Early detection and proactive support around the management of LTCs within this population.
• Learning disability, Autism, and ADHD acceptance in Leeds with a focus on services making reasonable adjustments and better meeting the needs of this population.

Key workstreams:

• Reducing reliance on inpatient care for people with a learning disability and / or autism.
• Step Up Crisis – alternative review and redesign to provide an alternative to hospital assessment and treatment and a proactive means of preventing placement breakdown.
• Review and improve integrated pathways for diagnosis, treatment, and support for autistic people and people with ADHD.
• Improve access to and uptake of mainstream health services responding to the Health Facilitation Team evaluation, Autism access project outputs.
• Accuracy of GP registers and increase uptake of annual health checks.

Link to NHS National Priorities:

• Reduce reliance on inpatient care, while improving the quality of inpatient care, for adults and children with a learning disability and / or who are autistic.
• Continue to increase the number of people aged over 14 on the GP learning disability register receiving an annual health check and health action plan.
• Improve access to and uptake of mainstream health services:
  • The LeDeR programme (Learning from Lives and Deaths)
  • Learning from lives and deaths, people with a learning disability and autistic people.
  • Digital Reasonable Adjustment Flag

Link to Core20PLUS5:

• Focus on the most deprived communities and plus groups.
• Increase access to epilepsy specialist nurses and ensure access in the first year of care for those with a learning disability and / or autism.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

10% reduction in the gap in life expectancy between people with mental health conditions, learning disabilities and / or autism.

Link to West Yorkshire Programmes:

Mental Health, Learning Disabilities, and Autism

Link to Leeds Health and Wellbeing Strategy:

• A mentally healthy city for everyone.
• The best care in the right place at the right time.
• Promoting prevention and improving health outcomes through an integrated health and care system.

Link to local strategies and plans

• Being Me strategy
• Leeds Autism strategy

Serious Mental Illness Population

Population size: 12,452 people, includes all people over 18 years old with a diagnosis of Serious Mental Illness.

Serious Mental Illness Population Outcomes:

• People in Leeds with a serious mental illness receive care at the right time and in the right place.
• People in Leeds are proactively supported within the community.
• People in Leeds have timely access to crisis support.
• People in Leeds are discharged in an appropriate, timely and supported way.

Key workstreams:

• Community Mental Health Transformation
  • Design and implement a new model of care with PCNs and LCPs that responds to local needs and removed barriers to access so people can access care, treatment, and support as early as possible and be supported to live as well as possible in their community.
  • Further develop outreach and pathways to improve access to physical health checks and interventions for those with SMI.
  • Further improve and develop the early intervention in psychosis pathway, providing access to evidence-based interventions for those with at risk mental states (ARMS)
• Reducing inappropriate out of area mental health bed days
  • Mental health discharge challenge event with focus on peer support discharge workers and Acute Care Excellence (reducing unnecessary clinical variation, improving quality of acute impatient provision)
• Mental health crisis
  • Redesign of simplified access to MH crisis.
  • Embedding NHS 111 into this local crisis redesign.
  • Optimising value of MH spend through review of outcomes, experience and value of current MH crisis pathway, including responding to the evaluation of the community bases crisis house two-year pilot with LYPFT crisis team to reduce admissions for people with acute MH crisis support needs.
  • Implementation and evaluation of new delivery model for street triage.

Link to NHS National Priorities:

• Increase the number of adults and older adults accessing IAPT treatment.
• Increase in the number of adults and older adults supported by community mental health services.
• Work towards eliminating inappropriate adult acute out of area placements.
• Improve access to perinatal mental health services.

Link to Core20PLUS5:

• Focus on the most deprived communities and plus groups.
• Ensuring annual health checks for 60% of those living with SMI (bringing SMI in line with the success seen in learning disabilities).

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

• Achieve a 10% reduction in the gap in life expectancy between people with mental health conditions, learning disabilities, and / or autism.
• Achieve a 10% reduction in suicide rates.

Link to West Yorkshire Programmes:

Mental Health, Learning Disabilities and Autism

Link to Leeds Health and Wellbeing Strategy:

• A mentally healthy city for everyone.
• Strong, engaged, and well-connected communities.
• The best care in the right place at the right time.

Link to local strategies and plans:

Leeds Mental Health Strategy

Cancer Population

Population size: 27,806 people, includes all people with a diagnosis of cancer.

Cancer Population Outcomes:

• People living with cancer will receive person centred care.
• More cancers will be prevented.
• People with cancer in Leeds will be diagnosed earlier when evidence shows this to be beneficial.
• People will receive the safest and most effective cancer treatments that are available.

Key workstreams:

• Person centred care
  • Two weeks wait (2ww) frailty assessment clinics.
• Screening, prevention, and awareness
  • Leeds health awareness services with a focus on deprived and culturally diverse communities.
  • Primary care screening champions within 45 most deprived practices.
  • Lung fit health checks.
• Earlier diagnosis
  • Open access chest x-ray for people concerned about lung cancer symptoms.
  • Implement Faecal Immunochemical Testing (FIT) testing within the lower GI pathway.
  • Primary care Directed Enhanced Services (DES) to reduce ‘did not attend’ (DNAs) and improve 2ww pathway.
  • Pinpoint blood test evaluation.
  • New camera equipment within community tele-dermatology.
  • Increase training for practice nurses to request chest x-ray.
  • Increase non-specific symptoms pathway.
  • Develop new oral lesions pathway.
• Living with, and beyond cancer
  • Risk stratified pathways and development of digital remote monitoring systems.
  • End of treatment summaries to support people and recognise any signs to be aware of.
  • Develop robust and safe demobilisation plan for current community cancer support service and look at alternative provision within the community.

Link to NHS National Priorities:

• Increase rate of cancer cases diagnosed at stage 1 or 2.
• Reduce the number of people waiting longer than 31 and 62 days for treatment.
• Meet the 28-day Faster Diagnosis Standard.
• Cancer screening targets (bowel, breast, lung and cervical)
• Improve one year cancer survival rates.

Link to Core20PLUS5:

Earlier cancer diagnosis.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

• Increase the years of life that people live in good health.
• Increased early diagnosis rates for cancer, ensuring at least 1,000 more people will have the chance of curative treatment by 2024.

Link to Leeds Health and Wellbeing Strategy:

• The best care in the right place at the right time.
• Promoting prevention and improving health outcomes through an integrated health and care system.

Link to local strategies and plans

• Leeds Cancer Programme
• Leeds Teaching Hospital NHS Hospitals Trust Cancer work
• West Yorkshire Cancer Alliance

Long-Term Conditions Population

Population size: 242,528 people, includes all people over 18 years with a diagnosis of qualifying long-term condition and not in any other segment.

Long-Term Conditions Population Outcomes:

• People living with a long-term condition get the support and tools they need to be as healthy and well as they can be.
• People with a long-term condition return to and maintain their normal activities and lifestyle in ways that matter to them.
• People with a long-term condition take an active role in managing their condition

Key workstreams:

• Integrated weight management
  • Integrated weight management model development.
  • Nutrition and dietetics / enteral feeds / oral nutritional supplements.
• Multi-morbidity (three or more long term conditions plus serious mental illness).
  • Develop secondary prevention MDT / multimorbidity hub ambition.
  • Long COVID review.
  • Rehabilitation model development.
  • Self-management.
  • Cardio-renal-metabolic (CaReMe)
  • Digital remote monitoring.
• Cardiovascular Disease (CVD)
  • Lipids Maintenance Hypertension.
  • Remote monitoring / self-management.
  • Anticoagulation and thrombosis.
  • Integrated Heart Failure model next steps.
• Respiratory
  • Home Oxygen delivery across Yorkshire and Humber.
  • Community intravenous service (CIVAS).
  • Diagnosis and prescribing.
  • Asthma prescribing.
  • Spirometry and contribution to diagnostic hubs.
• Neurology
  • Community Neurological Rehab Service (CNRS) redesign.
  • Multiple sclerosis (MS), Epilepsy, Functional Neurological Disorder (FND) and Motor Neurone Disease (MND).
• Diabetes
  • National Diabetes Prevention Programme (NDPP).
  • Diabetes Remission.
  • NHS Treatment and Care performance.
  • Chronic Kidney Disease (CKD)
  • Continuous Glucose Monitoring (CGM

Link to NHS National Priorities:

• Increase percentage of patients with hypertension treated to NICE guidance.
• Increase the percentage of patients aged 25 – 84 years with a cardiovascular disease (CVD) risk score greater than 20% on lipid lowering therapies.
• Increase the number of people supported via the NHS diabetes prevention programme – reflecting the NHS’s contribution to wider government action to reduce obesity prevalence.

Link to Core20PLUS5:

• Focus on the most deprived communities and plus groups.
• To allow for interventions to optimise blood pressure and minimise the risk of myocardial infarction and stroke.
• Address over reliance on reliever medications; and decrease the number of asthma attacks.
• Increase access to real-time continuous glucose monitors and insulin pumps across the most deprived quintiles and from ethnic minority backgrounds; and Increase proportion of those with Type 2 diabetes receiving recommended NICE care processes.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

We will increase the years of life that people live in good health.

Link to West Yorkshire Programmes:

Supporting Long Term Conditions.

Link to Leeds Health and Wellbeing Strategy:

• A city where everybody can be more active, more often.
• Promoting prevention and improving health outcomes through an integrated health and care system.
• Support for carers and enable people to maintain independent lives.
• A mentally healthy city for everyone.

Link to local strategies and plans

• Leeds Diabetes Strategy
• Leeds Stroke Priority Report

Frailty Population

Population size: 62,381 people, includes any person over 60 and with an electronic Frailty Index sore greater than 5.

Frailty Population Outcomes:

• Living and ageing well defined by ‘what matters to me’.
• Identifying and supporting all people in this population group and assessing their needs and assets, as an individual and as a carer
• Reducing avoidable disruption to people’s lives as a result of contact with services.

Key workstreams:

• HomeFirst Programme
  • Review of intermediate care services and pathways / processes to reduce delays.
• Dementia needs
  • Coordinateeed dementia action plan to identify, support and manage more complex need.
• Virtual Ward
  • Hospital at Home.
  • Remote monitoring.
• Reactive Care
  • Urgent community response.
  • Falls response.
  • Falls prevention.
• Proactive Care
  • Anticipatory care falls strength and balance.

Link to NHS National Priorities:

• Two-hour Urgent Community Response (UCR).
• Virtual ward capacity.
• Reduce general and acute bed occupancy.
• Reduce the number of medically fit to discharge patients in our hospitals (and community provision).
• Recover the dementia diagnosis rate.

Link to Core20PLUS5:

Focus on the most deprived communities and plus groups.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

We will increase the years of life that people live in good health.

Link to West Yorkshire Programmes:

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

Link to Leeds Health and Wellbeing Strategy:

• Promoting prevention and improving health outcomes through an integrated health and care system.
• Support for carers and enable people to maintain independent lives.
• The best care in the right place at the right time.
• A mentally healthy city for everyone.

Link to local strategies and plans:

Age Friendly Leeds

End-Of-Life Population

Population size: 3095 people, includes all people over 18 years and on palliative care register.

End-of-Life Population Outcomes:

• People approaching the end of their life are recognised and supported on time.
• People approaching the end of life live and die well according to what matters to them.
• All people approaching the end of life receive high quality, well-coordinated care at the right place at the right time and with the right people.
• People approaching the end of life and their carers are able to talk about death with those close to them and in their communities. They feel their loved ones are well supported during and after their care.

Key workstreams:

• Enhance initiatives and capacity to raise community awareness and address barriers to care and support including linkage and analysis of routinely collected data, alongside targeted inquiry, to inform strategic action.
• Enhance earlier identification and recognition of people approaching the end of their life in Leeds, utilising digital needs identification, to enable timely and effective support to patients, families, carers, and communities.
• Improve the uptake and quality of digital Advanced Care Plans (Planning Ahead), including the interoperability of digital ACPs across providers, to facilitate high quality coordinated care.
• Continue to improve pathways and integration for end of life care across and within all providers with particular focus on out of hospital provision and effective use of acute hospital services.
• Maintain and enhance 24/7 access to care, support, advice, and guidance across all settings in Leeds.
• Maintain the coordinated education and training provision for end-of-life care professionals in Leeds targeting areas of identified need.

Link to Core20PLUS5:

Focus on the most deprived communities and plus groups.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

We will increase the years of life people live in good health.

Link to West Yorkshire Programmes:

Palliative and end of life care.

Link to Leeds Health and Wellbeing Strategy:

• The best care in the right place at the right time.
• Support for carers and enable people to maintain independence.

Link to local strategies and plans:

Leeds Adult Palliative and End of Life Care Strategy 2021-2026

Same Day Response Care Delivery Board

Those accessing ‘on the day’ urgent services.

Outcomes:

• People are easily able to access the service that can provide the most responsive and appropriate care to meet their unplanned same day needs
• People’s same day care needs are met wherever they present (if possible), and where they need to be cared for elsewhere, this feels seamless and integrated.
• Care is high quality, person-centred and appropriate to people’s same day care needs now, whilst considering how these might change in the future.

Key workstreams:

• Primary Care Advice Line Plus:
  • Creating a new single gateway: working with Yorkshire Ambulance Service to identity and ‘push’ referrals to Urgent Community Response (UCR) via Single Point Urgent Referral (SPUR) as clinically triaged from ambulance stack and assessing impact of primary / community clinicians ‘pulling’ from the stack and providing UCR.
• Children urgent care
  • Paediatric Acute Respiratory Infection (ARI) hub – Leeds Community Ambulatory Paediatric Service (CAPS) for Children requiring physical examination for respiratory symptoms.
• 24 / 7 integrated Primary Care Services
  • Same Day Primary Care services.
  • Integration between services across the 24hr period.
  • Digital access to support same day.
• Maximise Primary Care Advice Line and develop same day emergency care
  • Avoid unnecessary ED attendances by facilitating healthcare providers to get people to the right place for their care.
• Urgent Community Response
  • Two-hour crisis response offer.
  • Telecare Rapid Falls response.
  • Virtual wards (hospital at home and remote monitoring).

Link to NHS National Priorities:

• Improve A&E waiting times to align with 4-hour target, reduce 12-hour waits.
• Improve category 2 ambulance response times to an average of 30 minutes.
• Reduce adult general and acute (G&A) bed occupancy levels.
• Step up out of hospital capacity including Virtual Ward Capacity.

Link to Core20PLUS5:

Focus on the most deprived communities and plus groups.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

We will increase the years of life that people live in good health.

Link to West Yorkshire Programmes:

Same Day Emergency Care.

Link to Leeds Health and Wellbeing Strategy:

The best care at the right place at the right time.

Link to local strategies and plans:

• NHS planning submission for same day response

Planned Care Delivery Board

Includes anyone being referred for, or awaiting a planned care procedure, treatment, or appointment either in a community or hospital setting.

Outcomes:

• Planned care services are accessible to all regardless of who they are.
• People are supported whilst waiting for all planned care services.
• People agree appropriate and realistic shared health goals, and actively participate in their achievement.

Key workstreams:

• Managing capacity and elective care recovery
  • Community Gynae re-design.
  • Procurement Community Ophthalmology Services.
  • Procurement ENT and Adult Hearing Loss Services.
  • COVID Urgent Eyecare Service (CUES).
  • Procurement of Community Gastro / Endoscopy services
  • MSK Service Review.
• Earlier Diagnosis
  • Implementation of Leeds Community Diagnostic Centres.
  • Direct access to diagnostics understanding uptake and variation across Leeds.
• Waiting support
  • Waiting Well for Planned Care – support provided by Care navigator / support workers targeting people in the most deprived areas and working with PCNs that have highest utilisers of A&E whilst waiting for planned care.
  • Shape up for Surgery care navigator / support worker expansion to ensure patients are optimised for surgery / treatment with a focus on the most deprived areas.
• Outpatients redesign
  • Expansion of Advice and Guidance.
  • Increase use of Patient Initiated Follow up (PIFU).
  • Reduction in outpatient follow up.

Link to NHS National Priorities:

• Eliminate waits of over 65 weeks for elective care (except where patients choose to wait longer or in specific specialties).
• Deliver the system specific activity target.
• Increase the percentage of patients that receive a diagnostic test within six weeks.
• Deliver diagnostic activity levels that support plans to address elective and cancer backlogs and the diagnostic waiting time ambition.
• Performance against 18-week Referral to Treatment waiting time standard.

Link to Core20PLUS5:

Focus on the most deprived communities and plus groups across core clinical areas.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

We will increase the years of life that people live in good health.

Link to West Yorkshire Programmes:

Recover and transform planned care services.

Link to Leeds Health and Wellbeing Strategy:

• The best care in the right place at the right time.
• An inclusive, valued, and well-trained workforce.
• Promoting prevention and improving health outcomes through an integrated health and care system.

Link to local strategies and plans:

• NHS planning submission for planned care, diagnostics, and outpatients.
• Leeds Teaching Hospital NHS Trust Transformation Programmes across Diagnostics, Planned Care and Outpatients.

Primary Care

Outcomes:

• Improved care experience for people, with patients receiving appropriate and timely access, advice and care.
• Improved health outcomes
• Reduced health inequalities.
• An improved work experience for staff, volunteers, and carers

Key workstreams:

• Optimising access to primary care
  • Implementation of the Primary Care Access Recovery Plan with a focus on cloud-based telephony, review capacity and demand models of care and new online consultation system and expanding the role of community pharmacy.
• Cardiovascular Disease prevention and diagnosis
  • Quality improvement across the Primary Care Network to address:
    • identification of hypertension
    • detection and management of atrial fibrillation (AF)
    • addressing cholesterol in the context of CVD risk, including detection and management of familial hypercholesterolaemia (FH).
    • earlier diagnosis of heart failure
  • Annual health checks for people with a learning disability
    • With a focus on those patients that have not received an annual health check in previous 18 months.
  • Tackling neighbourhood health inequalities
    • Focussing on meeting unmet need at a local community level (PCN / LCP).
  • Dementia diagnosis
    • Practices to review dementia prevalence rate and identify patients at clinical risk of dementia and offer assessment and referral.
  • Personalised care
    • Targeted programme of social prescribing to an identified cohort with unmet need.

Link to NHS National Priorities:

• Make it easier for people to contact a GP practice, including by supporting general practice to ensure that everyone who needs an appointment with their GP practice gets one within two weeks and those who contact their practice urgently are assessed the same or next day according to clinical need.
• Continue the trajectory to deliver more appointments in general practice.
• Increase the workforce (recruit 26,000 (515wte for Leeds) Additional Roles Reimbursement Scheme by March 2024
• Support the Health and Wellbeing of the Workforce through supporting the Quality and Outcomes Framework (QOF) Quality Improvement module.
• By 30 June 2023, PCNs to develop an access improvement plan which will improve patient experience of contacting their practices and being assessed and / or seen within the appropriate timeframe (for example same day or within 2 weeks where appropriate).

Link to Core20PLUS5:

Focus on the most deprived communities and plus groups.

Link to West Yorkshire Integrated Care Boards 10 Big Ambitions:

• We will increase the years of life that people live in good health.
• Address the health inequality gap for children living in households with the lowest incomes.
• 10% reduction in the gap in life expectancy between people with mental health conditions, learning disabilities and / or autism.

Link to West Yorkshire Programmes:

Primary Care Transformation

Link to Leeds Health and Wellbeing Strategy:

• The best care in the right place at the right time
• Support for carers and enable people to maintain independent lives.
• Promoting prevention and improving health outcomes through an integrated health and care system

Link to local strategies and plans:

• Gore GP Contract
• Fuller Stocktake
• Access Recovery Plan
• PCN Directed Enhanced Service

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