Appendix Two – Leeds Operational Plan Implementation

APPENDIX TWO: Leeds Operational Plan Implementation

The following pages describe initiatives that our Population and Care Delivery boards will be oversee implementation of or continued implementation of over the next year to impact our partnership goals, the West Yorkshire 10 big ambitions or NHS national objectives.

Cancer Population Board

CAN1 – Earlier Diagnosis – Implement FIT

Agreeing and implementing pathway change to incorporate earlier Diagnosis Implement Faecal Immunochemical Testing within lower GI two week wait pathway.

Population Outcome link: People with cancer living in Leeds with be diagnosed earlier where evidence shows this to be beneficial.

System Goal link: Goal 2 increase early identification and intervention.

West Yorkshire 10 Big Ambition link: Earlier diagnosis rates for cancer.

Impact on NHS national objective: Meet the cancer faster diagnosis by March 2024 and increase the percentage of cancers diagnosed at stages 1 and 2

Start date: July 2023

CAN2 – Earlier Diagnosis – Pinpoint

Evaluation of the Pinpoint blood test which aims to use biomarkers, patient history and demographics to create a cancer risk score for patients attending primary care with symptoms.

Population Outcome link: People with cancer living in Leeds with be diagnosed earlier where evidence shows this to be beneficial.

System Goal link: Goal 2 increase early identification and intervention.

West Yorkshire 10 Big Ambition link: Earlier diagnosis rates for cancer

Impact on NHS national objective: increase the percentage of cancers diagnosed at stages 1 and 2.

Start date: April 2022

CAN 3 – Earlier Diagnosis – Teledermatology

Rollout of new cameras for teledermatology in primary care. Work is ongoing to identify funding to also replace dermatascopes and to create a larger pool of camera stock.

Population Outcome link: People with cancer living in Leeds with be diagnosed earlier where evidence shows this to be beneficial.

System Goal link: Goal 2 increase early identification and intervention.

West Yorkshire 10 Big Ambition link: Earlier diagnosis rates for cancer.

Impact on NHS national objective: Meet the cancer faster diagnosis by March 2024 and increase the percentage of cancers diagnosed at stages 1 and 2.

Start date: June 2023

CAN4 – Earlier Diagnosis – Open Access Chest X-Ray

Restarting of the open access chest x-ray service for patients with concerns around lung cancer symptoms. The re-launch will be accompanied by a publicity campaign to ensure that as many people as possible can benefit from the service.

Population Outcome link: People with cancer living in Leeds with be diagnosed earlier where evidence shows this to be beneficial.

System Goal link: Goal 2 increase early identification and intervention.

West Yorkshire 10 Big Ambition link: Earlier diagnosis rates for cancer.

Impact on NHS national objective: Meet the cancer faster diagnosis by March 2024 and increase the percentage of cancers diagnosed at stages 1 and 2.

Start date: September 2023

CAN5 – Earlier Diagnosis – Practice Nurse Training enable to request chest x-rays

Training to enable practice nurses to access ICE and request chest x-rays for patients for whom they have a concern of lung cancer. This will cut down on the need for GPs to make these referrals and for patients to reattend following a nurse appointment.

Population Outcome link: People with cancer living in Leeds with be diagnosed earlier where evidence shows this to be beneficial.

System Goal link: Goal 2 increase early identification and intervention.

West Yorkshire 10 Big Ambition link: Earlier diagnosis rates for cancer.

Impact on NHS national objective: Meet the cancer faster diagnosis by March 2024 and increase the percentage of cancers diagnosed at stages 1 and 2.

Start date: April 2023

CAN6 – Earlier Diagnosis – Brain and central nervous pathway

Work to develop a straight to test pathway for brain two week wait referrals.

Population Outcome link: People with cancer living in Leeds with be diagnosed earlier where evidence shows this to be beneficial.

System Goal link: Goal 2 increase early identification and intervention.

West Yorkshire 10 Big Ambition link: Earlier diagnosis rates for cancer.

Impact on NHS national objective: Meet the cancer faster diagnosis by March 2024 and increase the percentage of cancers diagnosed at stages 1 and 2.

Start date: June 2023

CAN7 – Screening and Prevention – Primary Care Screening Champions

Funding to pay for protected time for individuals in the 45 most deprived practices in Leeds to put in place programmes to encourage increased uptake of cervical and bowel screening amongst their patient populations.

Population Outcome link: People living with cancer will receive person centred care.

System Goal link: Goal 2 increase early identification and intervention.

West Yorkshire 10 Big Ambition link: Earlier diagnosis rates for cancer.

Start date: April 2023

CAN8 – Person Centred Care – Breast Pain Clinic

Implementation of a specific breast pain clinic to ensure that patients who are suffering from breast pain but who otherwise do not meet the two week wait (2ww) criteria for referral are able to access advice, support, and treatment as necessary.

Population Outcome link: People living with cancer will receive person centred care.

System Goal link: Goal 2 increase early identification and intervention.

West Yorkshire 10 Big Ambition link: Earlier diagnosis rates for cancer.

Impact on NHS national objective: Increase the percentage of cancers diagnosed at stages 1 and 2.

Start date: October 2022

CAN9 – Person Centred Care – Pre-hab

Launch of a service funded by Macmillan to ensure that patients undergoing cancer treatment are physically prepared and fit enough to withstand the treatment that they are due to undergo and that patients maintain a healthy lifestyle after treatment. This will help to ensure that as many treatments as possible are successful.

Population Outcome link: People living with cancer will receive person centred care.

System goal link: N/A

West Yorkshire 10 Big Ambition link: Earlier diagnosis rates for cancer.

Impact on NHS national objective: N/A

Start date: June 2023

CAN10 – Person centred care – Two week wait frailty assessment clinics

Developing frailty clinics to assess frail patients who have been referred on the 2ww pathway (starting with Lower GI) to ensure that they are fit for investigations, that they are aware of what pathways entail and that they want to continue with diagnosis and treatment.

Population Outcome link: People living with cancer will receive person centred care.

System Goal link: Goal 1 reduce to preventable unplanned utilisation across health settings.

Impact on NHS national objective: Meet the cancer faster diagnosis standard by March 2024 and continue to reduce the number of patients waiting over 62 days.

Start date: October 2022

CAN11 – LTHT Transformation Programmes

A range of programmes being led within LTHT by the corporate Cancer Team, including:

• Lung screening
• MDT streamlining
• Cardio-Oncology
• Pelvic Exenteration
• patient education programmes
• end of treatments summaries
• health needs assessments / cancer care reviews

Optimal Pathways:

• Head and neck
• Gynaecology
• Prostate
• Bladder
• Lung
• Skin
• Colorectal
• Upper GI
• Pancreas

Population Outcome link: People will receive the safest and most effective cancer treatments that are available.

West Yorkshire 10 Big Ambition link: Earlier diagnosis rates for cancer.

Impact on NHS national objective: Meet the cancer faster diagnosis standard by March 2024, continue to reduce the number of patients waiting over 62 days and increase the percentage of cancer diagnosed at stages 1 and 2.

Start date: Across 2023

Children and Young People Population Board

CYP1 – Keeping Children Safe from Harm – Compassionate Leeds

The Compassionate Leeds case identifies areas where our current systems are failing to provide the intervention and support that children and families need which align to the themes of improvement identified through the national Early Help Review. The case develops our response to supporting our most vulnerable cohorts of children and young people with the ultimate aim of addressing the impact of trauma and adverse life experiences. There are seven discreet projects that sit within the case:

1. Integrated Trauma Resource Team.
3. Community mental health offer.
4. Child and Family hubs.
5. Cluster based neurodevelopmental support.
6. Neurodevelopment assessment and training for children looked after.
7. Therapy for adolescents on the edge of care.

Population Outcome link: Children are safe from harm.

System Goal link: Goal 2 increase early dentification and intervention.

West Yorkshire 10 Big Ambition link: We will increase the years of life that people live in good health and halt the trend in childhood obesity.

Impact on NHS national objective: Improve access to mental health support for children and young people in line with the national ambition for 345,000 additional individuals aged 0-25 accessing NHS funded services and continue to address health inequalities and deliver on the Core20PLUS5 approach.

Start date: June 2023

CYP2 – Children’s System Flow

Aim to deliver better system flow for children, which creates a proactive and reactive model of population health management, in which children are seen earlier, and in the most appropriate location. The case describes an approach to system flow in two parts:

1.Children’s Care in the Community

1a. Child and Family Community Hubs

1b. Children’s Ambulatory Paediatric Service (CAPS)

2.Optimisation of the Children’s Assessment and Treatment (CAT) Unit

2a. Healthier at Home

2b. Community IV antibiotics service

2c. Other virtual wards

This is all underpinned by an expansion of the CAT workforce which also enables better optimisation of the CAT rota.

Population Outcome link: Children in Leeds are healthy.

System Goal link: Goal 1 to reduce preventable unplanned care utilisation.

West Yorkshire 10 Big Ambition link: We will increase the years of life that people live in good health.

Impact on NHS national objective: Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals.

Start date: April 2023

CYP3 – Children’s Mental Health Prevention (Children are happy and have fun) – Prevention / timely access to services

Several projects are included within this workstream to ensure children and young people receive timely access to community based mental health services these also involve a number of thematic reviews to ensure best value.

These include:

• Roll out of the Mental Health Support Teams.
• Review of our third sector SEMH offer (The Market Place and Leeds Mind (THRU).
• Review of our locality-based support offer (including MindMate Wellbeing cluster support).
• Review of the digital support offer.

Population Outcome link: Children are happy and have fun.

System Goal link: Goal 2 increase early identification and intervention.

West Yorkshire 10 Big Ambition link: We will increase the years of life that people live in good health.

Impact on NHS national objective: Improve access to mental health support for children and young people in line with the national ambition for 345,000 additional individuals aged 0-25 accessing NHS funded services and continue to address health inequalities and deliver on the Core20PLUS5 approach.

Start date: From 2020 – 2023 (multiple projects)

End of Life Population Board

EoL1 – Advanced Care Planning (ACP)

Launch new public Advanced Care Planning guide with Public Health and full review of system wide advanced care planning training. Which includes:

• Launch of new public advanced care planning guide – “what if things change”.
• Full review of system wide advanced care planning training

Population Outcome link: People are approaching the end of their life and are recognised and supported on time. All people approaching the end of life receive high quality, well-co-ordinated care at the right time and with the right people.

System Goal link: Goal 2 increase early identification and intervention.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: April 2023

EoL2 – Early Identification – TIMELY recognition Tool project

Progress trial in Systm1 practices. Engagement with practices regarding outcomes of trial, and its use in supporting early recognition of people nearing the end of their life. Academic validation.

Population Outcome link: People approaching the end of their life are recognised and supported on time.

System Goal link: Goal 2 Increase Early identification and intervention.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: January 2024

EoL3 – Education Programme

Clinical educator funded for 12 months by the Leeds Palliative Care Network to train 2,000 clinical support workers.

Population Outcome link: All people approaching the end of life receive high quality, well-co-ordinated care at the right time and with the right people.

People approaching the end of life and their carers can 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.

System Goal link: Goal 1 Reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: June 2023

Frailty Population Board

FR1 – Proactive care – National Anticipatory Care Framework (now Proactive Care Framework)

National Framework – Proactive Care Framework: provision of proactive, personalised health & care for people with multiple long-term conditions

Population Outcome link: 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.

System Goal link: Goal 1 Reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: October – December 2023

FR2 – Proactive Care – Restore 2 and Stumble Training

Training for care home staff in soft signs of deterioration and falls management.

Population Outcome link: Identifying and supporting all people in this population group and assessing their needs and assets, as an individual and as a carer.

System Goal link: Goal 1 Reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: April 2023

FR3 – Proactive Care – Frailty Training

In year funding – frailty training days led by community geriatrician for health and social care staff plus bespoke training for care home staff.

Population Outcome link: Identifying and supporting all people in this population group and assessing their needs and assets, as an individual and as a carer.

System Goal link: Goal 2 Increase Early identification and intervention

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: April 2023

Home First Programme – Frailty Board

HF1 – Enhanced Care at Home – Improving our urgent community offer to support people at home and reduce unplanned admissions

• Home Ward (virtual ward).
• Remote Health Monitoring.
• Quick Response (urgent and crisis response 2 hours).
• Emergency cover for carers.
• Rapid response to falls.
• Home Comfort.

Also includes early intervention – how we reduce avoidable admissions and attendances at hospital.

Population Outcome link: N/A

System Goal link: Goal 1 Reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Consistently meet or exceed the 70% two-hour urgent community response standard.

Improve A&E waiting times so that no less than 76% of patients are seen within 4 hours by March 2024 with further improvement in 2024 / 2025.

Start date: May 2023

HF2 – Active Recovery at Home – Increasing the number of people who are able to be supported at home following hospital discharge

Combining the current Reablement and National Housing Trust (NHT) services Expanding the offer of these combined services to support more people at home.

Population Outcome link: N/A

System Goal link: Goal 1 Reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

Impact on NHS national objective: Reduce adult general and acute bed occupancy to 92% or below.

Improve A&E waiting times so that no less than 76% of patients are seen within 4 hours by March 2024 with further improvement in 2024 / 2025.

Start date: May 2023

HF3 – Rehab and Recovery Beds – optimising and recommissioning intermediate care beds in Leeds

• Reducing our reliance on spot purchased beds.
• optimising the current community care beds to reduce length of stay.
• designing the model for and recommissioning the rehab and recovery beds in Leeds to a reduced number.

Population Outcome link: N/A

System Goal link: Goal 1 Reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

Impact on NHS national objective: Reduce adult general and acute bed occupancy to 92% or below.

Improve A&E waiting times so that no less than 76% of patients are seen within 4 hours by March 2024 with further improvement in 2024 / 2025

Start date: May 2023

HF4 – Transfers of Care – streamlining our transfers of care between acute and intermediate care services to reduce the non-value-added time

Population Outcome link: N/A

System Goal link: Goal 1 Reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

Impact on NHS national objective: Reduce adult general and acute bed occupancy to 92% or below.

Improve A&E waiting times so that no less than 76% of patients are seen within 4 hours by March 2024 with further improvement in 2024 / 2025.

Start date: May 2023

Healthy Adults Population Board

HA1 – System flow health inclusion – Out of hospital project for those with no fixed abode / multiple complex disadvantages

This workstream has several parts:

• Defined service specification for matrix transfer of care teams for vulnerable adults.
• Development work on scaling up nine temporary housing unit beds as part of current out of hour project.
• Emerging work on those on prison release pathways who end up accessing mental health inpatient services (via LYPFT) shortly after release.

Population Outcome link: People in Leeds live well, and a standard of living which supports their health and wellbeing.

System Goal link: Goal 1 Reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: Increase the years of life that people live in good health.

Impact on NHS national objective:

• Reduce general and acute bed occupancy to 92% or below.
• Continue to address health inequalities and deliver on the Core20PLUS5 approach.

Start date: July 2023

HA2 – Women’s Health

A life course approach to women’s health reduces pressures on waiting lists (gynaecology some of the longest waiters and second most used service in planned care) and increases overall health of women.

Focus on pelvic floor health, endometriosis and menopause pathways also link to mental health of women.

Population Outcome link: People in Leeds will be physically healthy.

System Goal link: Goal 2 – increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: Increase the years of life that people live in good health.

Impact on NHS national objective:

• Make progress towards the national safety ambition to reduce stillbirth, neonatal mortality, maternal mortality, and serious intrapartum brain injury.
• Continue to address health inequalities and deliver on the Core20PLUS5 approach.

Start date: to be confirmed.

HA3 – Community Strengths

• Community Grants Scheme: eight LCPs funded to define, develop and implement hyper local health and wellbeing intervention.
• Social Prescribing: Proactive person-centred approach to working with people in their communities to address nonclinical health and wellbeing needs, and to connect with services to address wider determinants of health.
• Working hyperlocal to develop and pilot a social prescribing community of practice that bring together disparate parts of the system under a shared purpose.
• Community hubs delivering support in and with communities experiencing the greatest health inequalities to enable connection with health and care services using digital means.

Population Outcome link: People in Leeds will be mentally and physically healthier for longer and where needed, supported to live well.

System Goal link: Goal 1 reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: Increase the years of life that people live in good health.

Impact on NHS national objective:

• Continue to address health inequalities and deliver on the Core20PLUS5 approach.
• Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals.

Start date: March 2023

HA4 – System Flow Healthy Adults – Social Prescribing (SP) in A&E; home plus; unplanned care for healthy adults

Pilot project with SP embedded in A&E working with repeat high intensity users of the service.

• Home Plus: the Home Independence and Warmth Service (branded as Home Plus (Leeds)) is aimed at enabling and maintaining independent living through improving health at home. It does this through addressing:
  • risk of falling
  • energy efficiency and affordability
  • warmth and condensation / damp
  • hazards relating to electrics, plumbing and gas that require repairs.
• Data driven approach to understand unplanned care usage by the Healthy Adults segment. Data cut by method of attendance, conveyancing rates, admission conditions, non-admission conditions. All to be cut by:
  • Age
  • Gender
  • Ethnicity
  • Indices of multiple deprivation (IMD) / Primary Care Network (PCN).

Population Outcome link: People in Leeds will be mentally and physically healthier for longer and where needed, supported to live well.

System Goal link: Goal 1 reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: Increase the years of life that people live in good health.

Impact on NHS national objective:

• Continue to address health inequalities and deliver on the Core20PLUS5 approach.
• Improve A&E waiting times so that no less than 76% patients are seen within four hours by March 2024.

Start date: March 2023

Long Term Conditions Population Board

LTC1 – Multimorbidity (3 long-term conditions (LTC) plus mental health)

Digital remote monitoring implementation for 3 plus long-term conditions and mental health.

Population Outcome link: People with a long-term condition take an active role in managing and improving their condition and the prevention of future multi-morbidities.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals.

Start date: September 2023

LTC2 – Multimorbidity (3 long-term conditions (LTC) plus mental health) Long Covid review and rehabilitation model development

Population Outcome link: N/A

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals.

Start date: In development.

LTC3 – Multimorbidity (3 long-term conditions (LTC) plus mental health) – delivery of respiratory steering group work

• MART – implementation of AZ work with target three Primary Care Networks.
• Expansion of pulmonary rehab.
• Spirometry next steps.

Population Outcome link: I’m as healthy as I can be with my long-term condition.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals.

Start date: January 2023

LTC4 – Multimorbidity (3 long-term conditions (LTC) plus mental health) – delivery of diabetes steering group work

• Conclude local diabetes remission pilot (learnings blend with integrated weight management model).
• Facilitation of NHS diabetes Prevention Programme
• Referrals treatment and care implementation
• Continuous glucose monitoring implementation.

Population Outcome link: I’m as healthy as I can be with my long-term condition.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals.

Start date: January 2022

LTC5 – Multimorbidity (3 long-term conditions (LTC) plus mental health) – delivery of cardiovascular (CVD) steering group work

• Coordination of hypertension and lipids work.
• Heart failure work exit
• Anticoagulation next steps

Population Outcome link: I’m as healthy as I can be with my long-term condition.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Increase percentage of patients with hypertension treated to NICE guidance to 77% by March 2024.

Start date: January 2022

LTC6 – Multimorbidity (3 long-term conditions (LTC) plus mental health) – delivery of neurology steering group work

• CNRS Phase 1 implementation and phase 2 business case development
• FND pathway mapping and next steps

Population Outcome link: I’m as healthy as I can be with my long-term condition.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: October 2022

LTC7 – Lipids – innovation for healthcare inequalities project delivery

West Yorkshire / Academic Health Science Network funded Health Inequalities project

Population Outcome link: N/A

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Increase the percentage of patients aged between 25 and 84 years with a CVD risk score greater than 20% on lipid lowering therapies to 60%.

Start date: July 2023

LTC8 – Lipids – System transformation fund project Lipids

Project delivery on behalf of West Yorkshire and Leeds.

Population Outcome link: N/A

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Increase the percentage of patients aged between 25 and 84 years with a CVD risk score greater than 20% on lipid lowering therapies to 60%.

Start date: July 2023

LTC9 – Home Oxygen – delivery of home oxygen contract across Yorkshire and Humber

Delivery of home oxygen contract across West Yorkshire (WY) plus implementation of WY Quality, Innovation, Productivity and Prevention (QIPP) with VAT legal change granted.

Population Outcome link: N/A

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Increase the percentage of patients aged between 25 and 84 years with a CVD risk score greater than 20% on lipid lowering therapies to 60%.

Start date: July 2023

LTC10 – Integrated Weight Management

Options appraisal if Integrated Weight Management is not supported.

Population Outcome link: People with a Long-term condition take an active role in managing and improving their condition and the prevention of future multi-morbidities.

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals.

Start date: July 2023

Maternity Population Board

M1 – Maternity and Neonatal Voices Partnership

• Deep dive into engagement with service users to ensure care is accessible and close to home.
• Work with LTHT on staff satisfaction survey’s / staff feedback.

Population Outcome link:

• People receive personalised maternity care.
• People receive the support they need to improve or maintain their emotional wellbeing.
• Safe and effective high-quality maternity care is accessible for everyone.
• People are prepared for parenthood.

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: Achieve a 50% reduction in stillbirths, neonatal deaths, brain injuries, and a reduction in maternal morbidity and mortality by 2025.

Impact on NHS national objective: Make progress towards the national safety ambition to reduce stillbirth, neonatal mortality, maternal mortality, and serious intrapartum brain injury.

Start date: May 2023

M2 – Gestational Diabetes

Provide targeted healthy eating and physical activity interventions, infant feeding support, future pregnancy planning education and deliver community-based group peer support sessions to manage diabetes and unhealthy maternal weight.

Population Outcome link:

• People receive personalised maternity care.
• People receive the support they need to improve or maintain their emotional wellbeing.
• Safe and effective high-quality maternity care is accessible for everyone.
• People are prepared for parenthood.

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: Achieve a 50% reduction in stillbirths, neonatal deaths, brain injuries and a reduction in maternal morbidity and mortality by 2025.

Impact on NHS national objective: Make progress towards the national safety ambition to reduce stillbirth, neonatal mortality, maternal mortality, and serious intrapartum brain injury.

Start date: May 2023

M3 – Doulas

Health inequalities non-recurrent funding was used to mobilise the Leeds Doula service. This would require further funding from September 2023 (identified in the health inequalities in community pre-value proposition). The maternity population board, through their logic models, have identified this as a key priority to ensure “people received personalised maternity care safely”

Population Outcome link: Families and babies are supported to achieve optimum physical health.

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: Achieve a 50% reduction in stillbirths, neonatal deaths, brain injuries and a reduction in maternal morbidity and mortality by 2025.

Impact on NHS national objective: Make progress towards the national safety ambition to reduce stillbirth, neonatal mortality, maternal mortality, and serious intrapartum brain injury.

Start date: July 2023

M4 – Maternity Mental health (for West Yorkshire)

The aim of MMHS is to fill the gap not already met by other services and provide support to women experiencing moderate to severe or complex mental health difficulties, including trauma relating to their birth experience, fear of birth itself (tokophobia), and trauma relating to pregnancy and baby loss (including loss through removal into social care).

Population Outcome link:

• People receive personalised maternity care.
• People receive the support they need to improve or maintain their emotional wellbeing.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: Achieve a 50% reduction in stillbirths, neonatal deaths, brain injuries and a reduction in maternal morbidity and mortality by 2025.

Impact on NHS national objective:

• Make progress towards the national safety ambition to reduce stillbirth, neonatal mortality, maternal mortality, and serious intrapartum brain injury.
• Improve access to perinatal mental health services.

Start date: May 2023

Mental Health Population Board

MH1 – Community Health Transformation – mobilisation of new integrated model of care for community mental health with local care partnerships and primary care networks

Piloting and testing of newly designed multiagency integrated MH hub model in three local care partnership areas (4 PCNs) ahead of phased roll out across all LCP / PCNs in Leeds.

Population Outcome link: People’s quality of life will be improved by timely access to appropriate mental health information, support, and services.

System Goal link: N/A

West Yorkshire 10 Big Ambition link: Reduce the gap in life expectancy for people with mental health conditions.

Impact on NHS national objective:

• Achieve a 5% year on year 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.

Start date: July 2023

MH2 – Community Mental Health transformation – Psychological therapies

Developing and increasing capacity in psychological therapies for people with SMI and more complex needs.

Population Outcome link: People’s quality of life will be improved by timely access to appropriate mental health information, support, and services.

System Goal link: N/A

West Yorkshire 10 Big Ambition link: Reduce the gap in life expectancy for people with mental health conditions.

Impact on NHS national objective:

• Achieve a 5% year on year 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.

Start date: April 2023

MH3 – Community Mental Health Transformation – Developing and testing new workforce roles

Including within primary care (including Additional Roles Reimbursement Scheme roles) and in the third sector.

Population Outcome link: People’s quality of life will be improved by timely access to appropriate mental health information, support, and services.

System Goal link: N/A

West Yorkshire 10 Big Ambition link: Reduce the gap in life expectancy for people with mental health conditions.

Impact on NHS national objective:

• Achieve a 5% year on year 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.

Start date: Commenced 2022 / 2023 and progressing to full delivery within new model of care from Q2 2023 / 2024.

MH4 – Improving access to psychological therapy

Working to reduce waiting times to access NHS talking therapies.

Population Outcome link: People’s quality of life will be improved by timely access to appropriate mental health information, support and services.

System Goal link: N/A

West Yorkshire 10 Big Ambition link: Reduce the gap in life expectancy for people with mental health conditions.

Impact on NHS national objective: Increase the number of adults and older adults accessing IAPT treatment.

Start date: 2022 / 2023, in progress

MH5 – Mental Health Crisis – review and evaluation of mental health crisis provision and models of crisis alternatives

Undertaking a deep dive analysis of value and outcomes being delivered in our crisis services pathway, to help inform how we can, reduce the inequalities in access, and improve the experience and outcomes for people accessing support, making the best use of available resources.

Population Outcome link: People’s quality of life will be improved by timely access to appropriate mental health information, support, and services.

System Goal link: N/A

West Yorkshire 10 Big Ambition link: Reduce the gap in life expectancy for people with mental health conditions.

Impact on NHS national objective: Work towards eliminating inappropriate adult acute out of area placements.

Start date: June 2023

MH6 Community Health Transformation – physical health severe mental illness

Further develop outreach and pathways improve access to physical health checks and interventions for people with SMI.

Population Outcome link: N/A

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: Reduce the gap in life expectancy for people with mental health conditions.

Impact on NHS national objective: N/A

Start date: Q4 2022 / 2023 testing outreach models in early implementer sites for new model of care.

MH7 – Community Health Transformation – Early intervention in psychosis pathway

Further develop Early Intervention in Psychosis (EIP) to incorporate identification and intervention for those with at-risk mental states.

Population Outcome link: N/A

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: Reduce the gap in life expectancy for people with mental health conditions.

Impact on NHS national objective: Achieve a 5% year on year increase in the number of adults and older adults supported by community mental health service.

Start date: April 2023 (investment for ARRS pathway in Q3 2022 / 2023 recruitment-recurrent investment for delivery from 1 April 2023).

MH8 – Mental health crisis – street triage

Implementation and evaluation of new delivery model for Street Triage.

Population Outcome link: N/A

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: Reduce the gap in life expectancy for people with mental health conditions.

Impact on NHS national objective: Work towards eliminating inappropriate adult acute out of area placements.

Start date: Redesigned model implementation commenced April 2023

Planned Care Delivery Board

PC1 – Early Diagnosis – Community Diagnostic Centres (CDCs)

Business case approved to develop three sites as part of the CDC model for Leeds, this will expand diagnostic capacity at Seacroft Hospital, Armley and Beeston medical centres for a range of diagnostic tests, including CT, MRI, plain film x-ray, ultrasound, phlebotomy.

Population Outcome link: Planned care services are accessible to all regardless of who they are.

System Goal link: Goal 2 Increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Increase the percentage of patients that receive a diagnostic test within 6 weeks in line with the March 2025 ambition of 95%
• Deliver diagnostic activity levels that support plans to address elective and cancer backlogs and the diagnostic waiting time ambition.

Start date: Implementation underway across all three sites, to be delivering additional diagnostic activity by Q2 2023 / 2024. A business Case for 2023 /2024 and 2024 / 2025 submission due June 2023.

PC2 – Earlier Diagnosis – Leeds Teaching Hospital NHS Trust transformation Programme Diagnostics

Multiple projects:

• Delivery of 6 week wait recovery.
• Responsible requesting.
• Opening new Pathology Estate.
• Community Diagnostic Centres.
• Launch Pathology Lab Information System.

Population Outcome link: N/A

System Goal link: Goal 2 Increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Increase the percentage of patients that receive a diagnostic test within six weeks, in line with the March 2025 ambition of 95%.
• Deliver diagnostic activity levels that support plans to address elective and cancer backlogs and the diagnostic waiting time ambition.

Start date: In progress.

PC3 – Managing Capacity and Elective Recovery – Covid urgent eyecare services (CUES)

Service established August 2020 during COVID-19 pandemic, mandated request by NHS England as routine eye screening had ceased. The service is delivered by Primary Eyecare Services Ltd, the lead for the network of 35 optical practices. Month on month increasing demand for service and evaluation evidencing impact on primary care and A&E services (to a lesser degree).

Population Outcome link: N/A

System Goal link: Goal 1 Reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals.
• Improve A&E waiting times so that no less than 76% of patients are seen within 4 hours by March 2024 with further improvement in 2024 / 2025.

Start date: Service is already established however due to rising demand for service, review of usage and funding model to be undertaken to sustain the service longer term.

PC4 – Managing Capacity and Elective Recovery – Ear, nose and throat and adult hearing loss re-procurement

• Procurement of community services – new contract to be in place April 2024
• Potential Quality, Innovation, Productivity and Prevention (QIPP) opportunities to be identified – longer term savings in bulk buying of hearing aids / reduction in costs of replacement batteries as rechargeable etc.

Population Outcome link: Planned care services are accessible to all regardless of who they are

System Goal link: Goal 2 Increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Eliminate waits of over 65 weeks for elective care by March 2024 (except where patients choose to wait longer or in specific specialities).
• Elective activity levels as a proportion of 19/20 activity reaching 108%.

Start date: April 2024

PC5 – Managing Capacity and Elective Recovery – Gastro re-procurement

• Procurement of community services – new contract to be in place July 2024.
• Potential Quality, Innovation, Productivity and Prevention (QIPP) opportunities to be identified in current contract and for new services.

Population Outcome link:

• Planned care services are accessible to all regardless of who they are.
• People are supported whilst waiting for planned care services.

System Goal link: Goal 2 Increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Eliminate waits of over 65 weeks for elective care by March 2024 (except where patients choose to wait longer or in specific specialities).
• Increase the percentage of patients that receive a diagnostic test within six weeks in line with the March 2025 ambition of 95%.

Start date: July 2024

PC6 – Managing Capacity and Elective Recovery – Harmonisation commissioning policies

Contribution to ensuring commissioning policies and access to treatments is consistent and equitable across the Integrated Care Board (cuts across population and care delivery boards).

Population Outcome link: N/A

System Goal link: N/A

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: September 2023

PC7 – Managing Capacity and Elective Recovery – Leeds Teaching Hospital NHS Trust transformation programme – planned care

Multiple projects:

• Theatre Productivity
• Day Case
• Patient optimisation
• Reducing non-elective pressures
• BADS

Population Outcome link: N/A

System Goal link: N/A

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: in progress.

PC8 – Managing Capacity and Elective Recovery – Opthalmology re-procurement

• Re-procurement of community-based ophthalmology services – Any Qualified Provider (AQP) window to be reopened to extend current contracts for 1 year until 30/09/24.
• Review of services to identify Quality, Innovation, Productivity and Prevention (QIPP) opportunities – Single Point of Access Cataracts (in line with regional approach) – priorities TBC

Population Outcome link:

• People are supported whilst waiting for planned care services.
• Planned care services are accessible to all regardless of who they are.

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness).

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Eliminate waits of over 65 weeks for elective care by March 2024 (except where patients choose to wait longer or in specific specialities)
• Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals.

Start date: October 2024

PC9 – Outpatient Redesign – Increased use of Patient initiated follow up (PIFU)

Converting appropriate patients from routine planned follow up, to follow up initiated by the patient as clinically indicated.

Population Outcome link: people are supported whilst waiting for planned care services.

System Goal link: N/A

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Elective activity levels as a proportion of 2019 / 2020 activity reaching 108%.

Start date: In progress.

PC10 – Outpatient Redesign – Advice and Guidance

Encouraging clinicians to seek advice and guidance on management and treatment of their patients from an appropriate specialist, so that their condition can be appropriately and safely managed without the need for OP referral.

Population Outcome link: people are supported whilst waiting for planned care services.

System Goal link: N/A

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Reduce unnecessary GP appointments and improve patient experience by streamlining direct access and setting up local pathways for direct referrals.
• Eliminate waits of over 65 weeks for elective care by March 2024 (except where patients choose to wait longer or in specific specialities).

Start date: In progress.

PC11 – Outpatient Redesign – reduction in outpatient follow up (OPFU)

Supporting LTHT project team in developing and delivering phased reduction in OPFU activity by 25% (compared to 2019 / 2020 activity), through programme of Clinical Service Unit targeted benchmarking, identification of opportunities, and implementation.

Population Outcome link: people are supported whilst waiting for planned care services.

System Goal link: N/A

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Eliminate waits of over 65 weeks for elective care by March 2024 (except where patients choose to wait longer or in specific specialities).
• Elective activity levels as a proportion of 2019 / 2020 activity reaching 108%.

Start date: February 2023

PC12 – Outpatient Redesign – Leeds Teaching Hospital NHS Trust Transformation Programme – outpatients

Multiple projects:

• Pathway optimisation, inc. reducing DNA / Canx, clinic utilisation, video / telephone consults, patient hub, estate optimisation.
• OP Quality and improvement, inc. standardisation of process, Robotic Process Automation (RPA), enhanced patient information and patient interface.

Population Outcome link: N/A

System Goal link: N/A

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: February 2023

PC13 – Waiting support – waiting well for planned care

Funding for 1 x Care Navigator / Support worker (HI Funding) start date 2 May 2023.

This scheme will target the most deprived people on elective surgical waiting lists to support them to wait well and to reduce the number of acute attendances whilst waiting for care. Four Primary Care Network areas where we are seeing the highest numbers of people presenting at A&E whilst they are on planned care waiting list – these are:

• York Road
• Cross Gates
• Middleton and Hunslet
• Burmantofts, Harehills and Richmond Hill

Population Outcome link:

• People are supported whilst waiting for planned care services.
• People agree appropriate and realistic shared health goals and actively participate in their achievement.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Continue to address health inequalities and deliver on the Core20PLUS5 approach.
• Eliminate waits of over 65 weeks for elective care by March 2024 (except where patients choose to wait longer or in specific specialities).

Start date: April 2023

Primary Care Board

PRI1 – Optimising access to primary care

• Implementation of the access recovery plan which will improve access to primary care through focussing on cloud-based telephony, reviewing models of care through capacity and demand.
• Roll out of new online consultation system.

Population Outcome link: N/A

System Goal link: Goal 1 reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: 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.

Start date: October 2022

PRI2 – 24 / 7 integrated primary care services

Enhanced Access Service (since October replacing GP Extended Access).

Population Outcome link: 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.

Population Outcome link: N/A

System Goal link: Goal 1 reduce preventable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• 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.
• Continue the trajectory to deliver 50 million more appointments in General practice by the end of March 2024.

Start date: April 2023

PRI3 – Annual Health Checks for people with a learning disability

Focus on those patients who have not received an annual health check in previous 18 months (Quality Improvement Scheme).

Population Outcome link: N/A

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness)

West Yorkshire 10 Big Ambition link: 10% reduction in the gap in life expectancy between people with mental health conditions, a learning disability and / or autism

Impact on NHS national objective: Ensure 75% of people over 14 on GP learning disability registers receive an annual health check and health action plan by March 2024.

Start date: April 2023

PRI4 – Dementia Diagnosis

Practices to review their dementia prevalence rate and identify patients at clinical risk of dementia and offer assessment and referral (Quality Improvement Scheme).

Population Outcome link: N/A

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness)

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: Recover the dementia diagnosis rate to 66.7%.

Start date: April 2023

PRI5 – Increasing the primary care workforce including the Additional Roles Reimbursement scheme

Delivery of the Primary Care Workforce Action plan including increasing the number of Additional Roles Reimbursement Scheme (ARRS) employed workforce, developing recruitment and retention measures, supporting the health and wellbeing of the workforce to support increasing capacity of primary care services.

Population Outcome link: N/A

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Continue to recruit 26,000 Additional Roles Reimbursement Scheme roles by the end of March 2024.
• Continue the trajectory to deliver 50 million more appointments in General practice by the end of March 2024

Start date: April 2023

PRI6 – Increase uptake of vaccinations and immunisations (including flu and COVID)

Continue to support the delivery of all the vaccination programmes.

Population Outcome link: N/A

System Goal link: Goal 2 increase early identification and intervention (of both risk factors and actual physical and mental illness)

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: N/A

Start date: N/A

Same Day Response Care Delivery Board

SDR1 – Same Day Response (reducing people attending A&E) – PCAL+ Creating a new single gateway that brings together the Primary Care Advice Line (PCAL) and the Single Point Urgent Referral (SPUR) & Yorkshire Ambulance Service (YAS) push model

Working with YAS in testing out their ability to identify and ‘push’ referral to Urgent Community Response (UCR) via SPUR as clinically triaged from the ambulance stack and then secondly assessing the impact of primary / community clinicians ‘pulling’ patients from the stack and providing an UCR response.

Population Outcome link:

• 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.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Improve A&E wating times so that no less than 76% of patients are seen within 4 hours by March 2024 with further improvement in 2024/25
• Reduce adult general and acute bed occupancy to 92% or below.

Start date: In progress.

SDR2 – Same-Day response (reducing people attending A&E) – Children Urgent Care

Paediatric ARI hub – Community Ambulatory Paediatric Service (CAPS) service aims to provide same day provision for children that have been clinically assessed / triaged as requiring face to face physical examination and present with respiratory symptoms.

Population Outcome link:

• 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.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Improve A&E wating times so that no less than 76% of patients are seen within four hours by March 2024 with further improvement in 2024 / 2025.
• Reduce adult general and acute bed occupancy to 92% or below.

Start date: December 2022

SDR3 – Same-Day Response (reducing people attending A&E) – Maximise Primary Care Advice Line

Avoid unnecessary ED attendances by facilitating healthcare providers to get patients to the right place for their care sooner to enable better patient outcomes and experience. The service currently has access to approximately 50 same day emergency care pathways within LTHT.

Population Outcome link:

• 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.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: improve A&E wating times so that no less than 76% of patients are seen within four hours by March 2024 with further improvement in 2024 / 2025.

Start date: In progress.

SDR4 – Same-Day Response (reducing people attending A&E) – Developing Same Day Emergency Care

Same Day Emergency Care (SDEC) aims to reduce admissions and ED attendances by providing timely assessment, diagnosis, and treatment, improving patient experience and care.

Population Outcome link:

• 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 appropriated to people’s same day needs now, whilst considering how these might change in the future.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Improve A&E wating times so that no less than 76% of patients are seen within four hours by March 2024 with further improvement in 2024 / 2025.
• Improve category 2 ambulance response times to an average of 30 minutes across 2023 / 2024 with further improvements towards pre-pandemic levels in 2024 / 2025.

Start date: In progress.

SDR5 – Urgent community response.

Enhanced Community Response is to deliver urgent community response services aiming to reduce disruption to people’s lives via alternatives to Emergency Department (ED) attendance / admissions to hospital; shorten length of stay. Workstreams include:

• Same Day elements – Two-hour Crisis Response offer, Telecare Rapid Falls Response
• Virtual Wards (Hospital)

Population Outcome link:

• 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.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective:

• Improve A&E wating times so that no less than 76% of patients are seen within four hours by March 2024 with further improvement in 2024 / 2025.
• Reduce adult general and acute bed occupancy to 92% or below.
• Consistently meet or exceed the 70% two-hour community response standard.

Start date: In progress.

SDR6 – BARCA – high volume service user service

The BOST service works with service users and providers to identify the root cause of urgent and same day services high volume service use and work to resolve these causes.  The exact intervention(s) needed for each individual cannot be prescribed (due to the potentially diverse requirements), but the focus should be on reducing UEC usage and overall system spend on this group of service users.

Population Outcome link:

• 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.

System Goal link: Goal 1 reduce avoidable unplanned care utilisation across health settings through a focus on keeping people well.

West Yorkshire 10 Big Ambition link: N/A

Impact on NHS national objective: improve A&E waiting times so that no less than 76% of patients are seen within four hours by March 2024 with further improvement in 2024 / 2025.

Start date: In progress.

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