Joint Forward Plan Appendix 8

Appendix 8: Detailed Live Well Domain Plans – Be Well

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1.1 Be Well – Empowering Adults to Lead Healthy Lifestyles

1.1.1 Healthy Behaviours / Healthy Life for Everyone

Why is this important for people in Suffolk and North East Essex?

Everyone in SNEE should be able to live a healthy life with good physical, mental and social wellbeing. There is a clear social gradient in the harm to health from health behaviours and lifestyle factors which have been exacerbated by the Covid-19 pandemic. Action is needed to reduce health inequalities and prioritise the prevention of ill health.

There are several dimensions to a healthy life:

  • enjoying good physical health: eating healthily, being physically active, maintaining a healthy weight and sleeping well
  • avoiding those things that are harmful to health
  • being socially connected, having purpose, and contributing to the community and environment
  • taking notice, connecting, learning, and engaging in creative activity
  • emotional wellness and enjoying positive mental wellbeing
  • feeling safe in your home or community
  • a clean and sustainable environment

This is why we will take a holistic approach to prevention throughout the lives of children and adults rather than advancing multiple separate approaches for disease specific areas

A healthy life benefits everyone living in Suffolk and North East Essex by:

  • promoting good physical and mental health and wellbeing for everyone
  • improving the conditions that promote positive physical and mental health and prevent poor health.
  • preventing ill health e.g., diabetes, cancer, mental illness
  • helping people to live well with long term conditions e.g., COPD, diabetes, obesity
  • slowing the progression of some conditions e.g., dementia, frailty
  • helping people to recover from ill health e.g., depression, cancer

The 2019 Green Paper ‘Advancing Our Health: Prevention in the 2020s’ describes a new approach:

‘We need to view health as an asset to invest in throughout our lives, and not just a problem to fix when it goes wrong. Everybody in this country should have a solid foundation on which to build their health… This means moving from dealing with the consequences of poor health to promoting the conditions for good health and designing services around user need, not just the way we’ve done things in the past.’

Social, economic, and environmental factors, including the impact of deprivation affects our ability to live healthy lifestyles:

  • physical activity levels decrease as deprivation increases, from 72% active in the least deprived areas, to 57% in the most deprived areas
  • food is the largest item of household expenditure for low-income households, after housing, and energy costs
  • the current cost of living pressures impacts us all however those already in poverty are feeling the impacts greatest
  • the Covid-19 pandemic has exacerbated health inequalities and provided a clear illustration of the unequal impact of disease and poor health on deprived communities

What do we know about people’s local experiences?

People tell us that information on behaviour change would help them use a healthy living service or group. Over half of those who responded to a Public Health survey in Suffolk said that fun activities in groups would help them with behaviour change. However, there was a subsection of respondents that felt large groups are sometimes detrimental to successful personal outcomes and potentially off putting. A quarter of respondents to the survey had not accessed services as they would not feel comfortable using them. This was echoed in others who talked about anxiousness when attending group services.

Services that are relevant to people and convenient for them to use are important. People are seeking a flexible offer that fits around their lives and is responsive to changing needs. We also need to do more to reach communities who have not traditionally engaged in services and to address the determinants of poor health and wellbeing.

People commented on language around health behaviours noting the need to avoid stigmatising and blame.

How we plan to make a difference

  • Children, adults, and older people are supported to stop smoking
  • Children, adults, and older people are supported to maintain a healthy weight, be physically active and to eat and drink healthily
  • Children, adults, and older people are supported to get the sleep that they need
  • Young people, adults and older people have good sexual and reproductive health
  • Children, adults, and older people are socially connected and avoid loneliness
  • Children, adults, and older people have opportunities to volunteer to help them connect with and support others
  • Children, adults, and older people are able to live in a clean and sustainable environment
Children, adults, and older people are supported to stop smoking

By the end of 2023/24 we will have in place a smoking cessation and control strategy to support people to understand the dangers of smoking and vaping in order to reduce tobacco dependency and help people will feel supported to stop smoking.

By 2024/25 the NHS Plan Tobacco Dependency Treatment Programme will be in place across all acute, maternity, and mental health settings.

By October 2023 new smoking cessation services will be in place across the alliance with increased provision in community settings.

In 2023/24 we will publish a new Tobacco Control strategy responding to the national tobacco control plan.

In 2023/24 we will deliver a programme to address the high prevalence of smoking in routine and manual workers and disadvantaged communities in West Suffolk.

Children, adults, and older people are supported to maintain a healthy weight, be physically active and to eat and drink healthily

People know how to prepare food and drinks that will be healthier for them

By the end of 2023/24 we will have published a new Healthy Weight Strategy for Suffolk.

From 2024 we will deliver an annual programme of health awareness raising campaigns, incorporating both locally produced and national campaigns, aligned to identified priorities and the Suffolk and Essex health behaviours programmes (including digital offers).

People have healthier food and drink choices available in the places where they live and work

Working with partners and local communities we develop programmes to deliver whole system approaches to obesity in at least two places across SNEE by 2025.

From 2023 children and families, adults and older people living in poverty will be helped to have access to healthy food by accessing a range of food offers and cash first offers. We will know that we have been successful as we see more people moving from crisis support (foodbanks) to tailored and supported food outlet offers.

By 2025 we will have increased the uptake of Healthy Start vouchers in those eligible to 80% with a specific focus on increasing uptake in areas and in communities where uptake is low.

People have access to technology to help them make healthy nutritional choices

Making best use of technology widens access to information and advice to help people make healthy choices.

By October 2023 Suffolk Public Health and Communities Team and Essex Public Health will deliver a digital first approach for health behaviours, expanding the digital support for healthy behaviours.

All children are physically active at least an hour a day

The UK Chief Medical Officers’ Physical Activity Guidelines are clear that the evidence demonstrates that higher levels of time that under 5’s spend in physical activity is associated consistently with improved: adiposity (infants); motor development (infants, toddlers, pre-schoolers); cognitive development (infants, pre-schoolers); fitness (pre-schoolers); bone/skeletal health (pre-schoolers); and cardiometabolic health (pre-schoolers). Encouraging activity at an
early life stage promotes healthy growth and development; and helps build positive habits as children grow into adulthood.

Physical activity is associated with better physiological, psychological, and psychosocial health among children and young people. The Childhood Obesity Plan sets out guidelines that children and young people should get 30 minutes of their daily physical activity through the school day and 30 minutes outside of school. Activity during the school day should be delivered through active break times, PE, extra-curricular clubs, active lessons, or other sport and physical activity events.

The remaining 30 minutes should be supported by parents and carers outside of school time. There is good evidence to demonstrate that schemes such as the Daily Mile are effective at improving children’s physical health and wellbeing, mental health and wellbeing, and their learning.

Early years services and settings will be encouraged to follow best practice guidance for physical activity including active play.

We will work with Active Suffolk, Active Essex, and local authorities to increase the proportion of school-age children and young people who engage in moderate to vigorous intensity physical activity for at least 60 minutes every day by 10% by 2028.

Adults are supported to be more active as part of their regular routine

Regular physical activity is associated with decreased mortality and lower morbidity from several non-communicable diseases. Adults who are physically active report more positive mental and physical health.

Enabling people to combine their work life and exercise will encourage people to increase their levels of activity. Support can include healthier ways to travel to work such as walking or cycling, opportunities such as lunchtime exercise classes and on-line options and help for employees to be active during the working day.

Working with Active Suffolk, Public Health and Communities and District and Borough Councils we will publish a physical activity strategy for Suffolk by end 2023/24.

Working with our Active Partnerships and others we will develop a programme to support employers in SNEE to encourage employees to be more active by March 2024.

Commencing in October 2023, we will increase access via social prescribing and other means to physical activity programmes in the community by expanding the current exercise referral programmes across the whole SNEE area.

By October 2024 we will have developed a programme to support healthcare professionals to improve awareness, knowledge, confidence, and skills to promote physical activity to people within routine care as a way of preventing and managing ill health.

Adults with severe and complex obesity are supported to lose weight

We will review our Tier Three and Tier Four specialist weight management offers in SNEE by March 2024 and make any changes thereafter to our service offer.

Older adults are supported to remain active for as long as possible into old age

According to the UK Chief Medical Officers there is strong evidence that physical activity contributes to increased physical function, reduced impairment, independent living, and improved quality of life in both healthy and frail older adults. Physical activity in later life can also help treat and offset the symptoms of a range of chronic conditions (e.g., depression, CVD, Parkinson’s disease).

  • by 2025 we will have increased the availability of community-based activity programmes, including strength and balance classes, specifically focused on older adults across the SNEE area
  • we will support the managers and care workers in care settings to have good conversations about physical activity with residents and their families

Children, adults, and older people are supported to get the sleep that they need

People understand the principles of good sleep hygiene. This includes regular sleep times, and avoiding screen time, alcohol, and caffeine

There are many reasons why you might not be able to sleep well. Some people are naturally lighter sleepers or take longer to drop off, while some life circumstances might make it more likely for sleep to be interrupted, like stressful events currently or in the past. More information on sleep problems can be found on the every mind matters website.

We will deliver a campaign to promote awareness of good sleep hygiene for everyone by 2025.

We will help people with sleep disorders to access integrated physical and mental health support.

Vulnerable children, adults and older people have a safe and healthy environment to sleep

Sleeping safely involves not only avoiding injury, but also supporting comfort and good quality sleep. Children are safe and healthy when they have privacy, a hygienic bed and comfortable sleeping environment and are free from abuse or neglect.

We will provide support to people with health conditions to have a safe bed in their own home, in hospital or in care settings.

We will increase the proportion of babies, children, and young people in families where there are safeguarding concerns who are supported to have a safe bedroom with the facilities they need for healthy sleep.

We will deliver annual campaigns to promote awareness of safer sleeping for babies and toddlers and to inform parents and carers about coping with crying strategies.

Young people, adults and older people have good sexual and contraceptive health

People know how to maintain good sexual and reproductive health

We will continue to provide accessible information on sexual health and safer sex practices, which is culturally sensitive and meets the 2 See Sleep problems – Every Mind Matters – NHS ( needs of people at all ages and of all sexual orientations. Information will be made available in a range of settings.

Through the services we commission we will reduce inequality in access to a range of effective methods of contraception, planning for pregnancy, and personalised advice and care to enable people to access the best option to meet their needs and minimise the risk of sexually transmitted infections.

Working with public health and other partners we will eliminate the waiting times for long-acting reversible contraception created through the impact of Covid-19, by 2024/25.

People have the support they need with unplanned pregnancy

By 2024/25 we will have increased timely and flexible access for people to universal relationship, sexual health, and contraceptive advice to prevent unplanned pregnancy through the services commissioned through Public Health in Suffolk and Essex.

By 2024/25, young people at a higher risk of an early unplanned pregnancy will receive additional, targeted support.

By 2024/25, people will have access to tailored, high-quality care and support in the event of an unplanned pregnancy.

People have support for sexually transmitted infections

By 2024/25 we will ensure that timely access to testing and treatment for sexually transmitted infections and blood borne viruses, together with contraceptive advice, is universally available and targeted to the needs of the highest risk groups.

By 2028 we will have delivered at least 2 media campaigns to promote awareness of HIV and promote access to testing and treatment for HIV especially for high-risk groups.

By 2028 we will ensure equitable access to PrEP targeted at highest risk groups. This will help reduce the number of people who become aware of their HIV status at a late stage and use treatment as prevention to reduce incidence.

People will have equal access to services and support

By 2025 we will have delivered a programme of work to address the stigmas associated with STIs, unplanned pregnancies and HIV with people, families, health, and care staff, and the wider public.

By 2025/26 we will have developed and delivered a training programme for staff in health and care in good sexual and reproductive health, how to discuss it with vulnerable people and those with limited understanding and communication, issues of consent for vulnerable young people and adults, and how to promote positive relationships.

Children, adults, and older people are socially connected and avoid loneliness

People are supported to be socially included and less lonely

By 2028 we will have delivered two campaigns and supporting activity to improve public awareness of loneliness and social isolation.

By 2024/25 we will have developed and delivered a training programme to train staff who work with vulnerable groups e.g., older people, vulnerable younger people, and isolated parents to recognise when people who may be experiencing, loneliness or social isolation and to ensure they are supported appropriately.

By 2024/5 we will have increased the number of employers in SNEE who commit to the Campaign to End Loneliness pledge and who support their employees’ social wellbeing.

By 2024/25 all SNEE system partners will have committed to the Campaign to End Loneliness pledge.

By 2028 we will ensure that bereaved people have access to social support to avoid loneliness.

By 2025/26 we will have extended befriender, volunteer, and peer support schemes to include digital connections.

By 2025/26 we will have increased the capacity of social prescribing to promote social contact, particularly for those experiencing loneliness and isolation.

People are encouraged to volunteer to help them connect with and support others

Improved information on volunteering opportunities will help people to know the breadth of options and encourage them to try it.

We will work with partners to coordinate information on volunteering opportunities, promote options and the proportion of the population of SNEE who participate in regular volunteering

Children, adults, and older people are able to live in a clean and sustainable environment

We will reduce waste across the public sector wherever possible, including by 2024/25 eliminating where possible the avoidable use and availability of single-use plastics such as plastic cups and cutlery.

By 2028 we will have delivered two campaigns supported by community interventions to encourage people to grow their own fruit and vegetables to cut down on air miles, and to minimise packaging by using their own containers to bulk buy dry foods.

Please see section 7.9 Sustainability for further details on our Sustainability commitments.

We will know we are making a difference because we will see:

  • healthy life expectancy for males and females will increase from the 2018/19 baseline and the inequality in life expectancy will reduce over the course of this strategy to 2028
  • a lower percentage of people smoke or vape and there is a lower incidence of smoking related diseases
  • by 2028 the proportion of adults (aged 18+) classified as overweight or obese will have reduced to below 60% and will be maintained at below the national level
  • the rise in the prevalence of overweight and obesity in children in reception and year 6 of primary school will have halted by 2028 and will be maintained at below England level
  • the increase in the incidence of type 2 diabetes will have halted by 2028
  • by 2028 the proportion of the population (adults) meeting the recommended ‘5-a-day’ on a usual day will have increased by 5% on the 2019/20 rate
  • by 2028 the percentage of children and adults meeting the recommended levels of physical activity will have increased by 10% on 2021/22 rates
  • by 2028 the proportion of children and adults walking or cycling for travel regularly will have increased by 10%
  • by 2028 the proportion of SNEE residents who report low satisfaction or anxiety will have reduced by 5%
  • by 2028 rates of self-reported wellbeing, as recorded in the Emotional Needs Audit will improve by 5%
  • by 2028 the number of people who report a sense of wellbeing connection and belonging in their local community will improve by 10%
  • by 2028 total prescribed LARC excluding injections rate/1000 will have increased by 10%
  • by 2028 we will have achieved a 10% increase from 2022 baseline in rates of sexually transmitted infection testing across the SNEE population, with a higher rate of increase in higher risk groups
  • by 2028 the proportion of people requiring abortion services will have reduced by 5% from 2022 baseline levels
  • by 2028 the rate of conceptions in people aged 17 years and under will have reduced by 5%

Quote: ‘’So much of the work we do is about preventing ill health. This means understanding the factors that keep people well, ensuring they enjoy as many years as possible in relatively good health.

While there are many issues that affect health, from the quality of people’s environment to their education and opportunities for good work, we also know that certain behaviours can also have a significant positive or detrimental impact on personal wellbeing. That’s why we empower people to be healthy across a range of services and with different partners and our accompanying campaign and social marketing work also encourage people to make small changes to improve their health.

From our current integrated healthy lifestyle service, we are also developing a new partnership model with district and borough councils in Suffolk to provide a more localised, tailored offer to support people to lose weight, quit smoking and to be more active.
Cllr Andrew Reid, Suffolk County Council Cabinet Member for Public
Health and Public Protection and Chairman of Suffolk Health and Well-Being Board’’

Case Studies

Tackling physical inactivity in Essex head on

Essex was chosen by Sport England as one of 12 areas in England to tackle physical inactivity in a ground- breaking way. Our Local Delivery Pilot (LDP) focuses on three localities across Essex, two of which are Colchester and Tendring.

We aim to improve physical activity for everyone, but with a targeted focus on three populations: older people, families with dependent children and people with poor mental health. We are taking a whole system approach, increasing community engagement and cohesion through new social movements, networks, and communications.

We are developing community capacity and creating active environments. We are also learning from our experiences and creating sustainability. We are already developing new partnerships and aligning our strategies and priorities to this work. We will continue to work closely with all our partners to ensure our whole system change work links closely with wider developments and to share our learning.

Weight management for more people

Essex County Council’s weight management service had capacity for a tiny proportion of people who were overweight. Traditional services can foster dependence on professionally led models, rather than building individual and community resilience. We needed to massively increase the number of people supported to lose weight, and ensure improvements lasted for the rest of their lives.

We discussed with our provider, Anglian Community Enterprise (ACE), how to maximise local opportunities for weight management without over professionalising, and how to implement a more sensitive triage process which reflected the complexity of people’s excess weight on a continuum from relatively simple to relatively complex. We developed a new light touch delivery model
involving 30 new local delivery partners including CsVS, libraries, district councils and others offering social support for weight management, rather than a professionally led service. We also developed an online offer. These services achieved an average weight loss of 3.7kg.

We recognised more of the same won’t work, and our team was given latitude to explore the new, over which we have less direct control. We are part way through the journey, and next steps involve working more directly with people and communities as delivery partners.

1.1.2 Personalised Care

Why is this important for people in Suffolk and North East Essex?

Personalised care means people have choice and control over the way their care is planned and delivered, based on ‘what matters’ to them and their individual strengths, needs and preferences, which is essential if everyone in SNEE is to live well.

As the complexity of individual needs have changed and expectations towards healthcare have evolved over time, it has become apparent that there is a fundamental need for personalised care. Choice plays a big factor in everyday life, and that should be no different when it comes to decisions about the care we receive for our physical or mental health.

Personalised care represents a major practical change to the NHS and is a key part of the LTP. It is a whole system approach that requires a variety of services across the health, social care, public health, and community spectrum to be integrated around the individual in order to deliver better outcomes and experiences. It has also led to the creation of a range of new roles that further improve the quality of care that people receive and takes learning from the experiences of social care in delivering person centred care for adults, children, and families.

Research has shown that when people have the opportunity to be involved in decision making around personalised healthcare, there are generally better outcomes and experiences and reduced health inequalities. Specific benefits of personalised care include better adherence to medical advice – as the person was involved in the decision – and increased patient and clinician satisfaction.

Clear information and discussions with health and care professionals help people make informed choices about their care. This will help accelerate the programme to introduce patient initiated follow ups (PIFUs) as well as a greater understanding of how non-clinical interventions can help improve medical outcomes. Our ICS Personalised Care Strategy, Patient Choice, Shared Decision Making, Social Prescribing, and overarching personalised care and support
plans and workstreams have a key role in progressing this work.

Plans are in place as part of the ICS-wide Personal Care and Support Plan workstream to identify unmet need with proactive case-finding and collaboration across acute, primary care and VCSE. During 2022, personal care and support plans were further rolled out across care pathways and commissioned services. We are embedding the personalised care requirement as part of contract and commissioning approaches with our statutory and VCSE providers.

Each Alliance has been accelerating personalised approaches to follow-up care in hospitals for people on Discharge to Assess pathways 0 and 1 (those who can go home or need support within their home). As an example, the ‘Welcome Home’ Programme, established over winter 2021/22 will further enhance and support the pathway process when people are admitted to Ipswich Hospital’s Emergency Assessment Unit, Surgical Assessment Unit and Trauma and Orthopaedics and all hospital wards. The Welcome Home team follows through the journey of patients in hospital up to and including discharge and onward referral to the community based Connect for Health Social Prescribing service and our multi-cultural social prescribing service.

The seven day a week service model comprises three Whole Time Equivalent (WTE) social prescribing ‘Advice and Support co-ordinators’ managed by Citizens Advice Bureau who provide additional support and capacity to the existing discharge pathway in place by undertaking personalised care and support planning at ward level with the patient, their family, carers, and staff during their hospital stay as part of an enhanced holistic MDT approach. As part of Welcome Home, one-off Personal Health Budgets (PHBs) will be available to provide people with the support they need to leave the hospital safely and to help meet their health and wellbeing needs and outcomes in line with their personalised care and support plan.

The Personalised Care Programme requires that all people should:

  • be seen as a whole person within the context of their whole life, valuing their skills, strengths and experience and important relationships
  • experience hope and feel confident that the care and support they receive will deliver what matters most to them
  • access information and advice that is clear, timely and meets their individual information needs and preferences
  • be listened to and understood in a way that builds trusting and effective relationships with people
  • be valued as an active participant in conversations and decisions about their health and wellbeing
  • be supported to understand their care, treatment, and support options and, where relevant, to set and achieve their goals
  • have access to a range of support options including peer support and community-based resources to help build knowledge, skills,and confidence to manage their health and wellbeing
  • experience a coordinated approach that is transparent and empowering

What do we know about people’s local experiences?

In the past three years over 27,000 people were referred for a discussion with a social prescriber to work on the non-health and care aspects of their health and wellbeing. The number of social prescribers across our system has expanded so that there are social prescriber link workers covering our whole population, based in Integrated Neighbourhood Teams, PCNs and the VCSE sector.

Over the past year more than 13,000 people have been seen by a Health and Wellbeing Coach or a Care Co-ordinator, roles which are specifically set up to help people with complex health conditions or who need to make lifestyle changes because of their ill health. This year 1,400 people have had their needs met through a personal health budget which gives them choice and control over the services they receive.

Shared decision-making conversations happened across our system, with more than 6,000 logged into health records. These conversations gave the opportunity for people to understand more about the health options available to them and to make informed choices alongside their medical professional.

How we plan to make a difference

As an ICS we will work with people and professionals so that:

  • people can manage their own health and wellbeing
  • people have maximum choice and control over their health and wellbeing care and support
  • people have expert support to make the care decisions that are right for them in partnership with professionals who are caring for them
  • we work as a system to deliver personalised care

People are able to manage their own health and wellbeing

People have the advice and support they need to self-manage their health and wellbeing

Creating an online directory of services managed by Suffolk County Council that is easily accessible by people and professionals by April 2024. This would enable access to a range of holistic resources and services in their community or broader area which best match with their individual needs.

Continue to develop and expand the network of social prescribing link workers with more people able to access support.

Continue to work with partners across the system to ensure that access to social prescribing is supported and made available through links to existing pathways, promoting social prescribing services, and sharing communication and education which recognises that health and wellbeing outcomes are determined by more than health and care interventions, to increase the number of referrals to social prescribing link workers from professionals in our system.

Promoting Health Coaching for our staff so that they can work with people to manage their health and wellbeing goals. We aim to continue to offer at least 224 places locally, and to improve on that number over the next year.

Understanding the learning from the Healthwatch report into the outcomes from Health Coaching and taking the lessons learnt into practice by December 2023.

Ensuring professionals are trained and confident to use approaches which help people to identify lifestyle changes and how to build on their own assets, for example we will promote Making Every Contact Count and Signs of Safety training through our newsletters and training activities.

People have maximum choice and control over their health and wellbeing care and support

People’s care and support is based on what matters to them and their individual strengths and needs

Growing the understanding of the importance of personalised care and asking, “what matters” not just “what is the matter?”

Focusing care and support on maximising people’s opportunities for good health and independence, based on individual strengths and needs and addressing what is important to them.

Working with training providers in all our front-line services to ensure that personalised approaches are embedded in training courses, including induction training, so that more professionals feel confident to offer personalised care by April 2024.

We will promote the use of personalised care and support plans which include a discussion about what matters to people, with their key priorities and concerns included as integral elements to their plan with actions to take forward the plan agreed between professionals and service users.

Initiate proactive case finding and support to self-care in primary care to provide information, connection with social prescribers and health and wellbeing opportunities. This will help people to live well with their conditions.

People with complex needs will be able to access care co-ordinators to provide extra time, capacity, and expertise to support them in preparing for clinical conversations or in following up discussions with primary care professionals.

People are aware of their choice and control rights and have the information they need to make decisions about their care and how it is delivered.

People are given options, guidance, and support to help inform their own plan of action and how to access help when they need it.

People’s records are made and shared using best practice

A digital app holding shared records will be tested and then refined for use by people at the end of life.

Learning will be used to increase the circumstances where records are shared.

People with long term conditions and disabilities have more choice and control over how the funds for their health and wellbeing are spent.

Increasing the number of personal health budgets (PHBs) that are awarded as a key outcome from a personalised care and support plan with an aim to deliver 3,300 in 2023/24. This will mean that people are more involved in decisions about their health and care with their voice at the centre co-producing plans.

Moving to a more aligned system with social care so that people’s experience when they receive PHBs is co-ordinated and integrated.

Using people’s experience of personal budgets, community groups and a PHM approach to find out where PHBs can improve health equity and prioritise those areas for action.

Making sure that everyone with a right to have a PHB is offered one and that they are given sufficient information to make an informed choice.

Identifying new opportunities for offering people one off or ongoing PHBs so that they can have greater choice and control over the health and care support they receive including piloting during 2023/24 for people with SMI.

Working with people involved with cancer services, including people with cancer and their carers, to identify opportunities for PHBs, including for one off items of need.

Put in place a more streamlined, effective, and accountable financial management system for PHBs, starting with a feasibility study to identify the scope, potential partner organisations, opportunity, risks,and costs.

Engage with people who have used PHBs to find out their experiences and act on what they say.

Ensure that all transformation and commissioning approaches include a personal health budget offer as a matter of course.

People can access support for their health and wellbeing within their local communities

Social prescribing link workers, health and wellbeing coaches and care navigators across our system, including in PCNs will work with people to develop tailored plans and connect them with local groups and support services. Social prescribing can result in improved quality of life and wellbeing; and reduce demand on statutory health and care services.

People will be better informed about local groups and communities. Accurate and updated information enables people to access support independently, not solely when ‘prescribed’.

People have expert support to make the care decisions that are right for them in partnership with professionals who are caring for them

Shared Decision Making is promoted, through the uptake of national and local training, the use of Shared Decision-Making tools and pathway specific actions within health and care services, ensuring that a person’s voice is at the centre of a co-produced plan.

There is an increase in the number of personal care and support planning conversations taking place with people – asking “what matters to you” and addressing priorities of people and their families.

One off payment to help people stay at home and to help them return from hospital are available when this is the most effective way to offer support.

We will work as a system to deliver personalised care

As an ICS we will work together to deliver person centred, personalised care for all our population in SNEE that respects personal choice, addresses inequalities, and increases independence and wellbeing:

  • we will deliver a fundamental shift in how we work alongside people and communities, recognising that the importance of ‘what matters to someone’ is not just ‘what’s the matter with someone’
  • we will listen to what people are saying about their experience of personalised care before we make changes or undertake new work
  • we will prioritise the development of our workforce to enable our front-line teams with the necessary skills and resources to deliver personalised care within their everyday interactions.
  • increase the number of people who access training for personalised care from the Personalised Care Institute, local training opportunities or other on-line resources
  • ensure that personalised care approaches are woven through training for front line professionals and included in induction training
  • work with Social Prescribers, Health Coaches and Care Coordinators to ensure they have the training and peer support that they need in their roles
  • we will deliver personalised care priorities within the Live Well Domains and provide support and resources to empower system partners to embed personalisation across everything we do

We will know we are making a difference because we will see:

  • the delivery of the commitments throughout this plan to deliver personalised care
  • an increase in personalised care and support plans either patient held or recorded in our system to 78,000 by 2027/28
  • social prescribing conversations happening routinely as a recognition that improved health and wellbeing outcomes start with finding out “what matters to me”
  • over 35,000 social prescribing referrals made each year, increasing if we are able to recruit more social prescribers
  • an increase in personal health budgets to 6,500 by 2027/28, linked to personalised care and support plans

Case Studies

Pam’s Story

Pam was admitted to hospital following a fall at home. The medical team deemed her medically fit to go home. Her daughter contacted the ward and explained Pam had been showing signs of confusion and had left the gas hob on three times. It would have been unsafe for Pam to return home to the same situation.

Personalised Care and Support Plan

Pam was seen by the ward based social prescriber. She told him she felt highly anxious about going back home. She knew that her memory “sometimes let her down” and she knew that she might fall again and might forget to turn off the gas hob. What mattered to Pam was to remain at home, to be able to look after herself and to carry on cooking, just as she always had done.

What the Social Prescriber did

Purchased an electric hob using the discharge PHB fund. Pam was able to return home with a minimised risk of readmission or further harm or injury. Once home, Pam could cook and care for herself in the independent way she valued. With Pam’s agreement, she was referred to the fire brigade for a safety assessment. The social prescriber followed this up a week post discharge and liaised with the family to make sure they had the information they needed to act on the assessment outcomes for improved home safety.

Personalised Care Outcomes
  • Discharge was not delayed due to non-medical reasons.
  • Bed days saved = £2,800
  • Immediate health and safety concerns were addressed.
  • The PHB was used to meet Pam’s personalised wish to remain at home and to carry on cooking independently for herself.
  • Pam felt she had been listened to and she and her family felt happier about her going home.
Green Social Prescribing

The Outdoor Wellbeing Experience is a green social prescribing project providing non-medical interventions in Stowmarket. People are identified using PHM data and working collaboratively with GPs, people are offered appointments with a Social Prescribing Link Worker who undertakes a full ‘discovery’ session with everyone, identifying ‘what matters to them’. People are then offered a place on the Outdoor Wellbeing Experience, a 10-week programme where they undertake a range of outdoor activities including conservation, foraging and woodland management.

Case Study “Sue”

Personalised care and support plan:

Plan completed with the patient, following the principles of the plan and allowing “Sue” to be the leading voice throughout their hospital journey.

Discharge Support Fund:

Funding provided from our Discharge Support Fund to purchase a birth certificate to allow the patient to apply for permanent housing.


Purchasing a birth certificate allowed “Sue” to apply for permanent housing through their local council – previously they were unable due to having no Proof of Identity.

Social Life:

Having access to funds through their Proof of Identity allowed “Sue” to go out and socialise with friends.

Income Independence:

Having Proof of Identity allowed “Sue” to apply for financial support, which would provide financial independence to Sue.

“Sue” Story

“Sue” was admitted to hospital with worsening health problems stemming from a pre-existing condition. “Sue3” had been in a relationship that had broken down while they were in hospital- “Sue” had been living there as their fixed address. “Sue” had no Proof of Identity and was not receiving any financial support from local agencies.

Days saved from the patients estimated discharge date: 28 days

Amount used from the Discharged Support Fund: £40

Savings for the hospital: £6960 (based upon £20 per day patient stays within the hospital – information provided by CGH Finance)

1.1.3 Women’s Health

Why is this important for people in Suffolk and North East Essex?

A higher proportion of the population are female in England (around 51%) and this is also true of our local population across SNEE (source ONS data) Although women in the UK on average live longer than men, women spend a significantly greater proportion of their lives in ill health and disability. It is important to note that our focus on women’s health is inclusive, when we refer to women, we include those who are intersex, non-binary, and transgender men where appropriate.

In a national call for evidence in 2021 84% of respondents felt that women’s voices in relation to healthcare were not listened to. Not enough focus is placed on women-specific issues like miscarriage or menopause, and women are under-represented when it comes to important clinical trials. This has meant that not enough is known about conditions that only affect women, or about how conditions that affect both men and women impact them in different ways.

In 2022 the government launched their first Women’s Health Strategy for England. It sets out how they aim to improve the way in which the health and care system listens to women’s voices, and boosts health outcomes for women and girls. It takes a life course approach, focused on understanding the changing health and care needs of women and girls across their lives, from adolescents and young adults to later life.

We feel that this national drive is equally important for our system, where our health and wellbeing team supporting staff have started to gather evidence from women who work in health and care in SNEE.

Figure 1: Women’s health across the life course

Women’s health needs:

Adolescents and young adults (puberty-24)Middle years (25-50)Later years (51+)
HPV vaccinationMenstrual healthGynaecological conditions
Menstrual healthGynaecological conditionscontraception
Gynaecological conditionscontraceptionCervical Screening
contraceptionCervical ScreeningGynaecological cancers
Sexual health and wellbeingGynaecological cancersSexual health and wellbeing
Pregnancy, fertility, pregnancy loss, abortion care and postnatal supportSexual health and wellbeingPelvic Floor Health
Pregnancy, fertility, pregnancy loss, abortion care and postnatal supportPerimenopause and menopause
Pelvic Floor Health Breast cancer screening
Early Menopause and perimenopause
Table showing different areas of women’s health needs by age group

General health needs:

Adolescents and young adults (puberty-24)Middle years (25-50)Later years (51+)
Healthy behaviours e.g. healthy weight, exercise, smokingHealthy behaviours e.g. healthy weight, exercise, smokingHealthy behaviours e.g. healthy weight, exercise, smoking
Mental health Mental healthMental health
Long-term conditionsLong-term conditionsLong-term conditions
Health impacts of violence against women and girlsHealth impacts of violence against women and girlsHealth impacts of violence against women and girls
Osteoporosis and bone health
Dementia and Alzheimers
Table showing different areas of general health needs by age group

Thematic priorities across the life course:

  • Women’s voices
  • Healthcare policies and access to services
  • Information and education
  • Health in the workplace
  • Research, evidence and data

In the NHS>70% of staff are women and >80% in the care sector. We have heard that sometimes women struggle to gain support and reasonable adjustments in the workplace, that conversations with GP’s can be challenging regarding menopause for example. Menopausal people can suffer up to 34 symptoms that may also be indications of other conditions such as long covid or depression, so diagnosis in a short appointment time is often difficult. There have been issues with
supply of hormone replacement therapy and the cost of medications needed to treat the potential variety of symptoms experienced during peri and post menopause.

Although some women’s health conditions are spoken about more frequently now, stigmas and taboos still exist, so often women still find it challenging to discuss symptoms and feelings of isolation are frequently experienced.

To achieve sustainable change and improvement, it is important to recognise that better health for women extends beyond our health and social care system. Every sector in society has a role to play. The Women’s Health Strategy has a six-point long-term plan for transformational change:

  1. ensuring women’s voices are heard – tackling taboos and stigmas, ensuring women are listened to by healthcare professionals, and increasing representation of women at all levels of the health and care system
  2. improving access to services – ensuring women can access services that meet their reproductive health needs across their lives, and prioritising services for women’s conditions such as endometriosis. Ensuring conditions that affect both men and women, such as autism or dementia, consider women’s needs by default and being clear on how conditions affect men and women differently
  3. addressing disparities in outcomes amongst women – ensuring that a woman’s age, ethnicity, sexuality, disability, or where she is from does not impact upon her ability to access services, or the treatment they receive
  4. better information and education – enabling women and wider society to easily equip themselves with accurate information about women’s health, and healthcare professionals to have the initial and ongoing training they need to treat people knowledgably and empathetically
  5. greater understanding of how women’s health affects their experience in the workplace – normalising conversations on taboo topics such as periods and the menopause to ensure women can remain productive and be supported in the workplace and highlighting the many examples of good practice by employers
  6. supporting more research, improving the evidence base and spearheading the drive for better data – addressing the lack of research into women’s health conditions, improving the representation of women of all demographics in research, and plugging the data gap and ensuring existing data is broken down by sex

The national strategy also has seven priority areas related to specific conditions or areas of health these are:

  1. menstrual health and gynaecological conditions
  2. fertility, pregnancy, pregnancy loss and post-natal support
  3. menopause
  4. mental health and wellbeing
  5. cancers
  6. the health impacts of violence against women and girls
  7. healthy ageing and long-term conditions

The 10-year timeframe of the strategy at national level recognises that achieving these ambitions requires long-term cultural and system changes.

Some work within our system has already taken place including a focus on understanding menopause. This work has included:

  • a four-month programme of research led by the University of Suffolk looking at menopause, diversity, and inclusion.
  • a system-wide developed menopause policy to raise awareness of issues and to support staff working in health and care and to raise awareness with health and care professionals
  • system-wide menopause friendly employer accreditation status for all health and care organisations and partners
  • evaluation via surveys and focus groups regarding experiences and support needed.
  • internal and external evaluation of the effectiveness of the menopause support provided.
  • a multi-pronged approach to eliminating stigmas and taboos via training and awareness sessions, social media, and creation of a podcast regarding menopause as part of the ‘Hidden Voices’ series with Healthwatch Essex
  • work with GP’s regarding the cervical screening program and considerations for menopausal people.

What do we know about people’s local experiences?

In the national survey violence against women and girls ‘featured in the top five topics selected by respondents aged 16 to 29 and from the mixed/multiple ethnic group. In the public survey, only 9% of respondents said they had enough information about specialist services such as sexual assault referral centres and female genital mutilation (FGM) clinics. Responses from organisations and experts highlighted that some groups of women are at higher risk of experiencing certain forms of violence and abuse than others, for example disabled women experience higher rates of domestic abuse than non-disabled women, and lesbian and bisexual women are more likely to have experienced abuse than heterosexual women. Responses highlighted that the health impacts of violence and abuse, including domestic abuse, are wide ranging and extensive and can have long-term impacts on women and girl’s physical and mental health.’ (Source: Women’s Health Strategy for England).

How we plan to make a difference

Building on our existing program of personalised care and shared decision-making we wish to ensure that this is embedded in all areas of women’s health, for example in management of long-term gynaecological conditions and gynaecological procedures. We want to ensure that more research takes place both clinical and to understand women’s experiences. We will ensure that there is female representation at all decision-making forums, mirroring that which is happening at national level at both system and local level. We wish to appoint a women’s health ambassador for SNEE who can liaise with universities to contribute to the design of curricula for health and care professionals, who will be involved in policy making and in commissioning and delivery of services. We will work with colleagues in Public Health to understand women’s health inequalities as well as there being inequalities between men and women there are also inequalities between women who live in deprived areas and wealthier areas of the country, this is likely to be reflected in similar areas in our system.

We will connect with EDI networks to ensure that our strategy is inclusive and supports all those affected by issues including for example transgender men, and those who are non-binary. We will also ensure that our strategy considers the differences experienced by women of different ethnicity and culture, sexual orientation and the challenges experienced by women with disabilities as examples of the diverse population that we serve.

We want to ensure that our healthcare professionals are able to understand and spot the signs of abuse in order to support women and girls in SNEE. We also want to ensure that survivors of abuse and violence have access to trauma-informed services, and work with our partners to provide information for our local employers to support women and girls in and out of the workplace. SNEE ICB works in collaboration with the Suffolk Safeguarding Partnership (SSP), Essex
Safeguarding Adults Board (ESAB) and Essex Safeguarding Children Board to safeguard those members of our communities most at risk of harm and learn lessons from reviews to prevent future harm. Together with our partner agencies, education services and voluntary sector we will focus our work in 3 key areas:

  1. safe at home
  2. safe in our communities
  3. safe safeguarding systems across SNEE ICS

More information regarding this can be found in Section Trauma and Abuse – Safeguarding Children and Adults at Risk.

Our key commitments are:

  • the appointment of a women’s health ambassador to advocate for women in all aspects of health and care, from research to training and commissioning and design of services, by December 2023
  • the creation of a menopause centre of excellence working with the University of Suffolk, the University of Essex, Healthwatch Suffolk and Essex and partners by December 2023
  • the formation of a system women’s health forum to hold accountability for the aims and deliverables by March 2024
  • ensuring female representation at all decision-making forums, mirroring that which is happening at national level at both system and local level by March 2024
  • the creation of an EDI workstream building on the research completed with the University of Suffolk regarding EDI and menopause. To review issues such as gender and screening programmes, equality of access and diversity research by
  • December 2024 and connect with EDI networks to ensure that our strategy is inclusive and supports all those affected by issues including for example transgender men, and those who are nonbinary
  • the collation of baseline data, both quantitative and qualitative, and creation of KPIs by July 2024
  • the triangulation of existing research on women’s health systemwide and the creation of a research workstream to increase clinical research on women’s health by December 2024
  • we will work with colleagues in Public Health to understand women’s health inequalities as well as there being inequalities between men and women there are also inequalities between women who live in deprived areas and wealthier areas of the country, this is likely to be reflected in similar areas in our system
  • we will also ensure we consider the differences experienced by women of different ethnicity, culture, sexual orientation, and the challenges experienced by women with disabilities as examples of the diverse population that we serve

More information regarding this can be found in Section Trauma and Abuse – Safeguarding Children and Adults at Risk.

We will know we are making a difference because we will see

Priority KPIs agreed as part of a dashboard:

  • performance monitored via the women’s health forum, and governance agreed to ensure board oversight.

We will know we are making a difference when we begin to achieve on the outcomes from our five-year plan and evaluation demonstrates that women feel that a difference has been made. In the national survey women felt that they had to ‘persistently advocate for themselves’ to push for further investigation or diagnosis. We aim to ensure that there is no such necessity and that our local strategy enables the improvement of the health, wellbeing, and care of women in SNEE. (Women’s Health is an area of development nationally and within SNEE ICB. Further detail will be provided in the 2024/25 JFP once commitments are more defined.)

Quote: “The Women’s Health Strategy described stark inequalities in the outcomes that women can expect from health and care in the NHS. This is simply not good enough. We have a moral imperative to make this right, starting by listening to the women in our system and what they want us to deliver on.”
Dr Andrew Kelso, Medical Director, NHS SNEE ICB

Case Studies

Following creation of a menopause network, which now has over 400 members an external evaluator asked whether the support, training and sessions had been beneficial. Here is a selection of responses:

Clinical Consultant Working in a Local Acute Trust

‘I am a bit shocked at how ill-informed I am as a doctor. I had very little useful undergraduate training on menopause (although that was >25 years ago and I would hope things are changing) and I suddenly find I am of that age and need to know this stuff! I think awareness is improving thanks to Davina McCall, but there is still a significant way to go. The NHS has a very high proportion of staff who will be directly affected by menopause, and I am very grateful to you for setting up these sessions to better inform staff who will be affected the organisation that employs these staff.’

Practice Nurse working in a GP Surgery

I attended the Menopause Check in and Chat session for the first-time last week, it was a brilliant opportunity to meet with other professionals within our wider team. I came away from the session with a sense of fulfilment. This inclusive group provided valuable support to all those who attended, people from all walks of life who are experiencing the same struggles with Menopause. Here people were able to share stories, support and guidance and tips on how to navigate through such a tough but potentially liberating time. Part time I am also a Practice Nurse within Primary Care, this session gave me food for thought on how I can best support my patients through this time; also, as a woman who is in a same-sex relationship, I felt empowered to support my own partner who has started her Menopause journey very recently.’

1.1.4 Oral Health

Why is this important for people in Suffolk and North East Essex?

The best oral health throughout life is essential if everyone in SNEE is to start well, live well and age well. It is important to consider that oral and general health are inextricably linked with bidirectional relationship of oral diseases and general diseases to includes diabetes, dementia, cardiovascular disease, pneumonia, low birth weight babies, for example. This means an improvement or degradation in one has a directly similar impact on the other. For instance, stabilisation of gum disease has sufficient impact on diabetic health that it can remove the need for a second-line diabetic medication.

Oral health is the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort, or disease of the craniofacial complex. Oral health is considered to be a key aspect of general health and wellbeing, with good oral health being linked to good quality of life. Oral health directly affects a number of aspects of daily life that can improve or degrade an individual’s quality of life.

What do we know about people’s local experiences?

By geography, the East of England region generally has some of the best oral health in England, with only 23% of adults having dental decay (compared to 28% in London, 34% in the North East and 39% in the West Midlands), only 42% display signs of visible plaque (compared to 67% in the South West and 81% in the North West) and 20% displaying “excellent oral health”, the highest rate in England. Despite this, however, there are several areas within the East of England where there are particularly poor oral health outcomes. Indeed, periodontal (gum) disease is the 6th most prevalent disease in the world.


Oral health in children in Suffolk is generally better than the England average, with lower rates of dental decay and hospital admissions for dental extractions. There are, however, inequalities in child oral health in Suffolk, with children living in the most deprived areas having statistically significantly higher rates of dental decay than children living in the most affluent areas of Suffolk.

According to data from 2019, Colchester has the highest percentage of 5-year-olds having one or more teeth with decay involving the pulp in northeast Essex and the highest percentage of 5-year-old children with incisor decay. Both are higher than the England average.

Areas such as Lowestoft, South Waveney and the Forest Heath area of West Suffolk had the highest rates of dental decay in Suffolk 5-yearolds in 2019. Although overall prevalence was not as high in Stowmarket, those children experiencing dental decay had on average a far greater number of teeth showing signs of decay.

At a regional level, there are known inequalities in terms of dental decay by ethnicity, with children of Asian/Asian British ethnicities having statistically significantly higher rates of incisor decay than children of Black, Mixed or White ethnicities.


Oral health in adults in Suffolk is generally similar to the England average, with mortality rates from oral cancer similar to the national rates and, according to the limited data from the National Dental Epidemiology Programme in 2018, slightly lower rates of dental decay and slightly higher rates of functional dentition (where 21 or more teeth are present) for Suffolk residents. Data on oral health in adults is more limited than for children.

Oral health in adults in north east Essex is poorer than the England average, with nearly 4 out of 10 adults having active decay, Essex has the fourth highest percentage of adults with bleeding on probing among similar counties.


During 2020, more than 2,000 NHS dentists quit the NHS dentistry which affected service users nationwide. SNEE have seen a reduction of Dentists offering NHS treatment over the past 12 month. In 2019/20 there were 565 dentists which equates to 57 dentists per 100,000 population, currently there is 488 Dentists offering NHS treatment in SNEE which equates to 49 dentists per 100,000 population. This is lower than the national average of 57 dentists per 100,000 population.

Accessibility of appointments with NHS dentists in SNEE is lower than regional and national averages – success rates when trying to book NHS dental appointments were much lower for residents of SNEE than both the East of England regional and England national average. The number of people seen by NHS dentists significantly dropped in 2020/21 compared to the previous year, which is consistent with the national picture. Access to dental services was severely impacted by COVID-19 lockdown measures and the need for enhanced infection prevention and public health measures. This has created a backlog of people with oral health treatment needs.

Across SNEE 280,781 adults were seen by an NHS dentist between June 2020 and June 2022, which equates to 35.6% of the adult population. This is lower than the England average (36.9%). Between June 2021 and June 2022 91,466 children were seen by an NHS dentist in SNEE which equates to 46.1% of the population, this is in line with the average in England (46.2%). West Suffolk and Colchester had the lowest NHS dental activity rates in 2021/22 across SNEE.

The Office for Health Improvement and Disparities highlights:

Dental decay is the most common non communicable disease with sugar being the principal dietary factor in the development of dental decay. Studies have reported that lockdowns implemented due to COVID-19 prompted an increase in nhealthy dietary changes, with people having more snacks rich in salt and sugar. With many dental practices being prompted to shut, this is expected have a knock-on effect, and the percentage of adults with an active decay is now expected to be much higher, reflecting a greater need for dental services in the population.

According to data from 2018, nearly 4 out of 10 adults in Essex (38.9%) have active decay which is the highest among similar counties. This is much higher than England (26.8%) and East of England (24.9%) average, Suffolk is in line (25%) with the East of England and below the average for England.

There is a large proportion of Suffolk adults that have existing dental treatment needs (80.5%), this is highest amongst comparable counties and above the average in East of England (77.1%). Although Essex is lower than the regional average (at 73.1%) it is the second highest among comparable counties, both are higher than the England average (70.5%). The data predates COVID; therefore, the treatment needs of adults would have increased due to the pandemic.

How we plan to make a difference

The ICB will ensure that:

  • the provision of behaviour-management advice and techniques that reduce or prevent oral health problems to children, adults, and older people through public health campaigns, working with schools, universities, and health care professionals (Prevention)
  • ensuring access to high quality oral health services for children, adults, and older people (Access)
  • equality of access to oral health services (Access)
  • no delay to urgent acute or mental health treatment because people cannot access NHS Dentistry (Urgent and Emergency Care Access)
  • everybody in pain or post-trauma will have advice, support, and timely treatment from an NHS Dental service across SNEE (Urgent and Emergency Care Access)
  • people will be able to access a single point of contact, to identify where there nearest NHS dentist is available and get a check-up in a timely manner (Access)
  • all domiciliary and community specialist care services in SNEE will be available to people in a timely manner, with courses of treatment being undertaken to support long-term care (Specialist Access)
  • people will have oral health services that are integrated and based on best practice (Integration)
  • there is local training capacity for dental professionals (Training and Development)

Children, adults, and older people can be provided with behaviour-management advice and techniques that reduce or prevent oral health problems through public health campaigns, working with schools, universities, and health care professionals


Deliver the Starting Well Core Initiative supporting dentists to see more children from a very young age to form good oral health habits, preventing tooth decay. Children and their families need the right advice and support to maintain good oral health and create positive habits for life. Education involves an integrated approach between parents, early year’s provision, schools, social care, and communities to help with strategies such as supervised brushing and preventing worsening of dental disease.

Continue to ensure children and young people and adults’ social care support good oral health in children and young people. Poor oral health is one indicator of potential parental or carer neglect. Social care and oral health providers should work in an integrated way to share any safeguarding concerns and support the people and families they work with on an ongoing basis, by October 2024.

Increase awareness campaigns by July 2023 to promote good oral health, linked to wider public health campaigns such as healthy eating and reduced sugar intake, alcohol, and smoking, and including information on risks of oral cancers. Improving awareness helps prevent future oral health problems.

Information should be accessible in a range of formats, and adaptable to be age appropriate. Dental Care Professional Champions can play a key role in awareness raising about good oral health within the community. Community pharmacies are also involved in these. The new pharmacy contract requires pharmacies to be promoting sugar reduction, providing awareness campaigns on these topics and in supporting self-care and as part of minor illness management.

Making every contact count, and increasing relationships between primary medical care, secondary medical care and dental surgeries starting April 2023 with more formal phased processes aimed for October 2024.

Improving people’s access to sugar-free medications to help reduce the risk of tooth decay starting January 2024.

Supporting people to self-care their oral health. Individualised assessment and prescriptive care pathways cover four domains: decay, periodontal disease, soft tissues, and tooth surface loss. A self-care plan is agreed with the person based on their levels of risk in these areas following an oral health assessment, piloted from April 2025.

Children, adults, and older people have access to high quality oral health services


Children and young people, adults, and older people with additional or complex needs, are diagnosed with oral health problems early.

Staff will work with vulnerable children and young people, adults, and older people to ensure they have prompt and full access to primary care oral health services on an ongoing basis. Earlier diagnosis of oral health problems enables earlier treatment and prevents more invasive treatment later on. Tailored advice should also be given to the person and their carers about how to maintain good oral health.

Primary and secondary care oral health providers having sufficient capacity and a range of expertise to meet people’s needs in a timely way. Community-based and secondary care services need to meet the challenge of increasing levels and complexity of local demand and work in an integrated fashion. Expertise is particularly important for people with complex needs (both dentally and generally), and people with dementia, physical or learning disabilities that impact on their ability to self-care.

We will look to start increasing capacity in both Primary and Secondary care providers from its current level, with activity going live from October 2023, with the aim to ensure that we meet our statutory responsibility of meeting “all reasonable requirements for the provision of primary dental services’’.

More oral health services provided to residential schools and residential care homes, so that everyone living in an institutional setting has equality of access to oral health services in accordance with NICE guidance, phased from October 2024.

We will work with the University of Suffolk and the University of Essex alongside other dental professionals to supply additional much needed NHS dental provision and training opportunities, including contracted placements across SNEE. The aim is to develop a series of facilities, working in a ‘hub and spoke’ model where the right treatment is provided by the right person at the right time in the right environment. The upskilling of all members of the dental team will be paramount in facilitating this.

The ICB aims to start additional dental provision being made available from August 2023 with a number of procurements being undertaken from April 2023, the ICB will ensuring training places and training opportunities are in all applicable contracts procured from April 2023.

People have equality of access to oral health services

We will identify areas and communities with lower rates of access to services and ensure sufficient capacity and range of services by October 2024. Population health approaches can support the system to eliminate unwarranted variation.

No treatment for an urgent health treatment will be delayed by people not being able to access NHS Dentistry

We will work with our health colleagues, to identify specialities that are impacted by dentistry access, and support the creation of pathways from those specialities such as for, diabetes, cardiovascular, oncology and rheumatology into dental clinics or surgeries across SNEE to ensure that people can access treatment in a timelier fashion phased from June 2024.

Nobody in pain or after trauma is unable to get advice, support, and timely treatment from the NHS Dental service across SNEE

We will work with our urgent and emergency care colleagues, in EDs, Urgent Treatment Centres, 111 and 999 to support the creation of pathways for people in pain, into dental clinics or surgeries across SNEE to ensure that those in pain or who have had trauma can access treatment in a timelier fashion by October 2023.

In addition, once emergency or urgent care has been provided, the person will then be signposted into appropriate services of prevention and stabilisation to reduce the risk of the need to reattend for urgent care.

People will be able to access a single point of contact, to identify where there nearest NHS dentist is available and get a check-up in a timely manner

We will work with Healthwatch Suffolk and Essex, dental surgeries, and our community dental providers to promote a universal single point of contact online, that can identify where people within SNEE can access dentistry by June 2025. Alongside this, we will work with 111 to ensure people are directed to dental services that will accept new patients on an ongoing basis.

Homeless, transient populations and at-risk groups can use priority pathways through NHS Commissioned services, to access dental support with the first pilots by December 2023

The domiciliary and community specialist care services can assess people in a timely manner, with courses of treatment being undertaken to support the long-term care of this cohort

We will work with our community specialist and domiciliary dental providers to ensure referral pathways are widely available across SNEE healthcare professionals and work with Healthwatch, 111, 999 and ED service to ensure referrals for those most in need are available on an ongoing basis by April 2024.

People have oral health services that are integrated and based on best practice

PCNs will support dentists to develop services and be full partners in integrated care in our local neighbourhoods by April 2025. PCN support is key to reducing variation in access to services and so health inequalities, and to promoting integrated working.

Dental health pathways between primary and secondary care will work in a joined-up way. Improving care pathways between primary and secondary care will enable more integrated care and help provide a better experience.

Improve co-ordination of care between dental and medical colleagues via direct links to primary and secondary medical services.

There is local training capacity for dental professionals

We will work in partnership to support the development of Suffolk’s Centre for Dental Development at the University of Suffolk by September 2023. The Centre for Dental Development will attract and train newly qualified dentists to work within this dental facility to supply additional much needed NHS dental provision across Suffolk as well as enabling leading edge education and training for the current and future dental workforce.

We will work with the University of Essex on an enhanced level of care through upskilled dental care professionals as detailed in the national Advanced Clinical Practitioner apprenticeship, in partnership with Health Education England (HEE). This will integrate clinical colleagues in similar fashion to those already working within wider healthcare services and more effectively and efficiently spread workload across the dental team by September 2024

We will work with the entire dental system to support changes in the types of workforces and what the current workforce can do by offering a more modern training integrated with wider health care, this will offer a new model of dental care, a new model of organising care and a new model of workforce.

Work closer with HEE to improve the workforce in SNEE with integrated care to maintain and offer career pathways for dentists into Level 2 accreditation etc.

We will know we are making a difference because we will see:

  • We will know we are making a difference because we will see:a10% fewer children with one or more decayed, missing or filled teeth by 2026
  • 20% fewer hospital admissions for dental decay in children aged 0-5 years by 2026
  • fewer child protection cases for health neglect where lack of dental access to healthcare is a factor
  • increased access to the Starting Well Core Initiative, and health outcomes
  • 200% more students attending oral health sessions in schools, and health outcomes by 2024
  • increased awareness of good oral health among children and adults
  • improved access to NHS dentistry for children and adults, including in residential settings by September 2024
  • increased access to sugar free medications across SNEE
  • increased access to personalised self-care for oral health, and health outcomes
  • improved quality, capacity and health outcomes of oral health monitoring and access to treatment for people with health conditions.
  • improved access to oral health care pathways ensuring people are seen in the most appropriate settings
  • increased local capacity to train and educate dental professionals

Case Studies

Mrs B, a 37-year-old female who had undiagnosed gastric reflux disease which caused the enamel on her teeth to be severely damage. Mrs B woke up with significant pain on the left side of her mouth and contacted her GP. The GP was unable to provide support and signposted Mrs B to 111 for advice on where to get help, 111 provided Mrs B with a website, and advice on local dental practices on where to get help. Mrs B was unable to get help at any local practice, all reporting that they had no capacity. Within a week Mrs B’s pain had increased so much that she called 999, 999 sent an ambulance crew, who were unable to control the pain, so transferred her to the hospital’s ED. Mrs B was assessed by the oral surgeons at ED and it was agreed to remove multiple teeth. Mrs B was then admitted for 7 days. The above plan, when implemented, will offer Mrs B many more options to resolve her dental pain before having to have surgery under a general anaesthetic.

1.1.5 Eye Health

Why is this important for people in Suffolk and North East Essex?

Demand on eye care is rapidly increasing and for acute care, is now the largest speciality when looking at outpatient appointments. It is estimated that partial sight and blindness in adults costs the UK economy around £22 billion per year. Poor eyesight not only leads to social isolation and loneliness but also is a known risk factor to comorbid chronic illness and cognitive decline, dementia, falls and mortality. For most people a decline in eye health is avoidable and treatable.

The burden of eye conditions and vision impairment in not borne equally, often far greater in people living in rural areas, those with low incomes, women, older people, people with disabilities and ethnic minorities. A SNEE wide demand and capacity modelling of eye care in early 2022 showed a potential 19% growth in 75+ age ranges over the next five years who account for over 40% of all eye care activity (Attain Eye Care Demand and Capacity Modelling 2022).

Eye conditions that can cause vision impairment and blindness – such as cataract, trachoma, and refractive error – are the main focus of national prevention and other eye care strategies but other main drivers of local demand outlined below are equally important to reflect in our local plan:

Myopia (near-sightedness): Increased time spent indoors and increased “near work” activities are leading to more people suffering from myopia. Increased outdoor time can reduce this risk. Diabetic retinopathy: increasing numbers of people are living with diabetes, particularly Type 2, which can impact vision if not detected and treated.

Nearly all people with diabetes will have some form of retinopathy in their lifetimes. Routine eye checks and good diabetes control can protect people’s vision from this condition.

Late detection: Due to weak or poorly integrated eye care services and the impact of isolation through the pandemic, many people lack access to routine checks that can detect conditions and lead to the delivery of appropriate preventive care or treatment.

In SNEE an Eye Care Committee with representation from eye care experts working locally in primary and secondary care have overseen the recovery of waiting lists formed during the pandemic and are now focussing on improving local services to ensure not only are they joined up but are delivering the very best of eye health care for our local population future proofing for the growth in demand in line with the growth in our ageing population.

What do we know about people’s local experiences?

Demand across the system (27,000 referrals a year) is driven by several eye conditions with cataract, glaucoma and medical retina referrals being the highest in volume. Most of our total activity for eye care takes place in secondary care (76%). Nationally the England rate of admission to hospital for all cataract surgery in people aged over 65 years and over has increased by 16% in the five years leading up to the pandemic (Vision Atlas 2021).

Overall SNEE ranks above the average nationally in term of secondary care outpatient referrals but also has above average deprivation and older population ratings.

Community Glaucoma management

Only 12% of suspect glaucoma and 8% of stable glaucoma patients in Ipswich and East Suffolk are referred into acute care, saving a minimum of 4853 outpatient appointments per annum and supporting people to be cared for closer to home. 97% of glaucoma monitoring in the community in Ipswich and East Suffolk is undertaken by community Ophthalmology partners.

Minor Eye Care Services (MECs)

In Northeast Essex, 78% of people referred to MECs are managed within primary care with a reduction in this type of activity being seen in secondary care demonstrating a positive shift towards more care provided closer to home.

SNEE generally provides well for urgent and primary eye care provision with the Vision Atlas Report recognising that 74% of our East of England population have access to both services supported by primary care optometrists and their practice teams.

How we plan to make a difference

  • Our primary focus following Covid-19 is to continue to minimise the elective care waiting lists and ensure people get their surgery as quickly as we can supporting any people waiting to stay well so they remain fit for surgery
  • Our secondary focus has been to transform the eye care pathway, increasing the number of people supported earlier in the community, working collaboratively across local providers of eye care and ophthalmology to improve how we support improvements in high demand pathways
  • Our third focus will be a more preventative approach, early accurate detection by primary care services and effective management in the community
  • Our SNEE Eye Care ambition is to deliver safe, timely and sustainable eye care is underpinned by six key priorities:
  • The extension of the collaborative approach across our ICS to deliver high volume surgical hubs that improve equity of access and productivity (from 2024 to 2028) and increase utilisation and collaborative working with community ophthalmology partners to maximise capacity within a community setting’.
  • The implementation of standardised and integrated pathways across cataracts, Community Urgent Eye Services/Minor Eye Care Services, Medical Retina, and glaucoma pathways including:
    • primary, secondary, community and independent-sector eye care services (2023 to 2025)
    • a risk stratification approach to support new to follow up outpatient appointments (2023 to 2024)
    • the development of our primary care optometrists as first-contact practitioners to deliver ‘Optometry First’ managing low risk people in the community as much as possible (2023 to 2025)
  • The embedding of digitally enabled system transformation (2023-2028) including:
    • implementation of electronic eye care referrals between primary optometry and hospital eye care services (2024 to 2025)
    • implementation of a scalable model of home care monitoring using multiple channels including PIFU, symptoms monitoring and video consultation (2023 to 2024)
    • the development of a scalable model of digital eye care hubs that can receive clinical data from any source and respond with the clinical expertise required to support non-hospital settings (2025 to 2027)
    • the development of plans for longer term integrated diagnostic digital diagnostics and care capabilities (2023 to 2024)
  • The continuation of improved delivery of all elements of the ‘adapt and adopt’ Outpatient Transformation programme relating to PIFU, Advice and Guidance and Virtual Consultation (2023 to 2027)
  • A greater focus on children and young people; specifically, eye screening and examinations which can detect eye health problems and prevent sight deficiencies (Years 1-2 2023-2025)
  • Education – ensuring that the public knows what services are available to them and how to access them. As part of this education for other health providers (GPs/Pharmacists / EDs etc.) to ensure people are properly sign posted to the correct services for their needs (Years 1-2 2023-2025)

We will know we are making a difference because we will see:

  • improved equity of access and ensuring our local population have access to the right care, first time, wherever they live across the SNEE ICS. Standardise all pathways, contracts, and finances 100% across the SNEE system by 2028
  • increasing utilisation of our community optometrists by at least 25% to support more people near their own home, thereby reducing demand on secondary care services. Optometry First becoming the first contact practitioner service for eye care
  • increased utilisation and collaborative working with community ophthalmology partners to maximise capacity within a community setting
  • by June 2025 we will have an integrated interoperable e-referral system across primary and secondary services
  • embed an eye health assessment in planned (and existing) service models for healthy ageing, dementia care, learning disability and autism, and include eye health in wider NHS activity for prevention of avoidable illness and inequalities

Quotes from service users:

  • “Convenient appointment with excellent care and clear information”
  • “Very helpful and efficient. Excellent treatment and everybody helpful, cheerful, and polite”
  • “I felt every care was being taken with my eyes, which is very important to me”
  • “Excellent caring service in a clean and well-appointed environment with friendly staff. It was a very professional experience, and I would highly recommend the service”

Case Study

Glaucoma Care in Ipswich and East Suffolk

Early diagnosis of glaucoma is vital so the condition can be monitored and treated before the person loses vision or to reduce the rate of visual loss. Across Ipswich and East Suffolk, there has been a successful glaucoma service operating for over eight years under a Lead Provider framework, with a number of commissioned glaucoma pathways including:

  • Glaucoma Referral Refinement (GRR) (IOP/visual fields) – Primary Care Optometry
  • Glaucoma ‘See and Treat’ – Community Ophthalmology Service
  • Glaucoma Management – Community Ophthalmology Service / Primary Care Optometry

The community model includes risk stratification, multidisciplinary working, virtual clinics, and active discharge of ‘stable’ patients from the hospital into the community service. The integrated care pathway allows for people to be managed within the community pre-referral, reducing the number of false positives, and utilising the multidisciplinary capacity provided by the Community Ophthalmology Service. An integrated IT platform underpins the service, including provision of electronic referrals, a remote triage platform, centralised patient-centric medical eye records and telemedicine for remote consultant clinical decision making.

Key outcomes achieved in 2021/22 include:

  • Over 100 people seen on the GRR pathway were discharged
    • 70% discharged from service
    • o 30% referred to Community Ophthalmology/HES for glaucoma diagnosis
  • Over 1500 suspect glaucoma patients were managed within the community service
    • 88% were managed in the community
      • 61% were diagnosed with glaucoma and treatment was initiated
      • 27% were discharged
    • 12% were referred to HES
    • Over 3700 stable glaucoma patients (88%) were managed within the community service, 4% were referred to HES, and 4% were discharged

With this established glaucoma service, a minimum of 5000 HES outpatient appointments were saved. Whilst providing essential capacity within the community and supporting the HES capacity challenges, people are also being seen closer to home.

Page last modified: 15 August 2023
Next review due: 15 February 2024