Joint Forward Plan

Read the Joint Forward Plan as HTML web text or download as a PDF.

Please note that the PDF document below is the most recent version of our Joint Forward Plan (2024-2029).

The HTML content below details the ICB’s 2023-2028 Joint Forward Plan. This is currently being updated and the most up-to-date version (2024-2029) will be available on this page soon.

1. Foreword

By Chair and Chief Executive

We are delighted to introduce our Joint Forward Plan (JFP) for the NHS Suffolk and North East Essex Integrated Care Board (the SNEE ICB). It has been built on the views of the community that we listened to during our engagement exercise and drafted with the input of many colleagues in our system. Our vision is to deliver the best possible outcomes for every one of the million people in Suffolk and north east Essex.

Our ICB is part of an equal partnership across the NHS, local government and voluntary, community and social enterprise (VCSE) sector, increasingly characterised by positive relationships between local health and care leaders and a genuine ‘can do’ attitude that enables meaningful partnership and integrated thinking and working at every level. We are committed to improving health and wellbeing outcomes for the local population we serve and we are ambitious about what we can achieve together.

Our ICB plays an important role in this system by bringing the local NHS together in a spirit of collaboration and driving forward improvements to our services. In the past year we have seen extraordinary efforts to reduce long waiting times, significantly increase volumes of cancer treatments and to maintain safe services during periods of industrial action, to name three examples.

In the coming years, we are determined to deliver further improvements across a wide range of areas captured in this plan. The golden thread that runs through this plan is our ambition to tackle health inequalities, namely the significant gap in life expectancy that we see in our system.

The plan sets out a series of commitments based upon our ‘Live Well’ domains, beginning with ‘Start Well’ through to ‘Die Well’. We will assess our performance in delivering our commitments over the next five years by measuring performance against one or more target indicators in each domain. These are the lead key performance indicators where we wish to target improvements, with a particular focus on reductions in health inequalities. We have so many enablers and assets in Suffolk and north east Essex (SNEE) to deliver this plan.

Our most important assets are our communities and workforce and the culture of collaboration that we aim to build. We hope you enjoy reading the plan and that it inspires you to support its delivery. Thank you for everything you do to support the health and wellbeing of our population in Suffolk and north east Essex.

Professor Will Pope, Chair, Suffolk and North East Essex ICB and Dr Ed Garratt OBE, Chief Executive Suffolk and North East Essex ICB

2. Executive Summary

2.1 Scope of the Joint Forward Plan

This document sets out a five-year delivery plan for the SNEE ICB¹. The JFP explains how the SNEE ICB, as a statutory organisation, will contribute to the collective ambitions of the SNEE Integrated Care System (ICS), as an NHS commissioner as well as through its role in bringing together health and care partners to deliver shared leadership and joint action to improve the health and wellbeing of the one million people who live locally.

ICBs and their partner NHS trusts and NHS foundation trusts are required to prepare an annual JFP in line with the legal responsibilities set out in the Health and Care Act 2022. This delivery plan describes a series of delivery priorities and measurable targets the SNEE ICB aims to attain between 2023 and 2028. It articulates detailed delivery plans and how delivery priorities are informed by local, regional, and national strategic drivers.

In doing so, this document aligns to the three principles of JFPs² which decree that they:

• are fully aligned with the wider system partnership’s ambitions
• support subsidiarity by building on existing local strategies and plans as well as reflecting the universal NHS commitments and
• are delivery-focused, and include specific objectives and milestones for the ICB to attain by 2028

NHS bodies have a common duty (referred to as the ‘Triple Aim’) to have regard to the wider effect of their decisions on:

• the health and wellbeing of local people
• the quality of services provided or arranged by an ICB and other relevant bodies and
• the sustainable and efficient use of resources by the ICB and other relevant bodies

The JFP articulates the SNEE ICB’s commitment to deliver on the ‘Triple Aim’ by improving public health, preventing ill-health, and reducing health disparities for our population.

2.2 Our Population

There are 1,058,560 people registered with general practitioners (GPs) across SNEE – 413,188 in Ipswich and east Suffolk, 370,589 in north east Essex and 265,688 in west Suffolk³.

Of the population whose ethnicity is known, the majority are white (94.7%), higher than the national average of 86.7%. Of the remaining population, 2.1% are Asian/Asian British (national average is 7%), 1% are Black/African/Caribbean/Black British (national average is 3.1%), 1.7% are mixed/multiple ethnic groups (national average is 2.1%) and 0.5% are classified as other (national average is 0.95%).
The proportion of people aged over 65 across SNEE is 23%, higher than the average across England of 19%⁴.

SNEE is spread across a mix of urban, rural and coastal areas, with pockets of significant deprivation – there are 116,673 people in SNEE living in the 20% most deprived areas nationally, of which the majority live in Tendring and Ipswich. This includes the Brooklands and Broadway areas of Jaywick, which are the most deprived Lower Super Output Areas (LSOAs) in the country, whilst Ipswich is the most deprived area in Suffolk; (46% of LSOAs in Ipswich are in the most deprived 30% nationally). West Suffolk has one LSOA in the 20% most deprived nationally in St Edmundsbury in Bury St Edmunds.

Differences in the level of deprivation across SNEE have undoubtedly accelerated the emergence of health inequalities. There is a life expectancy gap between individuals born in the most deprived communities in SNEE and those in the least deprived. The difference in average life expectancy is 7.4 years in men and 5.9 years in women⁵.

Different causes of death contribute to the difference in life expectancy between our most deprived and least deprived communities. Leading causes of death include circulatory conditions, cancer and respiratory conditions. Several underlying risk factors are implicated in their causation, including tobacco, high body mass index, diabetes, dietary risks, high blood pressure and alcohol.

2.3 Engagement feedback

The SNEE ICB has a collective ambition for everyone in Suffolk and north east Essex to be able to get involved in its work. Consistent with this, the JFP is built on the engagement work carried out in the development of the ICS Strategy, which took place with people living and working in SNEE from September to December 2022. Over 600 people responded via online surveys, community group discussions, a pop-up video booth and direct contact with the Integrated Care Partnership (ICP) team to inform the strategy. Between 16 January and 22 February 2023, further engagement was undertaken on the draft JFP. During this period, there were over 1,000 visits to the LetsTalk SNEE online platform – 340 people voted using quick polls, 280 ideas were submitted and there were 330 downloads of the draft document and executive summary.

Approximately 100 people attended an in-person meeting. The aim was to enable effective and meaningful involvement and to ensure all people and communities had the opportunity to contribute to the development of this document.

Eight core themes on what matters most to people were identified:

1. Access – including access to all services as well as opportunities and activities to support healthy living. People also noted the ability to get to and from appointments and activities.
2. Mental health – including services for both children and young people and adults.
3. Prevention, health education and information – supporting and enabling people and communities to manage their own health, stay healthy and know how to access support.
4. Personalisation and reasonable adjustments – both personalised care in response to a person’s specific conditions and the adjustments made to support good health outcomes. This might include communication, physical access or a person’s cultural beliefs and values.
5. Digitalisation – the importance of being aware of innovations and progress that can be enabled through the use of new technology, whilst also recognising that not everyone is willing or able to use technology.
6. Workforce – consideration for recruitment, retention, training and wellbeing.
7. Primary care – the development of primary care across SNEE.
8. Children and young people with special educational needs – services, support and interventions to support young people with a special educational need.

The JFP explains how we have incorporated this feedback into identification of our priorities and delivery plans and how this has been triangulated with other strategic drivers.

Please see Appendix 2 for a full report on our engagement work.

2.4 Strategic drivers

There are a number of strategic drivers at a national, regional or local level that influence the priorities and delivery plans set out in the JFP.

2.4.1 National context

The NHS Long Term Plan (2019-2029) (LTP) sets out the national 10-year strategy to make the NHS fit for the future and to improve care by:

• making sure everyone gets the best start in life
• delivering world-class care for major health problems and
• supporting people to age well

As an ICB, we will collaborate across all sectors to deliver the objectives of the NHS Long Term Plan by listening to what local people say, and co-produce solutions that provide the right care and support for people and communities.

The JFP also provides our response to how we will deliver on universal NHS commitments, including (but not limited to) commitments on service recovery, such as the ‘delivery plan for tackling the COVID-19 backlog of elective care’ and the ‘delivery plan for recovering urgent and emergency care services’.

Published in May 2022, the Fuller Stocktake Report considers how the implementation of integrated primary care can be accelerated by incorporating the current four pillars of general practice, community pharmacy, dentistry, and optometry across systems.

The SNEE ICB’s local response to the Long Term Plan and Fuller Stocktake Report is set out through the JFP.

2.4.2 Regional and local context

The Integrated Care Strategy for the SNEE ICS (www.sneeics.org.uk) describes a shared vision from the perspective of ‘what matters’ to people living in SNEE. The ICS is united on four collective ambitions:

• Making the best health and wellbeing a genuine reality for all
• Opportunity of health equality for everyone
• Everyone being able to ‘Live Well’ – Start Well, Be Well, Stay Well, Feel Well, Age Well, Die Well
• A genuinely ‘can do’ health and care system that people can trust

The Essex and Suffolk joint strategic needs assessments (JSNAs) assess the current and future health and care needs of the SNEE population and the key priorities are set out in the local joint health and wellbeing strategies. This includes priorities across public health, mental health and wellbeing, children and young people’s services, supporting independent living, and addressing the wider determinants of health and health inequalities.

The JFP responds to all these regional and local ambitions, setting out the ICB’s contribution to their achievement.

2.4.3 Service demand

Across the country the performance of health and care organisations is set against a challenging backdrop of increasing demand for services. There are underlying demand pressures driven by demographic growth and morbidity changes. The NHS is currently experiencing challenges with workforce retention and skills gaps persist nationally.

The population of the SNEE ICS is estimated to increase 10% by 2036⁶ and the proportion of the population aged over 75 will increase from 10.3% in 2018 to 13.8% in 2032, an additional 45,000 people. The prevalence of multimorbidity (people with more than two illnesses or diseases) is between two and three times greater in the plus 75-year-old population relative to working age adults and an ageing population will have a greater health and care need. The JFP sets out how we will respond to this through initiatives to manage demand for services and maximise the capacity of our services.

2.4.4 Cost of living challenges

The SNEE ICB is conscious of the ongoing cost of living challenges driven by sharp increases in the cost of energy and food prices and ongoing inflationary pressures.

The SNEE ICB will respond to this through a commitment to:

• contribute to wider initiatives to co-ordinate and promote support to those who need it most
• combat the stigma of needing support
• identify the people who use our services who are struggling and
• identify our staff and volunteers who may be struggling

2.4.5 Financial position

Prior to the pandemic, NHS organisations in SNEE had delivered strong financial performance. Extraordinary amounts of additional funding were provided to systems as part of the emergency financial regime put in place by NHS England (NHSE) in response to the pandemic. In 2022/23, as part of the move towards ‘normal’ funding levels, the impact on the system was a funding reduction of £97m (5%) of our total allocation. We are expecting a similar level of financial challenge for each of the next two financial years and based on the current economic outlook it would be difficult to assume an improvement in the funding position beyond 2025. This, in common with the wider NHS, has had the effect of exposing an underlying and recurrent financial deficit which will require addressing over the short and medium term.

The JFP is therefore a key milestone, as it is the first opportunity since the pandemic response to outline how we will endeavour to deliver within financial constraints over the medium term.

2.5 Our vision and principles

Our vision, shared with ICS partners, is to deliver the best possible health outcomes for every one of the one million people living in SNEE. This JFP set outs the ICB’s contribution to delivering on this vision over the next five years.

A collective ambition of the SNEE ICS is to enable everyone in SNEE to ‘Live Well’. The SNEE ICB has defined its delivery priorities using the six domains of the Live Well model which also set out the six overall outcomes we wish to achieve:

1. Start Well – giving children and young people the best start in life.
2. Feel Well – supporting the mental wellbeing of our population.
3. Be Well – empowering adults to make healthy lifestyle choices.
4. Stay Well – supporting adults with health or care concerns to access support and maintain healthy, productive and fulfilling lives.
5. Age Well – supporting people to live safely and independently as they grow older.
6. Die Well – giving individuals nearing the ends of their lives choice around their care.

Our six Live Well domains and their priorities aim to reduce health inequalities for our local population. The SNEE ICB will contribute to the ICS’s collective ambitions to make the best health and wellbeing a genuine reality for all and provide the opportunity of health equality for everyone through the way in which it will work, by embedding a population health management approach and strong focus on directly targeting and addressing health inequalities.

Furthermore, the SNEE ICB will work with its health and care partners across the system, in placedbased alliances, across both counties, and within neighbourhoods to achieve the ICS’s collective ambition for all parts of the local health and care system to be working together as one team.

The SNEE ICB will do this by adopting the ICS’s six core principles for achieving a ‘can do’ health and care system that people can genuinely trust.

These principles include being:

• Collaborative – by focusing on system leadership and culture, and supporting our people and workforce across all sectors.
• Compassionate – by focusing on personalised care in all sectors, and supporting family carers and enabling genuine co-production.
• Courageous – by focusing on enabling equity, inclusion and social justice, ensuring clinical and care quality across all sectors and enhancing the roles of all clinical and care professionals.
• Community focused – by focusing on enabling a resilient VCSE sector, the importance of volunteering and the roles of community connectors, anchor institutions and community pharmacy.
• Creative – by focusing on the use of digital, data and technology, innovation and research and environmental sustainability.
• Cost-effective – by focusing on financial sustainability and the effective use of our collective health and care

2.6 Our delivery priorities

2.6.1 Health inequalities

Health inequalities are unfair and avoidable differences in health and wellbeing across the population, and between different groups within society. These inequalities are evident for people living in SNEE. Addressing health inequalities therefore is a key priority for the SNEE ICB. Effective action to address health inequalities in SNEE will require a coordinated and whole-system approach, with targeted prevention work using population health management as an enabler.

Our work on health inequalities will be informed by seven key areas:

1. Ensuring that reducing health inequalities by levelling up is core business for everybody.
2. Matching resources to need.
3. Being data-informed and evidence based.
4. Working using community-centred approaches and co-production.
5. Targeting our efforts through a Core20PLUS5 and prevention frame.
6. Using our position as community anchors to tackle the ‘causes of the causes’.
7. Ensuring our services and communication are digitally inclusive.

These priorities will be overseen by the Health Inequalities and Prevention Committee (HIPC) chaired by the Suffolk Director of Public Health to provide a focal point and strategic leadership on reducing health inequalities and embedding prevention across the ICB.

In addition, current system-wide actions are being taken to address health inequalities themed around five priority areas:

• Restoring NHS services inclusively.
• Mitigating against digital exclusion by providing equitable options through digital and non-digital routes, whilst understanding that some people prefer not to use technology.
• Ensuring datasets are complete and timely.
• Accelerating preventative programmes that proactively engage those at greatest risk of poor health outcomes (including Core20PLUS5) approach and
• Strengthening leadership and accountability.

2.6.2 Equality, diversity and inclusion in the workforce

The work delivered by the SNEE ICB would not be possible without the critical contribution of its diverse workforce. Diversity includes an array of characteristics including ethnicity, disability, gender, national origin, sexual orientation, age and religion – some of which are under-represented in certain NHS careers.

The SNEE ICB has committed to delivering the principles agreed by the SNEE ICP in December 2022 to ensure equality, diversity and inclusion (EDI) is enshrined within its ways of working. It will develop a five-year EDI strategy and objectives by the end of June 2023. This will articulate how we shall provide safe environments for learning and encourage a system-wide understanding, discourse and reduction of bullying, harassment or any other form of victimisation of people from protected characteristics.

To date, our system-based work has focused on race, including a commitment to deliver the regional anti-racism strategy. However, our body of work will expand to drive key improvements across the ICS:

• We will fully own our individual and collective responsibility to take immediate action to get the basics right, recognising the fundamental importance of EDI in the health and care workforce
• We will have a collective vision that in the future we should think about EDI as a business-as-usual function in health and care, because we will all be accepting of diversity and difference
• We will encourage diversity of thinking in system and pathway transformation
• We will empower our staff in health and care with appropriate resource and education

2.6.3 Our commitments

As part of the ICS’s shared vision to deliver the best possible health outcomes for every one of the one million people living in SNEE, we want to enable everyone in SNEE to ‘Live Well’. Our delivery priorities are organised on the six Live Well domains and are underpinned by a focus upon reducing health inequalities for our local population and ensuring EDI is central to our work.

The section below outlines our strategic framework. For each Live Well domain, which articulates the outcomes we are aiming to achieve, the SNEE ICB is making an overarching five-year commitment. These commitments relate to the outcomes we will strive to deliver as articulated in the SNEE ICS strategy, what we heard is important to our population, and what our workforce and partners tell us that we need to do better or do differently to improve the services we deliver.

Our vision

Deliver the best possible health outcomes for every one of the one million people living in Suffolk and north east Essex.

Start Well

Our outcome: Giving children and young people the best start in life.
Our five year commitment: We will ensure that children and young people have the best chance in life with a particular focus on those most in need.

Feel Well

Our outcome: Supporting the mental wellbeing of our population.
Our five year commitment: We will support people with mental health needs, including those with learning disabilities or autistic spectrum disorders, to stay mentally well and to get support in the community to live and thrive when they need it.

Be Well

Our outcome: Empowering adults to make healthy lifestyle choices.
Our five year commitment: We will empower people to lead healthy lifestyles and reduce the number of preventable deaths.

Stay Well

Our outcome: Supporting adults with health or care concerns to access support and maintain healthy, productive and fulfilling lives.
Our five year commitments:

1. Access to care: We will support people to access the right support, in the right time, in the right place for their health and care needs.
2. Early intervention: We will support adults with timely access to services to enable early detection and diagnosis of disease and risk factors to give people the best chance of maintaining a good quality of life.

Age Well

Our outcome: Supporting people to live safely and independently as they grow older.
Our five year commitment: We will ensure that people who are ageing are able to live safely and independently, experiencing a good quality of life.

Die Well

Our outcome: Giving individuals nearing end of life choice around their care.
Our five year commitment: We will enable people and their families to have high quality care and support from all health and care professionals involved at the end of their life.

We will achieve these outcomes and commitments via cross-cutting priorities, following set principles and utilising Enabler teams.

Our cross-cutting priorities

• Reduce health inequalities
• Enshrine equality, diversity and inclusion in our ways of working

Our principles

• Collaborative
• Compassionate
• Courageous
• Community focused
• Creative
• Cost-effective

Enablers

• Workforce
• Estates
• Digital
• Intelligence
• Procurement
• Communications & engagement
• Research & innovation
• Sustainability

We will assess our performance in delivering our commitments over the next five years by measuring performance against one or more target indicators in each domain. These are the lead key performance indicators with which we wish to target improvements in, with a particular focus on reductions in health inequalities. Delivery against the target indicators will be achieved through a broad programme of work detailed in full in the JFP and supporting annexes.

Start Well

• Reduce the neo-natal mortality rate by end of 2023/24 and reduce each year thereafter, addressing inequalities by prioritising reduction in unwanted variation in neo-natal mortality
• By 2028, no child or young person waits more than 12 weeks for child and adolescent mental health services (CAMHS) or 18 weeks for neurodevelopmental diagnostic (NDD) services, prioritising reductions in waiting times for ethnic minorities and those living in the 20% most deprived areas
• Reduce the hospital admission rate due to asthma of children or young persons living in the most deprived 20% of areas

Feel Well

• Achieve a 5% year-on-year increase in the number of adults supported by community mental health services
• Achieve a year-on-year reduction in hospital admission rate for mental health conditions
• Identify and reduce health inequalities amongst people with severe mental illness, by ensuring at least 90% of people, including those in all disadvantaged groups, receive a full annual physical health check and follow-up interventions by 2028

Be Well

• Halt recent increases in the number of overweight and obese children in reception and year 6 by 2028 and maintain prevalence below the national average
• Reduce the number of smokers in our population in line with only 5% of the population being smokers by 2030
• Increase each year the number of units of NHS dental activity delivered

Stay Well

Access to care:

• Increase our GP practice teams each year to meet the growing demand whilst increasing the number of trainees and apprentices
• No one waits more than one year for elective care by March 2025
• Increase by 10% each year the number of cases seen by the urgent community response service
• By 2028, 95% of patients attending A&E services wait no longer than 4 hours
• Reduce the number of acute hospital bed days utilised by people without a criterion to reside that are discharged on complex pathways (1-3)

Early intervention, prioritising early diagnosis and treatment for people living in the 20% most deprived areas:

• Increase the percentage of cancers diagnosed at stages 1 and 2 to 75% by 2028
• 80% of people with high blood pressure are identified and treated by 2028
• More than 85% of people with atrial fibrillation are identified and 90% of those at high risk of stroke are treated by 2028

Age Well

• Reduce each year the rate of emergency hospital admissions due to falls amongst the population aged over 65
• Reduce each year emergency acute hospital bed use (bed days per capita) for those over 65 years old
• Achieve the national 66.7% dementia diagnosis rate by October 2024 and an increase in dementia annual care plan reviews completed each year

Die Well

• Increase each year the percentage of people identified as approaching the end of life

Health inequalities (cross cutting)

• By 2028, reduce the number of deaths in under 75s considered preventable, reducing inequalities in our most deprived areas and amongst disadvantaged groups

The section below sets out the work programmes within each Live Well domain. However, the SNEE ICB recognises that there are key cross-cutting themes that apply to all areas of an individual’s health, such as GP primary care, personalised care, access to physical care for people with learning disabilities, consideration of carers and prevention, and parity in healthcare access for all which should be considered across each of the domains. Across each domain we will target our efforts through a health inequalities (including Core20PLUS5) and prevention frame.

Start Well Work Programmes

• Maternity and neo-natal care
• Children and Young People including CAMHS, Neuro Developmental, SEND, Community and Long Term Conditions

Feel Well Work Programmes

• Mental Health and Wellbeing
• Suicide Prevention
• Addictions
• Trauma and Abuse

Be Well Work Programmes

• Healthy Behaviours
• Personalised Care
• Women’s Health
• Dental/Oral Health
• Eye Health

Stay Well Work Programmes

• Elective Care and Diagnostics
• Urgent and Emergency Care including community
• Cancer
• Diabetes
• Respiratory
• Cardiovascular Disease
• Stroke and Stroke Rehab
• ME and CFS
• Neuro Rehab
• Learning Disabilities and Autism

Age Well Work Programmes

• Ageing Well Programme
• Dementia
• Carers

Die Well Work Programmes

• End of Life

2.7 How we will work differently

The SNEE ICB will focus on 12 key areas where we will work differently to achieve the delivery priorities of the Live Well domains. We will work in a collaborative way, contributing to the ICS achieving its collective ambition for all parts of the local health and care system to be working together as ONE team. And we will do this by embodying the ICS’s six core principles of a ‘can do’ health and care system.

1. Collectively accountable: The SNEE ICB has developed in partnership a framework that describes how we will work together while ensuring public accountability of the whole health and care system. We have developed a Functions and Decision Map which sets out the governance for the new integrated NHS in SNEE⁷.
2. Alliances: Our three ‘place-based systems of care’ are known locally as ‘alliances’ – the North East Essex Alliance, the West Suffolk Alliance and the Ipswich and East Suffolk Alliance, each defined by the footprint of local health and care partners as well as natural geography. The alliances of NHS, local authority, independent, voluntary and community sector partners work together with common purpose to plan and deliver meaningful integrated care to their local populations, given their distinct needs and assets.
3. Neighbourhoods: Neighbourhoods will enable health and care teams to focus on smaller, identifiable populations based on particular characteristics or needs. This enables greater flexibility by allowing different areas to find unique solutions for their challenges. Alliances oversee and support neighbourhood arrangements that cater to local populations, further embedding collaboration. Integrated neighbourhood teams (INTs) and Care Closer to Home teams will bring together physical, mental health and social care practitioners that work with general practices to provide a single coordinated care response for people, underpinned by prevention, self-care, early intervention, reablement and rehabilitation.
4. General practice and primary care networks: GP primary care remains the first point of contact for many people seeking health services. Primary care networks (PCNs) are crucial to the implementation of both the NHS Long Term Plan and this JFP, through more resilient delivery in local neighbourhoods, and the integration of health and care services to better respond to the needs of local populations. PCNs are key to addressing the wider ICS ambitions to improve population health and wellbeing, and building lasting relationships between partners, as recommended in the Fuller Stocktake Report. There are 22 PCNs across SNEE, providing essential primary care services with comprehensive coverage of the whole ICS area.
5. Collaboratives: Collaboratives see providers come together to provide the best possible services at scale. There are three core provider collaboratives in SNEE. The two integrated community and acute trusts, ‘West Suffolk NHS Foundation Trust (WSFT) and East Suffolk and North Essex NHS Foundation Trust (ESNEFT)’ are increasingly working together as one collaborative, whilst we are now establishing a new Suffolk Mental Health Collaborative and we are exploring development of a new Southend, Essex and Thurrock All Age Mental Health System Implementation Group.
6. Voluntary, Community and Social Enterprise (VCSE): Our local VCSE infrastructure organisations see a range of opportunities to increase the impact of the sector and build on the commitment to the VCSE sector being an equal partner within the ICS. The SNEE ICB fully endorses these opportunities and is committed to turning them into a reality.
7. Specialised Commissioning: Specialised services support people with a range of rare and complex conditions. NHSE has stated that specialised commissioning functions and budgets for some specialised services will be delegated from NHSE to ICBs from April 2024.
8. Population Health Management (PHM): In line with our PHM Strategy, we have made significant investment in our digital and data infrastructure and intelligence on population health need, and this will enable the design and delivery of a PHM approach. We will be deploying this new resource to understand both the causes and consequences of health inequalities in SNEE, supporting the development of new interventions and service models.
9. Medium Term Financial Plan: We are committed to using our resources in the most efficient and cost-effective way possible. We will develop a medium term financial plan underpinned by realistic and deliverable plans at an organisational level as well as cross-system transformation. We aim to develop sustainable solutions that will enable us to recover service standards whilst continuing to transform local services.
10. Quality and Safety: We will improve the quality and safety of health services for people in SNEE and create a health service that people and staff are proud of by: sharing and getting better at what we are good at, working closely with the public and our communities, clearly describing how we will improve and monitor quality, and working closely together to share responsibility for our work. The ICB has described how it intends to achieve this in the SNEE ICS Quality Improvement Strategy.
11. Clinical and Professional Leadership: Health equality for everyone requires our health and care professional leaders to work together as partners to deliver services which meet the distinct needs of our people. The SNEE ICS currently offers high impact One Team leadership development programmes for clinicians, managers, nurses, social workers and allied health professionals. These programmes are designed to build a network of effective leaders who can address the challenges in the health and social care system now and in the future.
12. Working in Partnership with People and Communities: The SNEE ICB strives to involve local people and communities in activities by promoting a culture of collaboration, respect, equality and transparency. We use a combination of virtual and face to face forums to ensure a wide range of people are engaged in our work.

2.8 Enablers

The SNEE ICB will focus on eight key enablers to the successful delivery of the JFP, as noted below:

1. Workforce: Strengthening our health and care workforce is the key enabler to delivering the benefits to the people living in SNEE. We will enable this to happen by following the four pillars of the NHS People Plan: looking after our people, belonging in the NHS, new ways of working and delivering care and growing for the future. Our ambition for our population is to have an integrated workforce that delivers care at the right time; in the right way; in the right place; by the right person.
2. Estates: Our ambition for our population is to have an integrated estate that allows the delivery of care at the right time; in the right way; in the right place; by the right person. Our Estates Infrastructure Strategy will address an ageing estate and maintenance backlogs, population growth, high levels of demand for services, pressures on revenue budgets for ongoing and future estate development, the effects of housing growth on local health infrastructure and a national desire to move service from acute sites to within community settings.
3. Digital: We will focus on i) leading system-wide action on data and digital: working with partners across the NHS and with local authorities to put in place smart digital and data foundations to connect health and care services to put people at the centre of their care; and ii) using joinedup data and digital capabilities to understand local priorities, track delivery of plans, monitor and address unwarranted variation, health inequalities and drive continuous improvement in performance and outcomes. How we will deliver this is set out in the SNEE ICS Digital, Data and Technology (DDaT) Strategy.
4. Intelligence: We aim to maximise the utility and value of our data and to use insights from analysis of data to become an intelligence-led system. This means integrating our data across organisations and providing insights on our population’s health and care needs, from person to system level. We will provide analysis to drive a shift towards PHM and to support decision making processes, including by ensuring all ICB committees are supported by an up-to-date understanding of activity, performance, and health inequalities.
5. Procurement: The principal aim of procurement is to deliver essential goods and services and improve outcomes, while increasing value from every pound spent by the NHS. The SNEE ICB and partner trusts are moving towards closer collaboration to procure common items together. The ICB will act as an Anchor Organisation to procure for social benefit. We are working to further develop and integrate the use of a single e-commercial system which enables NHS organisations to have visibility of each other’s sourcing and contract management systems.
6. Communications and engagement: ICB communications, public relations and engagement is central to service changes, new ways of working and communicating with internal and external audiences. We are dedicated to ensuring everyone has an opportunity to influence our decisions and codesign NHS services. We work with our partners in the NHS, local authority and VCSE sector to support people to better manage their health and meaningfully engage with the public, patients and carers to influence and support our commissioning decision making.
7. Research and innovation: Our ambition is to build a culture of research and innovation across our ICS that is responsive to those in most need in our communities. We will align innovation priorities with research strategy and ensure timely translation of research into practice. We will embed co-production in research and innovation to ensure the patient voice is integral to our work. We will develop a peer network of researchers and innovators to offer a range of opportunities to meet, learn, collaborate, share, and review research and innovation. We will share learning within our ICS and more widely, to help promote best practice regionally and nationally. With all our system partners, we will research and deliver innovative solutions that address our key local challenges and that make a positive and lasting health impact for our people.
8. Sustainability: We are acutely aware of the importance of sustainability in all our work, now and in the future. Environmental protection, tackling climate change and restoring nature are intrinsically linked to the health of our communities. Sustainability therefore not only supports the delivery of the JFP, but it also underpins its overarching needs. A Green Plan⁸ for 2022 to 2025 for the SNEE ICB has been agreed, detailing our current sustainability goals. We will continue to work closely with our partners across health, VCSE and public sector organisations. We will use our position to provide leadership and identify, share, and integrate resources and expertise.

2.9 Managing delivery of the Joint Forward Plan

The SNEE ICB has established several committees to assist it with the discharge of its duties and functions, including the delivery of the key priorities and goals set out in the JFP. The ICB Board remains accountable for all functions, including those that it has delegated to committees and subcommittees.

The ICB will undertake a continuous appraisal of the position, performance, and delivery of the key priorities and goals set out in the JFP via the ICB committees. The System Oversight and Assurance Committee (SOAC) has been established by the Board to support managing improvement, development and performance at ICS level. SOAC is a data-driven, evidence-based and rigorous committee that provides focus on supporting the spread and adoption of innovation and best practice between partners.

The SNEE ICB is held to account by NHSE for performance through the NHS Oversight Framework which sets out a broad range of measures. In addition, the JFP has set out local performance priorities that are important to the local population. Together these metrics form the ICB’s performance framework.

The ICB will publish an Annual Report in accordance with any guidance published by NHSE that sets out how it has discharged its functions and fulfilled its duties in the previous financial year. The JFP is a public document that will be reviewed, updated and confirmed annually.

3. Scope of this Document

3.1 Scope of the Joint Forward Plan

In line with the Health and Care Act 2022, Integrated Care Boards (ICBs) and their partner NHS trusts and NHS foundation trusts are required to prepare an annual Joint Forward Plan (JFP) at the beginning of the financial year. Legal responsibility for the Suffolk and North East Essex (SNEE)⁹ JFP resides with the ICB and partner NHS trusts and NHS foundation trusts. Primarily, this document sets out a shared five-year delivery plan for the ICB to contribute to the achievement of the ambitions of the integrated care strategy of the SNEE Integrated Care System (ICS).

This plan has therefore been developed in collaboration with a range of groups from across the system including stakeholders from:

• acute and community trusts
• care homes
• community care
• Essex Health and Wellbeing Board
• Healthwatch Suffolk and Healthwatch Essex
• hospices
• local alliances – West Suffolk, North East Essex and Ipswich and East Suffolk
• local government – Essex County Council and Suffolk County Council and the various district, borough and parish councils within SNEE
• mental health and learning disability (LD) providers
• primary care
• Suffolk Health and Wellbeing Board
• VCSE partners

This plan demonstrates how the ICB intends to address the key physical and mental health requirements of the population of SNEE, describing a series of outcomes, priorities and key metrics to be attained over the period 2023 to 2028. These are aligned to the core national, regional and local strategic drivers of the NHS including the NHS Long Term Plan (LTP), the Health and Care Act and the Core20PLUS5 approach, as well as the recent 2022 ICS Strategy developed by the SNEE Integrated Care Partnership (ICP). The JFP also sets out a series of actions in achieving both the universal NHS commitments and ambitions of the joint local health and wellbeing strategies (JLHWS) for Suffolk and Essex.

This document aligns to the three principles of JFPs denoted within the ‘Guidance on Developing the Joint Forward Plan¹⁰’ document circulated in December 2022:

• Principle 1: Fully aligned with the wider system partnership’s ambitions
• Principle 2: Supporting subsidiarity by building on existing local strategies and plans as well as reflecting the universal NHS commitments
• Principle 3: Delivery-focused, including specific objectives and milestones for the ICB to attain by 2028

The JFP for the SNEE ICB considers the ‘Triple Aim’, which is the duty to have regard to the wider effect of our decisions on inequalities in the system as well as:

• the health and wellbeing of our people
• the quality of services provided or arranged by the SNEE ICB and other relevant bodies
• the sustainable and efficient use of resources by the SNEE ICB and other relevant bodies

The core requirements of the ‘Triple Aim’ are therefore embedded within this JFP by our wholehearted commitments to improving public health, preventing ill-health, and reducing health disparities for our wider population.

Legislative requirements of the JFP are shown below, alongside the accompanying section of this document where it is covered:

• Describing the health services for which the ICB proposes to make arrangements (Section 5)
• Duty to promote integration (Sections 3, 5)
• Duty to have regard to wider effect of decisions (Sections 5.3, 6)
• Financial duties (Section 6.7)
• Implementing Joint Local Health and Wellbeing Strategies (JLHWSs) (Section 3)
• Duty to improve quality of services (Section 6.9)
• Duty to reduce inequalities (Section 5)
• Duty to promote patient involvement (Section 5.6.3.2)
• Duty to promote public involvement (Section 7.1)
• Duty to patient choice (Section 5)
• Duty to obtain appropriate advice (Section 8)
• Duty to promote innovation (Section 7.8)
• Duty in respect of research (Section 7.8)
• Duty to promote education and training (Section 7.2)
• Duty as to climate change (Section 7.9)
• Addressing the particular needs of children and young people (Section 5.4)
• Addressing the particular needs of victims of abuse (Section 5.5.3.4)

The JFP for the SNEE ICB is a public document which will be ratified by the Essex Health and Wellbeing Board (HWB) and the Suffolk Health and Wellbeing Board (HWB) in May 2023 followed by the ICB Board in late May 2023 and thereafter published by the end of June 2023. As JFPs are a five-year planning document, this document will be reviewed and updated/ confirmed annually before the start of each financial year.

3.2 Purpose, Functions and Governance of The Suffolk and North East Essex Integrated Care Board

The Health and Care Act 2022 completed the parliamentary process and received Royal Assent on 28 April 2022. This was an important step on the journey towards establishing ICSs, moving them onto a statutory footing with the establishment of ICBs.

Each ICS has an ICB, a statutory organisation bringing the NHS together locally to improve population health and establish shared strategic priorities within the NHS. When ICBs were legally established, clinical commissioning groups (CCGs) were abolished.

The ICB has taken on the NHS commissioning functions of CCGs as well as some of NHSE’s commissioning functions. It is accountable for NHS spend and performance within the system.

The SNEE ICB brings together partners responsible for planning and delivering health and care across SNEE to ensure shared leadership and joint action to improve the health and wellbeing of the one million people who live locally. The ICB Board is accountable to NHS England (NHSE), the Department of Health and Social Care and Department for Levelling Up, Housing and Communities.

The ICB Board meets as a unitary board and is collectively accountable for the performance of the ICB’s functions. The ICB Board is made up of a Chair and three non-executive members alongside the Chief Executive and executive director team and several partner members including:

• three representing NHS and foundation trusts
• two representing primary medical services
• two representing local authorities
• one representing the VCSE sector

The ICB has agreed a Scheme of Reservation and Delegation (SoRD) which is published in full in the ICB Governance Handbook. The SoRD sets out:

• those functions that are reserved to the board
• those functions that have been delegated to an individual or to committees and sub-committees
• those functions delegated to another body or to be exercised jointly with another body

The ICB Board has established several committees to assist it with the discharge of its functions including three placed based Alliance Committees alongside Finance, Quality, System Oversight and Assurance and an Executive Committee amongst others.

The ICB Board remains accountable for all the ICB’s functions, including those that it has delegated and therefore appropriate reporting and assurance mechanisms are in place as part of agreeing terms of a delegation.

The ICB committees have further delegated some functions to sub-committees (known as Groups). These include the underpinning structures for the committees as well as system wide transformation programmes and place-based Alliance programmes. The ICB Governance Handbook features the SoRD, the Functions and Decisions Map and the Terms of Reference for all ICB Committees and can be found on the SNEE ICB website¹¹.

In consultation with local partners, ICBs will produce a five-year plan – the JFP (updated annually), for how NHS services will be delivered to meet local needs.

3.3 Population needs

There are 1,058,560 people registered with general practitioners (GPs) across SNEE – 413,188 in Ipswich and east Suffolk, 370,589 in north east Essex and 265,688 in west Suffolk¹². The population within SNEE is projected to grow by 10% by 2036 which will likely increase demand on health and social care needs across the region.

Essex and Suffolk county councils produce comprehensive and on-going analysis to inform their respective JLHWSs. These joint strategic needs assessments (JSNAs) examine the current and future health and care needs of local populations in order to guide the planning and commissioning of services.

This evidence base underpins strategic development at the local authority level, ICB level and alliance level. Across the ICS, small area analysis is being used increasingly, for example, at ward and parish levels. SNEE is spread across a mix of urban, rural and coastal areas, each with contrasting levels of deprivation.

There are pockets of significant deprivation concentrated in certain communities including coastal areas; the most deprived neighbourhood in England according to the 2019 Index of Multiple Deprivation (IMD) is to the east of the Jaywick area of Clacton-onSea. As of 2019, Ipswich is the most deprived area in Suffolk, 45.8% of Lower Super Output Areas (LSOAs) in Ipswich are in the most deprived 30% nationally.

The most deprived LSOA is Ipswich is located across the Priory Heath area. West Suffolk has one LSOA in the 20% most deprived nationally in St Edmundsbury in Bury St Edmunds. The mix of urban, rural and coastal populations will likely contribute to a further increase in healthcare services across SNEE over the next five years.

Differences in the level of deprivation across SNEE has undoubtedly accelerated the emergence of some health inequalities (as detailed in Section 5.2). For example, the gap in life expectancy between the most and least deprived areas of Essex has widened to 7.5 years for men and 5.8 years for women. Similarly, in Suffolk, this gap is 7.4 years for men and 5 years for women.

The population of SNEE is predominantly white (94.7%), much higher than the national average of 86.7%. Of the remaining population, 2.1% are Asian/Asian British (national average is 7%), 1% are black/African/Caribbean/black British (national average is 3.1%), 1.7% are mixed/multiple ethnic groups (national average is 2.1%) and 0.5% are classified as Other (national average is 0.95%). The proportion of people aged over 65 across SNEE is 23%, higher than the England average of 19% which will exert further pressure on healthcare services from 2023 to 2028¹³.

There is alignment across SNEE in the use of a model developed by the Population Health Institute of the University of Wisconsin¹⁴ which provides a framework for considering the wider determinants of health. This model recognises a range of impacts on an individual’s health and demonstrates how to tackle these elements by focusing on those that have the greatest impact on health outcomes – health behaviours, socio-economic factors, clinical care and the built environment, as shown below.

Figure 1: Model for Determining the Wider Determinants of Health

This figure is described directly below the image.

SOURCE: Robert Wood Johnson Foundation and University for Wisconsin Population Health Institute in US to rank countries by health status

Model for Determining the Wider Determinants of Health: text description

The four wider determinants of health are: Health Behaviours, Socio-economic Factors, Clinical Care and the Built Environment.

The model suggests that Socio-economic Factors have the biggest impact upon a person’s health, contributing 40% of the overall impact. This is broken down further into Education (10%), Income (10%), Employment (10%), Family/Social Support (5%) and Community Safety (5%).

The second most impactful determinant of health, as shown by the model, is Health Behaviours which make up 30% of the overall impact upon a person’s health. This is broken down further into Diet/Exercise (10%), Smoking (10%), Alcohol Use (5%) and Poor Sexual Health (5%).

The third most impactful determinant of health, as shown by the model, is Clinical Care which makes up 20% of the overall impact upon a person’s health. This is broken down further into Access to Care (10%) and Quality of Care (10%).

The final, and least impactful determinant of health, as shown by the model, is the Built Environment which makes up 10% of the overall impact upon a person’s health. This is broken down further into Environmental Quality (5%) and the Built Environment (5%).

The framework is referenced in the Essex JLHWS, Suffolk JLHWS and the SNEE ICS Strategy, demonstrating a commonality of approach to public health of local alliances across the region.

Appendix 1 provides a summary of the Essex and Suffolk JSNAs.

3.4 Key factors driving the need for a JFP

3.4.1 Demand and Capacity

Across the country the performance of health and care organisations is set against a challenging backdrop of increasing demand for services. There are underlying demand pressures on the NHS and social care, driven by demographic growth and morbidity changes, with the pandemic increasing demand and negatively impacting on staff absence. This has caused an increase in elective waiting lists, in particular.

The NHS is currently experiencing challenges with workforce retention and skills gaps persist nationally. The SNEE ICS has shown a 27% growth in the workforce over the last six years, however retention challenges remain across the system. From April 2021 to April 2022 the turnover rate of care workers in Suffolk was 32.4% and the vacancy rate was 11.4%. Across Essex this was 36.3% and 15%.

This compares unfavourably against a turnover rate of 29% and vacancy rate of 10.7% for the whole of England and 32.2% and 11.3% in the Eastern region. This suggests a combination of retention issues of existing staff and the inability to fill additional roles created by new customer demand.

The population of the SNEE ICS is estimated to increase by 10% by 2036¹⁵. The population is also ageing, with the proportion of the population aged over 75 increasing from 10.3% in 2018 to 13.8% in 2032, an additional 45,000 people. The prevalence of multimorbidity (people with more than two illnesses or diseases) is between two and three times greater in the plus 75 year old population relative to working age adults.

Additionally, older people typically have more frequent contact with GPs and are at higher risk of emergency admissions. Therefore, an ageing population will have a greater health need and associated demand on primary care services. With outpatient referral rates ranging from around 4% to 6%, this will add demand for planned secondary care. If additional capacity in primary care cannot be achieved, this will also increase demand for urgent and emergency care services.

As shown in section 3.3, Essex and Suffolk county councils produce JSNAs and this evidence base provides insight on the drivers of demand. This includes a wide-ranging assessment of the most prominent health inequalities affecting care or access to care and how inequalities manifest as drivers of demand.

More proactive planning of services based on an understanding of current population and the drivers of future demand for services, through a population health management (PHM) approach will enable us to reduce demand for reactive care services and use those resources to provide better proactive care for more people. Section 6.6 provides further detail of our PHM approach and work.

3.4.2 Cost of Living Challenge

The SNEE ICB is conscious of the ongoing cost of living challenge driven by sharp increases in the cost of energy and food prices and ongoing inflationary pressures. In December 2022, the SNEE ICP set out a series of actions to better support local people during these challenges. The SNEE ICB is equally committed to meeting these goals, as set out below:

• We will contribute to wider initiatives to co-ordinate and promote support to those who need it most
• We will combat the stigma of needing support
• We will identify the people who use our services who are struggling
• We will identify our staff and volunteers who may be struggling

3.4.3 Financial Position

Prior to the pandemic, the NHS organisations in SNEE had delivered strong financial performance and met national financial targets consistently for a number of years. However, in line with the rest of the NHS, the difficulty the system was facing in meeting the increasing demands on services within financial constraints was intensifying.

Extraordinary amounts of additional funding were provided to systems as part of the emergency financial regime put in place by NHSE as part of the response to the pandemic. For SNEE in 2021/22, this equated to circa £292m (20%) of funding beyond ‘normal’ levels.

In 2022/23 as part of the move towards ‘normal’ funding levels the impact on the system was a funding reduction of £97m (5%) of our total allocation. We are expecting a similar level of financial challenge for each of the next two financial years and based on the current economic outlook it would be difficult to assume an improvement in the funding position beyond 2025.

The JFP is a key milestone in developing our system’s future as it is the first opportunity post the pandemic response to outline how we will endeavour to deliver on the strategy within financial and non-financial constraints over the medium term. Further detail on our approach to financial management can be found in Section 6.7.

3.5 What people have told us

As part of the ICS Strategy development, a series of engagement events took place with people living and working in SNEE from September to December 2022. Over 600 people responded via online surveys, community group discussions, a pop-up video booth and direct contact with the ICP team to inform the strategy. The key asks and observations from these workshops are summarised below and have been considered throughout the priority setting for the SNEE ICB as part of the JFP work:

• Timely access to health and care services
• Access to and the quality of primary care services
• Waiting for diagnosis, treatment and support has impacted significantly on people’s physical and mental health
• A need for joined up care by a competent, caring and compassionate workforce
• Inclusive, anti-discriminatory, individualised care
• A challenged health and care system but a system where people want the best health and care for everyone

The ICB built on the engagement work carried out in the development of the ICS Strategy through a range of engagement exercises on the draft JFP between 16 January and 22 February 2023. NHSE guidance on JFPs states that ICBs and partners are expected to engage with people for whom they have a responsibility and anyone else they feel is appropriate. During development of the JFP, the SNEE ICB continuously referred back to numerous engagement and coproduction activities that have taken place in recent years across the region. On this basis, the aim was to enable effective and meaningful involvement and to ensure all people and communities had the opportunity to comment, either on the sections most important to them or the whole document.

Engagement was designed to follow the structure of the Live Well domains, mirroring the format of the plan itself. Using the engagement platform LetsTalkSnee.co.uk a series of web pages were developed to define and break down each domain, outlining the key priorities. A series of public meetings were held to reach people who prefer to take part in person.

During the engagement period, there were over 1,000 visits to the LetsTalkSNEE platform. 340 people voted using quick polls, 280 ideas were submitted and there were 330 downloads of the draft document and executive summary. Approximately 100 people attended an in-person meeting. Eight core themes were raised through the engagement activity:

1. Access – including access to all services across primary care, secondary care, specialist care and the community as well as opportunities and activities to support healthy living. People also noted the ability to get to and from appointments and activities.
2. Mental health – including services for both children and young people and adults.
3. Prevention, health education and information – supporting and enabling people and communities to manage their own health, stay healthy and knowing how to access support.
4. Personalisation and reasonable adjustments – both personalised care in response to a person’s specific conditions and the adjustments made to support good health outcomes. This might include communication, physical access or a person’s cultural beliefs and values.
5. Digitalisation – the importance of being aware of innovations and progress that can be enabled through the use of new technology, whilst also recognising that not everyone is willing or able to use technology.
6. Workforce – consideration for recruitment, retention, training and wellbeing.
7. Primary care – development of primary care across SNEE.
8. Children and young people with special educational needs – services, support and interventions to support young people with a special educational need.

A fuller report on our engagement can be found in Appendix 2.

3.6 National context

An overview of national and regional priorities is provided in this section which have collectively influenced the content of the JFP. Specialist national commitments and strategies are subsequently referenced within each of the individual subsections of Section 5, Our Priorities. Local commitments are also detailed in Appendix 3, Our Partners’ Aligned Plans.

The NHS Long Term Plan¹⁶

The NHS LTP (2019-2029) sets out the national 10-year strategy to make the NHS fit for the future. It aims to improve care by:

• making sure everyone gets the best start in life
• delivering world-class care for major health problems
• supporting people to age well

These ambitions will be achieved through a number of ways:

• Doing things differently
• Preventing illness and tackling health inequalities
• Making further progress on care quality and outcomes
• Making sure NHS staff get the backing they need
• Making better use of data and digital technology
• Getting the most out of taxpayers’ investment in the NHS

As an ICB, we will collaborate across all sectors to deliver the objectives of the NHS LTP by listening to what local people say, and co-produce solutions that provide the right care and support for people and communities. We will use our resources effectively, maximising the assets in our people and communities and together we will think imaginatively to continually learn and develop. The SNEE ICB’s local response to the LTP is set out through the document.

Next steps for integrating primary care: Fuller Stocktake Report¹⁷

Published in May 2022, the Fuller Stocktake Report considers how the implementation of integrated primary care can be accelerated by incorporating the current four pillars of general practice, community pharmacy, dentistry, and optometry across systems.

Key challenges identified in the report include access and continuity of care, with frustrations shared by both people and staff alike.

The report finds that integrated neighbourhood ‘teams of teams’ need to evolve from PCNs and be rooted in a sense of shared ownership for improving the health and wellbeing of the population. PCNs should promote a culture of collaboration and pride, create the time and space within these teams to problem solve together, and build relationships and trust between primary care and other system partners and communities.

The SNEE ICB’s local response to the Fuller Report is set out in Section 5.7.3.2, Urgent and Emergency Care including Community and Section 6.3, GP and Primary Care Networks.

3.7 Regional context

Essex Health and Wellbeing Board – Joint Health and Wellbeing Strategy 2022 to 2026¹⁸

This JFP takes account of the Essex Joint Health and Wellbeing Strategy 2022 to 2026. The overall aim of this strategy is to see an improvement in health and wellbeing outcomes for people of all ages, and a reduction in health inequalities, by having a focus on supporting poor health prevention and promoting health improvement. This aligns to the ambitions of the JFP to support people to Live Well.

The strategy’s vision is to “improve the health and wellbeing of all people in Essex by creating a culture and environment that reduces inequalities and enables residents of all ages to live healthier lives”.

The Strategy sets out five key priority areas which align to our JFP:

1. Improving mental health and wellbeing, aligned to our intention to ensure people in SNEE “Feel Well” (Section 5.5)
2. Physical activity and healthy weight, as discussed in Section 5.6.3.1
3. Supporting long term independence, as highlighted in Section 5.6.3
4. Alcohol and substance misuse, as discussed in Section 5.5.3.3
5. Health inequalities and the wider determinants of health, as noted throughout Section 5, in particular Section 5.2

Suffolk Health and Wellbeing Board – Transitional Joint Health and Wellbeing Strategy 2022 to 2023¹⁹

The SNEE ICB JFP also takes account of the key priorities of the Suffolk Transitional Joint Health and Wellbeing Strategy 2022 to 2023. This strategy was developed by considering the wider determinants of health using an asset-based approach by working in collaboration with others. The vision described in the strategy is “to work with our communities and partners to put in place the building blocks required to make Suffolk a place where everyone can lead a longer, healthier and happier life”. Key priorities include: Public mental health: more people will have positive mental wellbeing. As discussed throughout Section 5.5, Feel Well Good work and health: more people will have access to good quality jobs and fair work as detailed throughout Section 6, Our Priorities and Section 7.2, Workforce of the JFP Listening and engaging with local voices: residents and communities will become more involved in decisions that affect their lives, health, and wellbeing as evidenced through the engagement undertaken on the JFP and in Sections 7.1 and 8 Wellbeing of children and young people: all our children and young people should be able to live happy, healthy, and fulfilled lives in communities where they feel safe, as noted within Section 5.4, Start Well

Suffolk and North East Essex ICS Strategy

The Integrated Care Strategy for the SNEE ICS is underpinned by a detailed new website www.sneeics.org.uk that sets out this work in a flexible, collective and central manner. The strategy builds on and brings together earlier work and thinking from across local partners and describes a shared vision from the perspective of ‘what matters’ to people living in SNEE. The ICS is united on four collective ambitions, which align to this JFP:

• Making the best health and wellbeing a genuine reality for all
• Ensuring the opportunity of health equality for everyone
• Enabling everyone to ‘Live Well’ – Start Well, Be Well, Stay Well, Feel Well, Age Well, Die Well
• Creating a genuinely ‘Can Do’ Health and Care System that people can trust

The strategy was developed through an inclusive process involving stakeholders from across SNEE including people with lived experience, clinicians and other professionals, elected leaders and others.

The JFP responds to each of these ambitions, setting out the ICB’s contribution to their achievement.

4. Our Vision, Outcomes and Principles

4.1 Vision and outcomes for the ICS

The ICS shared vision is to deliver the best possible health outcomes for every one of the one million people living in SNEE. In addition, one key collective ambition of the ICS is for everyone at all stages of their life to be able to ‘Live Well’ across the region of SNEE. We have therefore adopted, organised ourselves and defined the outcomes we wish to achieve using the six domains of the Live Well model.

Start Well – giving children and young people the best start in life

We want to ensure that children and young people across SNEE have the best possible start in life from preconception onwards and can have their physical and mental health supported as they grow and develop by reducing health inequalities and adopting tailored approaches where needed.

Feel Well – supporting the mental wellbeing of our population

The best possible mental health and resilience is essential if everyone in SNEE is to live well and age well. Good mental health is a state of wellbeing in which every individual realises their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to contribute to their community. Like physical health, people can experience both temporary and long-term mental ill-health.

Be Well – empowering adults to make healthy lifestyle choices

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.

Stay Well – supporting adults with health or care concerns to access support and maintain healthy, productive and fulfilling lives

Supporting adults with health or care concerns to access the right support, in the right time in the right place will enable them to live healthy, productive and fulfilling lives.

Age Well – supporting people to live safely and independently as they grow older

We will ensure that everyone ages well across SNEE and is enabled to live safely and independently. If and when they need support it will be provided proactively and support their needs.

Die Well – giving individuals nearing end of life choice around their care

End of Life care will impact most people in SNEE at some time, including those approaching the end of their lives, those that care for them and those who are bereaved. Over 10,000 people in SNEE are in the last year of their life and we wish to ensure that over this time they and those who care for them have the best and most equitable care and support from the resources we have available.

The SNEE ICB will contribute to the ICS collective ambitions to make the best health and wellbeing a genuine reality for all and provide the opportunity of health equality for everyone through the way in which it will work, in particular by embedding a population health management approach and strong focus on directly targeting and addressing health inequalities. Our six Live Well domains and the priorities therewithin are underpinned by a focus upon reducing health inequalities for our local population.

To support our vision and achievement of our outcomes, we believe that people and communities should always be given opportunity to be our partners in coproducing our services. To apply co-production purposefully, we will involve service users and/or carers in identifying the need and the approach, and then in the gathering of intelligence, through to making decisions, from start to finish.

We intend for all development work to consider and share what elements can be co-produced, the approach taken and, where necessary, to explain when and why it is impractical to apply co-production. We recognise that the availability of resources and time factors may necessitate concentrating on co-producing a part or parts of service development rather than the whole.

Furthermore, the SNEE ICB will work with its health and care partners across the system, in placedbased Alliances, across both counties, and within neighbourhoods to achieve the ICS collective ambition for all parts of the local health and care system to be working together as one team.

The SNEE ICB will do this by adopting the ICS’ six core principles for achieving a ‘can do’ health and care system that people can genuinely trust.

• Collaborative – by focusing on system leadership and culture, supporting our people and workforce across all sectors
• Compassionate – by focusing on personalised care in all sectors, supporting family carers and enabling genuine co-production
• Courageous – by focusing on enabling equity, inclusion and social justice, ensuring clinical and care quality across all sectors and enhancing the roles of all clinical and care professionals
• Community focused – by focusing on enabling a resilient VCFSE sector, the importance of volunteering and the roles of community connectors and anchor institutions and community pharmacy
• Creative – by focusing on the use of digital, data and technology, innovation and research and environmental sustainability
• Cost-effective – by focusing on financial sustainability and the effective use of our collective health and care

5. Our Priorities

5.1 Introduction to the ‘Live Well’ domains

As noted in Section 4, our vision is for everyone to Live Well in SNEE, as demonstrated by our adoption of the six Live Well domains which set out our overarching six outcomes for our local population.

The SNEE ICB’s key priorities for 2023 to 2028 are therefore organised based on these domains, as detailed in this section of the Plan. Subsections for each of the Live Well domains outline key sub outcomes, priorities and metrics to achieve over the JFP timeframe of 2023 to 2028. The Live Well domains are organised as set out below:

Start Well

• Preconception, Maternity and Neonatal Care
• Children and Young People including CAMHS, Neuro Developmental, SEND, Community and Long Term Conditions

Feel Well

• Mental Health and Wellbeing
• Suicide Prevention
• Addictions
• Trauma and Abuse

Be Well

• Healthy Behaviours
• Personalised Care
• Women’s Health
• Dental / Oral Health
• Eye Health

Stay Well

• Elective Care and Diagnostics
• Urgent and Emergency Care including community
• Cancer
• Diabetes
• Respiratory
• Cardiovascular Disease
• Stroke and Stroke Rehab
• ME and CFS
• Neuro Rehab
• Learning Disabilities and Autism

Age Well

• Ageing Well Programme
• Dementia
• Carers

Die Well

• End of Life

Our six Live Well domains and the priorities therewithin are underpinned by a focus upon reducing health inequalities for our local population and ensuring equality, diversity and inclusion is central to our work as detailed in the next two sections. The Live Well domains offer a methodology and structure to organise the contents of the JFP and the ensuring programmes of work. However, the SNEE ICB recognises that there are key cross-cutting themes that apply to all areas of an individual’s health, such as GP primary care, personalised care, access to physical care for people with learning disabilities, consideration of carers and prevention and parity in healthcare access for all which should be considered across each of the domains.

5.2 Health inequalities

5.2.1 Why is this important for people in Suffolk and north east Essex?

Health inequalities are unfair and avoidable differences in health and wellbeing across the population, and between different groups within society. These inequalities are evident for people living in SNEE.

There is a life expectancy gap between individuals born in the most deprived communities in SNEE and those in the least deprived. The difference in average life expectancy is 7.4 years in men and 5.9 years in women²⁰. This has increased over time, showing that health inequalities are widening. Health inequalities have also been documented between population groups across the four dimensions below:

• Protected characteristics outlined in the Equality Act (2010) e.g., age, gender, race, sexual orientation, and disability
• Socio-economic status and deprivation e.g., unemployment, low income, living in a deprived area, poor housing, and poor education
• Vulnerable groups in society (inclusion health groups) e.g., homeless people, Gypsy, Roma, and Traveller communities, vulnerable migrants and sex workers
• Geography e.g., rural or urban areas

Addressing health inequalities therefore is a key priority for the SNEE ICB. Understanding the causes and drivers of health inequalities and identifying opportunities for action across the ICS will help us do this effectively.

The modified Labonte Model (fig 2) illustrates how a broad and complex range of factors drive health inequalities. Effective action to address these will require us to adopt a population health approach.

This aims to improve physical and mental health outcomes across the population, while reducing health inequalities. It takes into consideration the wider factors that influence these outcomes and recognises the need to work with communities and across partner agencies.

Figure 2: (modified) Labonte Model

Description of Figure 2

The modified Labonte Model is an infographic which illustrates the range of factors that drive health inequalities. These include:

The wider determinants of health:

• Income and debt
• Employment/quality of work
• Education and skills
• Housing
• Natural and built environment
• Access to goods/services
• Power and discrimination

Psychosocial factors:

• Isolation
• Social support
• Social networks
• Self-esteem and self-worth
• Perceived level of control
• Meaning/purpose of life

Health behaviours:

• Smoking
• Diet
• Alcohol

Physiological impacts:

• High blood pressure
• High cholesterol
• Anxiety/depression

5.2.2 What do we know about people’s local experiences?

Across SNEE, different causes of death contribute to the difference in life expectancy between our most deprived and least deprived communities. Leading causes of death include circulatory conditions, cancer and respiratory conditions. Several underlying risk factors are implicated in their causation, e.g., tobacco, high body mass index, diabetes, dietary risks, high blood pressure and alcohol. Focused action to tackle these risk factors will not only prevent people from developing these conditions but will also reduce health inequalities. A system-wide focus on prevention, targeting areas where we have the strongest evidence for inequalities, is therefore important.

A draft of the JFP was shared on the online platform LetsTalkSNEE in January 2023 to gather feedback on key aspects of the document. Findings included:

• the need to address health inequalities in dental and oral health for marginalised groups
• 50% of respondents said that “understanding women’s health inequalities” was the most important action for the SNEE ICB. The remaining 50% were focused on the “development of a programme of analytics” in this field. All respondents felt that a reduction in inequalities was the most important measure for women’s health
• 100% of respondents said that “high quality care and reduced health inequalities” was the most important action for ME and Chronic Fatigue Syndrome

Reducing health inequalities was also a core ambition identified by Healthwatch Suffolk in the development of the SNEE ICS strategy.

5.2.3 How do we plan to make a difference?

Effective action to address health inequalities in SNEE will require a coordinated and whole-system approach, with targeted prevention work using PHM as an enabler.

PHM data will help the system to identify areas of focus and individuals or communities for targeted interventions. Linked datasets will provide insight into current and future population needs, allow targeted action to prevent ill health and reduce health inequalities, and enable the delivery of better coordinated care and better use of scarce resources.

It will enable us to move from data to action and have much greater impact than could be achieved previously.

Figure 3 provides a useful framework for consideration by health and care organisations across SNEE. It illustrates key areas for action across the spectrum of health and care. These include, for example, the distribution of health system resources like funding and workforce, looking at the access to, quality and experience of services, and major drivers of morbidity and mortality and their underlying risk factors.

Figure 3: Framework for Health Inequalities

Description of Figure 3

Health inequalities encompass both inequalities in healthcare and inequalities in health outcomes. Inequalities in healthcare are driven by factors specific to the patient and factors specific to the system.

Factors specific to the system include funding and workforce. Factors specific to the patient include:

• managing risk factors
• access
• diagnosis
• treatment
• experience

Inequalities in health outcomes are characterised by morbidity and mortality.

All of these factors are driven by:

• Socioeconomic gradient
• Disadvantaged groups (e.g. ethnicity, LGBTQ+, rurality etc.)
• Inclusion health groups (e.g. people who are homeless)

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The Core20PLUS5 framework is an NHSE national approach to help ICSs reduce health inequalities, as shown in the below infographics

Figure 4: Infographics for the Core20Plus5 Approach

The below infographics show populations who may be targeted to reduce health inequalities. These include the most deprived 20% of the national population as identified by the Index of Multiple Deprivation. This group is known as “CORE20”. Other target populations are described as ICS-chosen population groups experiencing poorer-than-average health access, experience and/or outcomes, who may not be captured within the Core20 alone and would benefit from a tailored healthcare approach e.g. inclusion health groups. These groups are known as “PLUS”.

The infographics also outline the key clinical areas of health inequalities and ways to address them:

• Maternity: ensuring continuity of care for women from Black, Asian and minority ethnic communities and from the most deprived groups.
• Severe mental illness (SMI): ensuring annual health checks for 60% of those living with SMI (bringing SMI in line with the success seen in Learning Disabilities).
• Chronic respiratory disease: a clear focus on Chronic Obstructive Pulmonary Disease (COPD), driving up uptake of Covid, Flu and Pneumonia vaccines to reduce infective exacerbations and emergency hospital admissions due to those exacerbations.
• Early cancer diagnosis: 75% of cases diagnosed at stage 1 or 2 by 2028.
• Hypertension case-finding: and optimal management and lipid optimal management.

Smoking cessation positively impacts all 5 key clinical areas.

For children and young people, key clinical areas are:

• Asthma: address over reliance on reliever medications and decrease the number of asthma attacks.
• Diabetes: increase access to Real-time Continuous Glucose Monitors and Insulin pumps in the most deprived quintiles and from ethnic minority backgrounds and increase proportion of children and young people with Type 2 diabetes receiving annual health checks.
• Epilepsy: increase access to epilepsy specialist nurses and ensure access in the first year of care for those with a learning disability or autism.
• Oral health: address the backlog for tooth extractions in hospital for under 10s.
• Mental health: improve access rates to children and young people’s mental health services for 0-17 year olds, for certain ethnic groups, age, gender and deprivation.

Core20 Across SNEE, 2019 Index of Multiple Deprivation (IMD) data showed that:

• 12.5% of LSOAs in SNEE fall into the 20% mostdeprived areas, as identified by national IMD data, including the Brooklands and Broadway areas of Jaywick which are the most deprived LSOAs in the country
• 116,673 people in SNEE living in the 20% most deprived areas nationally, of which the majority live in Tendring and Ipswich

PLUS populations – across SNEE these groups have been identified as:

• people from minority ethnic communities
• coastal communities
• rural communities
• people and groups facing the sharpest health inequalities (groups at risk of disadvantage or “inclusion” health groups) e.g., migrants, travellers, those who are homeless, those in prison and sex workers
• people with learning disabilities and/or autism
• people with more than one health condition

Five – Clinical focus areas including:

• Maternity: see Section 5.4 for further information
• Severe Mental Illness (SMI): this is covered in more detail in Section 5.5, Feel Well
• Chronic Respiratory Disease: please see Section 5.7 (5.7.3.5 – 5.7.3.7) for further details on respiratory ambitions of the SNEE ICB
• Early Cancer Diagnosis: our plans for Cancer are detailed in Section 5.7.3.3
• Hypertension Case-Finding and optimal management and lipid optimal management: further information on stroke and stroke rehab is available in Section 5.7.3.8

In addition, NHSE has more recently published an equivalent Core20PLUS5 for children and young people. Further details are provided in Section 5.4.

Our work on health inequalities will be informed by seven key areas.

1. Reducing health inequalities by levelling up is core business for everybody

• Delivery of a continued programme of training and resources to ensure we all understand health inequity and how to reduce it
• Health Inequality Impact Assessments and associated principles embedded across ICB planning, design and delivery of services
• Health inequalities as a core consideration across all governance structures and reporting e.g. board papers, performance frameworks

2. We will match resources to need:

• inequalities will be included in investment and prioritisation decisions
• financial and staffing resources will be shifted (proportionate universalism) to where the need is

3. We are data informed and evidence based as we are:

• driven by PHM, JSNA and Health Equity Audits
• focused on data quality and completeness of data

4. We do this work through community centred approaches and coproduction enabled by:

• building on community capacity to act together
• focusing on enhancing individuals’ capabilities to provide advice, information and support or organise activities around health and wellbeing in their or other communities
• communities and local services working together at all stages of planning cycle, from identifying needs through to implementation and evaluation
• connecting people to community resources, practical help, group activities and volunteering opportunities to meet health needs and increase social participation

5. We target our efforts through a Core20PLUS5 and prevention frame:

• focusing on the Core 20% most deprived population and PLUS groups
• preventing and managing those conditions which are the biggest drivers of health inequalities (secondary prevention)
• targeting behavioural risk factors (primary prevention)

6. We use our position as Community Anchors to tackle the ‘causes of the causes’ through:

• maximising social value
• sharing our assets with our communities
• recruiting a diverse workforce that is inclusive and representative of the local population

7. Our services and communication are digitally inclusive:

• providing reliable easy-to-understand health information in accessible formats for all people and communities

These priorities will be overseen by the newly formed Health Inequalities and Prevention Committee (HIPC) chaired by the Suffolk Director of Public Health to provide a focal point and strategic leadership on reducing health inequalities and embedding prevention across the ICB.

Reducing variation in performance will be a key priority across the JFP, with a particular focus on reducing health inequalities among the population living within the 20% most deprived areas and disadvantaged groups, in line with NHSE’s Core20PLUS5 strategy. Within the first year of the JFP, the HIPC will define the SNEE ICB’s approach to reducing health inequalities and the specific targets for performance indicators.

However, an overall aim of the committee is to reduce the number of deaths in under 75s considered preventable, prioritising a reduction in inequalities in our most deprived areas and amongst disadvantaged groups by 2028.

In addition, current system-wide actions are being taken to address health inequalities, themed around five priority areas:

• Restoring NHS services inclusively
• Mitigating against digital exclusion by providing equitable options through digital and non-digital routes, whilst understanding that some people prefer not to use technology
• Ensuring datasets are complete and timely
• Accelerating preventative programmes that proactively engage those at greatest risk of poor health outcomes (including Core20PLUS5 approach)
• Strengthening leadership and accountability

Please see Appendix 4 for a more detailed plan on the above five areas.

Quote: “Tackling health inequalities is the primary ambition of our Integrated Care System, as well as the one that drives me as a leader. I am very proud of the progress that has been made by so many partners in this ambition, albeit with so much work still to do. We don’t see the NHS as an illness service, but one that fights for social justice and is orientated towards prevention. Our challenge is to keep building positive impact through collaboration and to keep centred on the communities we serve rather than the service we work for.”

Ed Garratt OBE, Chief Executive SNEE ICB

5.3 Equality, diversity and inclusion in the workforce

5.3.1 Why is this important for people in Suffolk and north east Essex?

Within the NHS Constitution for England (Department of Health and Social Care 2015) it states that ‘high-quality care requires high-quality workplaces’; it also pledges to provide ‘a positive working environment’ to staff in addition to the legal right that ‘you are treated fairly, equally and free from discrimination’²¹.

In addition, there are two important pieces of legislation related to equality, diversity and inclusion (EDI):

1. The Equality Act 2010
2. Human Rights Act (1998)

As a public authority the ICB must ensure that none of our policies, procedures or strategies infringes the human rights of staff or patients. In practice this means treating individuals with fairness, respect, equality, dignity and autonomy whilst also safeguarding the rights of the wider community when developing policies and procedures and carrying out our functions.

It is widely recognised that the work delivered by the NHS would not be possible without the critical contribution of its diverse workforce. Diversity includes an array of characteristics – including ethnicity, disability, gender, national origin, sexual orientation, age and religion – some of which are underrepresented in certain NHS careers. Consequently, there is clearly more scope for the NHS to become more inclusive, diverse and equitable at every level.

The SNEE ICP agreed a set of commitments to ensure equality, diversity and inclusion is enshrined within its ways of working; this agreement was received and approved in December 2022.

Further to this, the SNEE ICB has also pledged to commit to these ambitions. Alongside our ICP partners the ICB will ensure that equality, diversity and inclusion is embedded in every
strand of our organisation, and to support better outcomes for the people we serve.

It is against the law to discriminate against someone because of the protected characteristics shown in Figure 5:

Figure 5: Protected Characteristics

The below graphic lists the protected characteristics:

• Disability
• Religion or belief
• Gender reassignment expression and identity
• Sexual orientation
• Sex
• Age
• Maternity and pregnancy
• Marriage and civil partnership
• Race

What do we know about people’s local and lived experiences?

Across the NHS broadly, themes around people’s experience include the increased likelihood of staff from ethnic minority backgrounds being performance managed and experiencing higher levels of bullying and harassment ^22,23,24. National data informs us that discrimination remains all too common for health and care colleagues, as well as service users and patients from the lesbian, gay, bisexual, transgender, queer or questioning and more (LGBTQ+) communities.

A 2018 national report25 found that one in eight (13%) of the 5,000 LGBTQ+ people surveyed experienced unequal and unfair treatment from healthcare staff ranging from micro-aggressions to homophobic bullying. Further studies describe significant health inequalities relating to outcomes, provision of services and health risk factors ^26,27.

Despite efforts to improve equality, inclusion and diversity in the SNEE ICS workforce, for example increasing ethnic minority representation in very senior roles, progress and improvement has been slow, as evidenced in our workforce data interrogation. Workforce data and staff survey results provide further evidence that barriers still exist with respect to career progression. For example, our workforce is predominantly female (72% in secondary care), but this percentage decreases when reviewing colleagues at senior paygrades within secondary care. One in five of our workforce are from an ethnic minority background (13.9% within the ICB itself) across all professional groups. This increases to 28% for Band 5s and it is evident that there are very few signs of progression to more senior roles.

As we review experiences over the last couple of years, we are mindful that there have been unique challenges in the NHS. However, our ethnic minority communities have been is proportionately impacted by COVID-19²⁸, this has also been the case for disabled communities – with many more lives lost to the virus, not least among our ethnic minority health and social care colleagues²⁹. When reviewing these issues, we shall ensure that we are considerate of ways in which protected characteristics (listed in Figure 5) interweave and cross-over on multiple levels (intersectionality). This approach to addressing discrimination and social inequalities, from a systemic and structural perspective, will ensure that we are able to capture patterns of discrimination, which previously may have been ‘invisible’ or overlooked.

How we plan to make a difference?

The NHS People Promise (2020)30 stated “We are compassionate and inclusive”, and “We each have a voice that counts”. Our mission will therefore be to understand and embrace EDI across the ICB. New EDI objectives and a strategy plan will be devised by the end of June 2023 for the next five years.

We shall provide safe environments for learning and encourage a system-wide understanding, discourse and reduction of bullying, harassment or any other form of victimisation of people with protected characteristics. To date, our system-based work has focussed on race, including a commitment to deliver the regional anti-racism strategy.

However, our body of work will expand to drive improvement across the ICB by:

• fully owning our individual and collective responsibility to take immediate action to get the basics right – because that is the right thing to do – recognising the fundamental importance of EDI in the health and care workforce
• having a collective vision that in the future we should think about EDI as a business-as-usual function in health and care, because we will all be accepting of diversity and difference
• encouraging diversity of thinking in system and pathway transformation
• empowering our staff in health and care with appropriate resource and education

Please see Appendix 5 for our fuller EDI plan detailing specific commitments under each of these headings.

5.3.2 How we will know we are making a difference

The EDI programmes and workstreams will be monitored by:

• Workforce Race Equality System Data
• Workforce Disability Equality System Data
• Organisational recruitment and retention data
• Equality Delivery System reporting
• Staff Survey analysis
• Contact reports of the Health and Care Academy
• Appropriate promotional campaign analytics
• Project reports and evidence from committee members

Staff Networks were launched over the last 12 months. Sustainability of these networks will be key to driving lasting change and also key to understanding their impact. We shall evaluate growth, maturity and understanding of the group objectives as this will be a marker of success.

We will have ICB networks mapped into provider networks and regional networks. The networks are listed below, with plans for development of further networks:

• Race, Equality and Cultural Heritage (REACH) Staff Network (previously known as BAME Staff Network) was re-launched in October 2021
• LGBTQ+ Staff Network – Launched March 2022

We shall also be looking for improvements with respect to numbers completing staff surveys and the negative experiences of staff and patients/public. The data which demonstrates our current situation with respect to workforce and representation will be reviewed and benchmarked across the region as well as nationally, with senior leaders held to account regarding these objectives.

These will be aspirational for international recruits and students/learners from diverse backgrounds, this should hopefully see growth in this sector of our workforce. Over the duration of our plan we shall ultimately hope to see a reduction in health inequalities and outcomes across all protected characteristics.

Quote: “We are very keen to create diverse and energetic teams in our health and care system and therefore capitalise on the differences in how people think and use their lived experiences to achieve the best outcomes for our people. We must get organisations to focus their resources and efforts in gaining insight and understanding of who the under-represented groups are in the system, rather than focussing on the most obvious ones. With all of the available data supporting diversity in the health and care workforce, it is critical we push our ambition from ‘desirable’ to ‘must have’ in order to optimise our patient outcomes and encourage more health and care staff to come and work in our Integrated Care System.”

Ganesh Baliah, SNEE ICS Strategic AHP Workforce Lead

5.4 Our commitments

As part of the ICS shared vision to deliver the best possible health outcomes for every one of the one million people living in SNEE, we want to enable everyone in SNEE to ‘Live Well’. Our delivery priorities are organised on the six Live Well domains and are underpinned by a focus upon reducing health inequalities for our local population and ensuring EDI is central to our work.

The table on page 34 shows our strategic framework. For each Live Well domain, which articulates the outcomes we are aiming to achieve, the SNEE ICB are making an overarching five year commitment. These commitments relate to the outcomes we will strive to deliver, as articulated in the SNEE ICS Strategy, what we heard is important to our population, and what our workforce and partners tell us that we need to do better or do differently to improve the services we deliver.

We will assess our performance in delivering our commitments over the next five years by measuring performance against one or more target indicators in each domain. These are the lead key performance indicators that we wish to ‘target’ improvements in, with a particular focus on reductions in health inequalities. Delivery against the target indicators will be achieved through a broad programme of work detailed in full in the JFP and supporting annexes.

Please see section 2.6.3 Our commitments to read our vision, target outcomes, five-year commitments, cross-cutting priorities, principles and identified enablers.

Start well

The first two years of life are a uniquely important period that set the foundations for lifelong emotional and physical wellbeing. As part of the SNEE ICS collective ambition for all to live well, we want children to start well – before conception, during pregnancy and birth, through childhood and into adolescence – including by supporting families who are experiencing, or at risk of experiencing, disadvantage. We want to ensure that children and young people have the best possible start and are also supported to grow and develop. This includes by tackling conditions such as asthma, the most common-long-term medical condition in children in the UK and a leading cause of health inequalities among children living in the most deprived areas, and by supporting children to have good emotional wellbeing by reducing unnecessary delays for specialist mental health care.

Commitment – We will ensure that children and young people have the best chance in life with a particular focus on those most in need.

• Reduce the neonatal mortality rate by end of 2023/24 and reduce each year thereafter, addressing inequalities by prioritising reduction in unwanted variation in neonatal mortality
• By 2028, no child or young person waits more than 12 weeks for Child and Adolescent Mental Health Services (CAMHS) or 18 weeks for Neurodevelopmental Diagnostic (NDD) Services, prioritising reductions in waiting times for ethnic minorities and those living in the 20% most deprived areas
• Reduce the hospital admission rate due to asthma of children or young persons living in the most deprived 20% of areas

Feel well

Good mental health is a state of wellbeing in which every individual realises their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community. Our population wants help to self-care, be involved in their care decisions, have better signposting to support services, and have that support better embedded in their community. The SNEE ICS has a collective ambition that the best health and wellbeing is a genuine reality for everyone. There are stark health inequalities associated with severe mental illness, including death from avoidable medical causes, and we want to take proactive and decisive action in addressing these. We will enable people to maintain good mental health and achieve good recovery whilst living in resilient communities, by delivering the best quality integrated mental health services and by tailoring them to the needs of those who need specialist care.

Commitment – We will support people with mental health needs, including those with learning disabilities or autistic spectrum disorders, to get support in the community to live and thrive.

• Achieve a 5% year-on-year increase in the number of adults supported by community mental health services
• Achieve a year-on-year reduction in hospital admission rate for mental health conditions
• Identify and reduce health inequalities amongst people with severe mental illness, by ensuring at least 90% of people, including those in all disadvantaged groups, receive a full annual physical health check and follow-up interventions by 2028

Be well

By investing in health as an asset and by promoting the conditions for good health we can move towards realising the SNEE ICS higher ambition for a healthy life for everyone. Everyone in SNEE should be able to live a healthy life with good physical, mental and social wellbeing and people tell us that with our support they can be empowered to make healthy lifestyle changes. We also know that access to NHS dentistry is an increasingly important issue for our population and the SNEE ICB has ambitious plans to improve oral health. There is a clear social gradient in the harm to health from negative health behaviours and lifestyle factors, including increased prevalence of obesity and smoking. We will therefore support people to make decisions consistent with good health.

Commitment – We will empower people to lead healthy lifestyles and reduce the number of preventable deaths.

• Halt recent increases in the number of overweight and obese children in reception and year 6 by 2028 and maintain prevalence below the national average
• Reduce the number of smokers in our population in line with only 5% of the population being smokers by 2030
• Increase each year the number of units of NHS dental activity delivered

Stay well – access to care

Timely access to all health and care services is one of the highest priorities for our communities. Location, convenience, and familiarity of services are important to people. Rising demand has placed challenges on services; however, long waits can leave people frustrated and risks increasing the acuity of conditions. Our population has experienced significant delays in access to the health and care it needs. We plan to support people to access the right support, in the right time, in the right place, by enabling timely access across urgent care services and by reducing waits for planned care.

Commitment – We will support people to access the right support, in the right time, in the right place for their health and care needs.

• Increase our GP practice teams each year to meet the growing demand whilst increasing the number of trainees and apprentices
• No one waits more than one year for elective care by March 2025
• Increase by 10% each year the number of cases seen by the urgent community response service
• By 2028, 95% of patients attending A&E services wait no longer than 4 hours
• Reduce the number of acute hospital bed days utilised by people without a criterion to reside that are discharged on complex pathways (1-3)

Stay well – early intervention, prioritising early diagnosis and treatment for people living in the 20% most deprived areas

We want to support adults with health or care concerns to maintain healthy, productive and fulfilling lives and the best quality treatment, care and support is needed if people are to ‘stay well’. This includes a significant focus on prevention, including early detection and diagnosis of disease and risk factors as well as timely intervention. Awareness of symptoms and prompt access to testing also enables early diagnosis. We know that the number of people living with cancer is increasing in SNEE and we know that earlier diagnosis of cancer is needed to address inequalities among our most deprived communities.

We also know that cardiovascular, diabetes and respiratory diseases are greatly associated with health inequalities and if not treated can lead to life-threatening conditions such as myocardial infarction and stroke.

Commitment – We will support adults with timely access to services to enable early detection and diagnosis of disease and risk factors to give people the best chance of maintaining a good quality of life.

• Increase the percentage of cancers diagnosed at stages 1 and 2 to 75% by 2028
• 80% of people with high blood pressure are identified and treated by 2028
• More than 85% of people with atrial fibrillation are identified and 90% of those at high risk of stroke are treated by 2028

Age well

The SNEE ICS has a collective ambition for everyone to live well as they grow older, particularly if they are living with frailty or dementia. The number of people living in SNEE aged 65 or older is set to increase by 33% in the next twenty years. One in 10 people aged over 65 are living with frailty and an increasing number of people are living with dementia, including many who do not have a diagnosis, and dementia accounts for more expenditure than heart disease and cancer combined. It is important to prevent frailty, prevent deterioration in those already frail, and mitigate the risk of preventable hospital admissions, such as due to falls.

Commitment – We will ensure that people who are ageing are able to live safely and independently, experiencing a good quality of life.

• Reduce each year the rate of emergency hospital admissions due to falls amongst the population aged over 65
• Reduce each year emergency acute hospital bed use (bed days per capita) for those over 65 years old
• Achieve the national 66.7% dementia diagnosis rate by October 2024 and an increase in dementia annual care plan reviews completed each year

Die well

Over 10,000 people in SNEE are in the last year of their life and we wish to ensure that over this time they and those who care for them have the best and most equitable care and support from the resources we have available. Key to this is the timely identification of the people who are approaching the end of their lives, communicating this with them and those who are important to them with sensitivity and honesty.

Commitment – We will enable people and their families to have high quality care and support from all health and care professionals involved at the end of their life.

• Increase each year the percentage of people identified as approaching the end of life

Health inequalities (cross-cutting)

Commitment – We will ensure a focus on reducing health inequalities by taking a systematic approach to identifying and resourcing opportunities to improve health and care access, experience and outcomes.

• By 2028, reduce the number of deaths in under 75s considered preventable, reducing inequalities in our most deprived areas and amongst disadvantaged groups

5.5 Start Well – giving children and young people the best start in life

Overall Outcome: Giving children and young people the best start in life
Overall Commitment: We will ensure that children and young people have the best chance in life with a particular focus on those most in need

5.5.1 Why is this important for people in Suffolk and north east Essex?

We want to ensure that children and young people across SNEE have the best possible start in life from preconception onwards and can have their physical and mental health supported as they grow and develop by reducing health inequalities and adopting tailored approaches where needed.

5.5.2 What do we know about people’s local experiences?

Key challenges and factors noted include:

• variation in the quality and quantity of services across SNEE leading to inequality and unacceptably long waiting times
• there is not enough focus on early intervention and prevention
• longer waiting times for assessment and treatment with a significant increase in referrals
• gaps in the current commissioned offer, particularly around tics and Tourette’s, sensory and epilepsy needs
• physical and mental health care is not joined up enough
• families unable to access support in a timely way
• families need support with healthy eating and lifestyle
• people feeling safe, having a positive birth experience, choice, and support
• better sources of information, delivered through various types of media, which is accessible and enable them to make informed decisions about what they want for their care
• personalising care to their individual situation to feel safe and to have a positive experience
• more flexible visiting times and overnight stays for hospital births, and birthing partners wanted to be more involved
• better communication with professionals using language which is easily understood and inclusive of their patients’ needs
• better awareness and recognition of perinatal mental health by healthcare professionals and other support postnatally such as signposting to community resources and infant feeding advice

5.5.3 How we plan to make a difference

Our priorities for Start Well are broken down into preconception, maternity and neonatal care, and children and young people.

5.5.3.1 Preconception, maternity and neonatal care

The key priorities we will achieve by 2028 are as follows:

• All babies and families will receive high quality care based on the best evidence available
• Women with heightened risk of preterm birth or a complex pregnancy will receive targeted care to keep them and their babies well during their pregnancy and birth
• Fewer babies will be born to parents who smoke during pregnancy reducing the number of • babies born prematurely and/or with low birth weight
• miscarriages and neonatal deaths
• babies who have long term health conditions such as respiratory conditions, cardiovascular disease and obesity
• Families will have continuity of carer during pregnancy, birth and the postnatal period. In particular, we will ensure continuity of care for women from minority ethnic communities and most deprived groups, aligned to the ambitions of the Core20Plus5 approach
• Families will be able to access services and information in a more convenient and efficient way. Digital technologies will help them make informed choices about their care, enabling them to have personalised care according to their needs and wishes
• Families will have an enhanced experience during the worrying period of neonatal critical care. Families and their babies will receive high quality specialist neonatal care. Neonatal care will be safe, effective, co-ordinated, and based on best practice
• Pregnant people, babies and families will be able to access joined-up antenatal care, birth facilities, postnatal care, mental health, specialist services, health visiting and social care services
• Families will be better supported to feed using evidence-based best practice
• Mothers, birthing people and their partners will have improved access to high quality perinatal mental health care
• Women will have improved postnatal physiotherapy to support them to recover from birth
• We will develop and support our workforce to offer high quality, kind and compassionate care for our service users and partners
• a reduction in the rate of infants with a brain injury occurring during or soon after birth from 5.33 per 1000 live births in 2017 to 2.50 in 2023/24

Further details on the plans for preconception, maternity and neonatal care are available in Appendix 6 – Start Well.

Quote: “Maternity and neonatal services have a critical role in providing every child with the best start in life. The Local Maternity and Neonatal System will focus on ensuring our services are based on the most recent research and national guidance, will support our staff to provide compassionate and personalised care, and will work with system partners to reduce any health inequalities our families may face. We strive to provide excellent care and support to all families within SNEE.”

Frances Bolger, Director of Midwifery

Public feedback: “Living in a rural setting made my pregnancy and early parenthood isolated and lonely”. Every pregnancy should have a named midwife and continuity of care”.

Case Study: Anna’s Story

Two and a half years ago I had a traumatic assisted delivery at Colchester Hospital which left me with a beautiful healthy baby boy, but a grade 4 tear and significant post-partum haemorrhage. It took me months to recover. We were told then that any future children would need to be delivered by caesarean section. I became pregnant again late last year.

When I arrived in triage for my pre-op I was incredibly nervous to even be in the building again. I cannot convey to you enough how wonderful Denise (midwife) and the whole team were on that day, putting us at ease and explaining everything. On the day of our caesarean section, Denise and the whole team were wonderful and made our section and daughter’s birth so special, we felt safe and cared for.

The continuity of having one main person care for us was the main factor in this, we completely trusted her and she was wonderful! I was home within 24hrs after the lovely Zelia and the obstetrician had checked us over. A few days later we had a follow up call from Denise to check I was fine and recovering well.

Working for the NHS myself, I am fully aware of the constraints placed on services, and I would therefore like to congratulate you on achieving what felt like gold standard care within what I am sure are very limited resources. We will be forever grateful to Denise and the Venus team for giving us a wonderful birth experience.

5.5.3.2 Children and Young People

The key priorities we will achieve by 2028 are as follows:

• Neurodevelopment Services – children, young people and families have access to a care pathway that facilitates standardised and improved ways of working across the system to achieve better outcomes
• Mental Health – children, young people and families will have access to excellent mental health and emotional wellbeing support enabling everyone to get the right support, at the right time, from the right people, in the right place and in the right way
• SEND – children, young people and families can access appropriate therapeutic support promptly, with identification of need at the earliest possible opportunity
• Asthma – children, young people and families will be more confident in managing their long term condition and get the correct interventions and support when needed with the hope of their asthma not worsening
• Epilepsy – children, young people and families will have access to epilepsy specialist nurses to support long term conditions. Those with learning disabilities or autism will have access in the first year of care
• Diabetes – children, young people and families will have access to diabetes teams to help manage their long term condition through childhood and in the transition period to adulthood and related services
• Learning Disability and/or Autism – through a Dynamic Support Register (DSR), Key Working Function (KWF) and Short Breaks Provision children and young people with a learning disability and/or autism with a co-existing mental health condition and/or who display behaviour that challenges, will not be admitted to a specialist hospital for treatment unless absolutely necessary. They will receive support that will enable them and their families to navigate the multidisciplinary system

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

• consistent reduction in Autistic Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD) assessment waiting times by September 2024 (18-month recovery plan)
• 95% of children and young people in care under 25 commence mental health treatment within 15 weeks of referral
• meeting access and waiting time standards in Eating Disorder Services with 95% seen within one week for urgent and within four weeks for non-urgent
• reducing wait times for assessment and treatment in mental health services. We expect an improvement towards the four weeks for referral to assessment and 18 weeks for referral to treatment standards in the next six months and to meet standards by December 2024

Further details on the plans for children and young people are available in Appendix 6 – Start Well.

Quote: “We have worked hard over many years listening to the voice of children and families so that we can shape services to the needs of the local population, this plan sets out those key areas that we continue to develop jointly with all our system partners including children and families to deliver better outcomes for all.”

Allan Cadzow, Corporate Director for Children and Young People, Suffolk County Council

Public feedback: “Happy, healthy children = happy, healthy futures”

Case study: Crisis, Help and Risk Intervention Service

Adam is a 16-year-old male who was referred to the Crisis, Help and Risk Intervention Service (CHRIS) following several visits to an Emergency Department (ED). Adam was seen in hospital five times during the same week prior to the CHRIS referral being received. He had tried to end his life by taking tablets, tying a ligature around his neck, and was found by police at the top of a railway bridge where he said he intended to jump. The formulation indicated that Adam’s crisis could be attributed to him being ‘stuck in the belief that he would only be safe in hospital, and the only action available to him was to be admitted. CHRIS work was mainly focused in helping Adam to shift from that belief and start to ‘see and accept that he can be better supported in the community.

CHRIS practitioners held consistent professionals’ meetings to ensure that the same messages were being conveyed to Adam – that he would no longer be admitted to hospital and that, as an alternative, his needs would be met by the community. CHRIS offered individual work with Adam (based on acceptance, value-based goals, belonging) and systemic work with Adam’s parents and the wider system. When closing the case, a structured and planned ending was provided to support the change being sustained.

Adam spoke of the ending being “sad but good sad” which was a massive step forward in his ability to tolerate emotions, something he could not do before. At the time of discharge, Adam had no incidents requiring him to attend ED for over a month. He has acquired a gardening job and starting to spend more time with his friends and was starting college in September 2022.

5.6 Feel Well – Supporting the mental wellbeing of our population

Overall Outcome: Supporting the mental wellbeing of our population

Overall Commitment: We will support people with mental health needs, including those with learning disabilities or autistic spectrum disorders, to stay mentally well and to get support in the community to live and thrive when they need it.

5.6.1 Why is this important for people in Suffolk and north east Essex?

The best possible mental health and resilience is essential if everyone in SNEE is to live well and age well. Good mental health is a state of wellbeing in which every individual realises their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community. Like physical health, people can experience both temporary and long-term mental ill-health.

5.6.2 What do we know about people’s local experiences?

Key factors and challenges noted include:

• People want help to self-care and understand the mental health benefits of balance and moderation in their lifestyle choices
• People want to be involved in care decisions, have the same choices and rights regardless of location, and have access to advocacy
• Better signposting is needed to support services including peer support groups, voluntary sector and therapeutic activities including art, singing and exercise
• People want mental health support to be better embedded in primary care and the community. Timely advice and guidance on physical and mental health issues together is needed to improve outcomes
• Every death by suicide can have a devastating effect on families, friends, colleagues, witnesses, frontline staff such as first responders and entire communities. Preventing suicide is a major public health issue and is a priority for health and wellbeing partners in SNEE
• Access, continuity of care and co-ordination is an issue, better support for finances and social issues is needed on discharge from acute services and organisations should communicate better and use the same terms
• Follow up support after a crisis episode or assessment in Emergency Department (ED) should be improved. People should have a ‘safety net’ to return back into care facilities if needed
• Further support is needed following a bereavement
• In 2020 the Commission on Alcohol Harm published a report ‘It’s Everywhere’ – Alcohol’s Public Face and Private Harm³¹”. The report describes the burden alcohol misuse places on public services and the economy. In England, the total cost of alcohol was estimated to cost the NHS £3.6 billion, while alcohol-related crime in England and Wales was estimated to cost society around £11.4 billion per year

5.6.3 How we plan to make a difference

Our priorities for Feel Well are broken down between mental health, suicide prevention, addictions and trauma and abuse.

5.6.3.1 Mental Health

The key priorities we will achieve by 2028 are as follows:

• Enabling people to maintain good mental health and physical health and be resilient by providing information and support on potential risks to mental health and how to maintain wellbeing. We will also provide greater access to resources that support and protect people’s wellbeing
• Ensuring people live in resilient and inclusive communities by providing local community services that work together to support people’s mental health throughout their lives
• Prompt access to mental health support for people and their carers by providing improved access to community-based integrated therapies and support. These services will cater to people with the most complex needs including people experiencing racial disparities in services and care
• Ensuring people receive the best quality integrated services to achieve recovery and good mental health, delivered in the right way, in the right place and at the right time. We will ensure our people receive the best quality community-based person-centred care, the best quality inpatient care provided locally and support people with gender dysphoria to receive high quality care
• Ensuring people receive the best care and support when experiencing a mental health crisis. We will achieve this by providing access to people in mental health crisis and their carers to community-based support to help avoid crisis and acute inpatient admission. In addition, we will provide prompt access to those who need crisis mental health services and the best quality emergency first response care to people in mental health crisis and their carers. We will also ensure people in emergency care settings have full access to mental health assessment and support

We will know we are making a difference because we will see³²

• delivery of the ongoing annual NHSE Mental Health Investment Standard (MHIS) providing increased parity across mental health and physical health services investment
• the proportion of people with severe mental illness receiving a full annual health check and follow-up interventions increasing from 2022/23 reported levels in 2023/24
• delivering of Early Intervention in Psychosis services at Essex Partnership University NHS Foundation Trust and Norfolk and Suffolk NHS Foundation Trust at NICE standards Level 3 or above including expansion of At Risk Mental Health Services by March 2025
• progress in eliminating inappropriate adult acute out of area placements by March 2025 and reduce the days spent in inappropriate out of area placements by adults needing non-specialist acute mental health inpatient care from 2022/23 levels
• an increase in coverage of 24/7 adult crisis resolution and home treatment teams, and community support by March 2024
• increasing access to specialist perinatal mental health care in 2023/24 against reported 2022/23 levels
• a reduction in hospital admissions for mental health conditions by 2026 supported by increased recruitment to primary care mental health practitioners and focus on early prevention and intervention approaches

Further details on the plans for Mental Health are available in Appendix 7 – Feel Well.

Quote: “Supporting the mental health and emotional wellbeing of our population is a key priority for our SNEE system. Good mental health and emotional wellbeing is achieved by ensuring that individuals, their families and carers can meet their emotional needs and they can access the right support at the right time. In SNEE we are committed to working with our partner agencies and service users with experience, to ensure that all parts of the system make mental health everybody’s responsibility and that the broader determinants of mental health are fully considered as part of the solution including preventive measures.”

Richard Watson, SNEE ICB SRO for Mental Health and Deputy Chief Executive, NHS SNEE ICB

Public feedback: “Clarity of where to get help early will stop crisis developing”

“As well as talking about mental illness we need to support and encourage mental wellness”

Case Study: Healthy Together (Suffolk Users Forum) – John’s Story (2022)

The SUF Healthy Together Service offers peer support for people with Serious Mental Illness (SMI), which includes bipolar disorder, schizophrenia and psychosis, who following a SMI annual physical health check would benefit from additional support to achieve physical health and wellbeing goals.

John was referred to Healthy Together for healthcare follow up appointments, including podiatry care, as his toenails had not been cut for over a year and he found walking painful. We called John the day after he was referred and his biggest concern on the day was that his kitchen sink has been blocked for six weeks. Despite him calling his housing provider, he had not been able to get the problem resolved. Following our call to the provider a plumber went out that evening and the sink was unblocked. John was pleased. He had been so upset because the issue had been going on for so long. He’d been unable to use his sink, his dishes were piled up high, and as it was summer, he was struggling with the high number of flies in his flat.

Working together we arranged for a private podiatrist to visit John at home. This has revolutionised his life, he is now pain-free and mobile. John has gone on to build a good relationship with the podiatrist, growing in self-confidence to arrange ongoing podiatry appointments. With support John has attended other health care appointments and now has more confidence to arrange and attend these by himself. He is now engaging well with his GP and NHS staff in both primary and secondary care.

John told us – “Brilliant work, since you have been on board, we have been chipping away at my healthcare needs and things are moving forward. Before nothing was happening. I’m so happy that you managed to get my sink unblocked as the people I tried to speak to weren’t very nice.”

5.6.3.2 Suicide Prevention

The key priorities we will achieve by 2028 are as follows:

• Focusing on evidenced-based interventions to reduce the risk of suicide in key high-risk groups
• Reducing access to the means of suicide
• Providing better information and support to those bereaved or affected by suicide
• Supporting the media to help deliver sensitive approaches to suicide and suicidal behaviour
• Improving research, data collection and monitoring of suicides
• Embedding a system-wide focus on self-harm prevention in children and young people and adults, because it is a key indicator of suicide risk

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

• age-standardised suicide rates in Suffolk not rising above England or regional averages by 2028 (Suffolk current position at the England average)
• age-standardised suicide rates in north east Essex reducing downwards to those of England or regional averages by 2028 (current north east Essex position as a national outlier)
• the SNEE ICB investing in a twelve-month dedicated suicide prevention role in north east Essex hosted by Essex County Council from April 2023
• a review into annual suicide data and real time suicide surveillance (RTSS) suicide reports which identify recommendations and focus attention on the factors driving higher rates of suicide within key groups and local communities
• an agreed SNEE cluster response protocol in place by 2024, which will ensure a timely and coordinated response to suspected clusters of suicides
• 100% of people reported to have been bereaved or affected by a suspected suicide will be provided with information about support services available by 2025
• an increase in the knowledge, training and confidence of general practitioners and primary care staff around suicide prevention practice from 2025
• all interventions applied to identified high risk groups will be based on nationally recognised best practice by 2028
• a system wide self-harm plan in place by the end of 2023, with actions delivered by 2028

Further details on the plans for suicide prevention are available in Appendix 7 – Feel Well.

Quote: “Every suicide is a tragedy that causes devastating impacts on families, friends, and broader communities. Seven out of ten people dying by suicide are not known to Mental Health Services, which demonstrates that the factors leading to someone taking their own life are complex and multi-dimensional. This is why suicide prevention, although led by Public Health teams, requires a system wide approach across SNEE. We will continue to work together to ensure that these avoidable deaths are prevented at every opportunity.”

Sara Dunling-Hall, Consultant in Public Health (Public Mental Health & Health Care Public Health), Suffolk County Council

5.6.3.3 Addictions

The key priorities we will achieve by 2028 are as follows:

• Children, adults and older people will avoid the dangers of tobacco. We will enable this by supporting people to live in a healthier, smokefree environment and by 2028 and we will have demonstrated progress towards the national smokefree 2030 target
• People are able to avoid or reduce alcohol and drug related harm. We will enable this by sharing public health messages on vaping as a smoking cessation aid by October 2023. By 2024, everyone entering hospital as an inpatient in acute mental health or maternity services will be asked about their smoking status
• People are able to avoid or reduce alcohol or drug related harm through the delivery of awareness campaigns and training programmes across SNEE
• People with serious gambling problems receive high quality specialist support by expanding NHS specialist clinics, and integrated working to help more people with serious gambling problems

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

• a year-on-year reduction in hospital admission rate for mental health conditions
• smoking-attributable mortality will have reduced from 2017-19 rates and will have remained below the England level by 2028
• we will have halted the rise in alcohol-related mortality and maintained mortality at below England level by 2028
• we will have halted the rise in deaths from drug misuse and maintained mortality rates at below England level
• smoking attributable hospital admissions will have reduced and will be maintained at below England levels by 2028
• the rate of smoking at the time of delivery will have reduced to 6% or less in line with national targets by 2028
• by 2024/25 all smokers who are inpatients in acute and mental health settings will be referred to smoking cessation services on an opt out basis
• the proportion of people who successfully complete alcohol treatment will have increased to at least the England rate (36.6% at 2021) by 2028
• the rates of successful completion of drug treatment (opiates) will have increased to 7% from the current rate of 6.1% by 2028
• more people will have successfully completed gambling addiction programmes

Further details on the plans for Addictions are available in Appendix 7 – Feel Well.

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Quote: “Alcohol and substance misuse seriously impacts on a person’s life, work and relationships, as well as the people around them. We will ensure commissioned services to support those who experience issues are integrated and consider their needs in the round.

Smoking continues to be the leading preventable cause of illness and premature death with areas such as Ipswich having some of the highest rates of smoking in the East of England – we will renew our collective efforts to help local residents.”

Stuart Keeble, Director of Public Health, Suffolk County Council

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Case Study: Supporting Communities of Drug and Alcohol Recovery in Suffolk

Peer support is an invaluable tool to support people to maintain their recovery and reduce harm from substance misuse. An effective example of this is the Recovery’s Got Talent Programme, initially funded through the Recovery Grant Scheme and now part funded through income generation from their activities.

The Recovery Grant Scheme awards small grants to financially assist in developing projects that will improve and sustain the recovery of clients engaged with, or who have completed drug and alcohol treatment and rehabilitation. The programme is led by people in recovery via a steering group supported by a dedicated worker from the specialist drug and alcohol treatment service. The group plan and put on an annual celebration of recovery – ‘Recovery’s Got Talent’.

The show is now in its sixth year and has provided people in recovery from addictions a platform to showcase their talents, from poetry performance to singing, dancing and even standup comedy. As a direct result of meeting due to Recovery’s Got Talent, a group of talented people in recovery have now formed the ‘East Coast Poets’ who meet virtually every week and have been invited to perform their poems and stories at the Theatre Royal and the Primadonna and SaxFest festivals. People state that finding a meaningful use for their time is one of the hardest aspects of sustaining recovery from addiction and preventing relapse. The creative communities of recovery which have developed across Suffolk as a direct result of the success and appetite for Recovery’s Got Talent provide this.

5.6.3.4 Trauma and Abuse – Safeguarding Children and Adults at Risk

The key priorities we will achieve by 2028 are as follows:

• Safe at home: all healthcare services will have a domestic violence and abuse policy, have a lead person responsible for the response to domestic violence and abuse and will train staff to recognise the signs of possible domestic violence and abuse
• Safe in our communities: Health Strategic Needs Assessments will be completed and a strategy will be developed that reflects the voices and lived experiences of the communities in SNEE by the 31st January 2024
• Safe safeguarding systems across SNEE: we will continue to explore system issues and processes to improve and maintain compliance with national requirements via initial health assessment reviews. Designated professionals for looked after children will continue to explore and support health assessment provision for the increased numbers of separated migrant children placed into SNEE

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

• a data sharing and reporting framework that provides regular data intelligence of domestic and sexual violence and abuse by 2024
• appropriate commissioning within the SNEE ICB to prevent, treat and manage serious violence by January 2024
• delivery of bespoke training sessions on the Mental Capacity Act for primary care in 2023 across SNEE

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Quote: “It has been said that the true measure of any society can be found in how it treats its most vulnerable. We will continue to work in partnership across the ICB to raise awareness of abuse and support those who have experienced trauma through the life course. This JFP reflects our joint ambition to ensure the population of the SNEE ICB are safer at home, safer in our communities and are supported and protected by our safeguarding systems.”

Fiona Ellis, OBE, Co-founder and CEO of Survivors in Transition

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Case Study

As a result of work completed by the Designated team domestic violence notifications from the Police are now shared and added to health records but this has not always been the case. Below is a real local case study which clearly demonstrates the significant benefits to this process. Jack is a 4 year old boy with speech delay. His Mum and Dad’s relationship is an abusive one with at least two domestic violence Police notifications attached to his health record.

His speech therapist (SALT) was due to see Jack and was reviewing his records before the appointment when she noted the domestic violence notification. She also noted a recent Multi-Agency Safeguarding Hub (MASH) entry to his record which stated following the Police involvement a safeguarding referral had been made to consider the risk to Jack following his Dad’s violent outburst towards his Mum. The outcome from the MASH was that Mum had been spoken to and confirmed the relationship had ended and Dad was no longer having contact with Jack. MASH then made the decision that there was no need for social care involvement. However, it was noted on the MASH entry to the health record that if professionals had evidence the relationship had resumed a further MASH referral should be made.

During the speech therapy appointment, they discussed what Jack did at the weekend and Mum explained they’d had a lovely time with Dad at the beach. Following some advice from the Named Nurse the SALT was clear she would need to discuss this with Mum after the appointment without Jack present when she was able to explain her concern and the need to make a further safeguarding referral. Mum understood the need for this and appreciated the therapist’s honesty. Between the SALT and MASH they agreed a safe time for MASH to contact Mum to discuss the concerns (ensuring Dad was not with her). She was then supported by social care to safely separate from Dad and move to a new area.

This identification of ongoing risk and Mum’s consequent safe separation from Dad was as a direct result of the sharing of information from Police into health records and the clear outcome MASH had recorded for health professionals to see. It demonstrates excellent partnership working between the SALT and MASH putting the safety and wellbeing of Jack and his Mum as a high priority.

5.7 Be Well – Empowering adults to lead healthy lifestyles

Overall Outcome: Empowering adults to make healthy lifestyle choices

Overall Commitment: We will empower people to lead healthy lifestyles and reduce the number of preventable deaths

5.7.1 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.

5.7.2 What do we know about people’s local experiences?

Key factors and challenges noted include:

• People tell us that information on behaviour change would help them use a healthy living service or group
• 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 stigmatisation and blame
• 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
• According to data from 2018, nearly 4 out of 10 adults in Essex (38.9%) have active tooth 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
• 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
• 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

5.7.3 How we plan to make a difference

Our priorities for Be Well are broken down into healthy behaviours, personalised care, women’s health, dental/oral health and eye health.

5.7.3.1 Healthy Behaviours / Healthy Life for Everyone

The key priorities we will achieve by 2028 are as follows:

• 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 by better understanding the principles of good sleep hygiene and ensuring vulnerable people of all ages have a safe and healthy environment to sleep
• Young people, adults and older people have good sexual and reproductive health by providing information on how to maintain good sexual and reproductive health and providing the support needed to those with unplanned pregnancies. We will also ensure there is timely access to testing and treatment for sexually transmitted infections and ensure services and support are provided equally to the population of SNEE
• Children, adults and older people are socially connected and avoid loneliness by running awareness campaigns to tackle the stigma of loneliness, encouraging people to volunteer to feel better connected
• Children, adults and older people are able to live in a clean and sustainable environment
• Children, adults and older people are supported in reducing the serious health concerns relating to obesity including improving access to an integrated Tier 1-4 weight management service

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

• healthy life expectancy for males and females increase and the social gradient in healthy life expectancy reduce over the course of this strategy to 2028
• by 2028, a reduction in the number of deaths in under 75s considered preventable, reducing inequalities in our most deprived areas and amongst disadvantaged groups
• the proportion of adults (aged 18+) classified as overweight or obese reduce to below 60% and stay below the national level by 2028
• the prevalence of children being overweight and obese in reception and year 6 of primary school halted by 2028 and maintained at below the national level
• a 5% reduction in the rate of conceptions in people aged 17 years and under by 2028
• a review of options for the recommissioning of Tier 3 and 4 services by 2028 and an integrated offer created for Tier 1-4 services

Further details on the plans for Healthy Behaviours are available in Appendix 8 – Be Well.

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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 encourages 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 Wellbeing Board

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Public feedback

“Volunteering is vital, volunteers underpin healthy communities”

“To enable healthy communities it is necessary to tackle issues such as better public transport, cheaper healthy food, housing”

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Case Study: 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 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.

5.7.3.2 Personalised Care

The key priorities we will achieve by 2028 are as follows:

• People can manage their own health and wellbeing by providing the appropriate advice and support needed to self-manage their care
• People have maximum choice and control over their health and wellbeing care and support. We will ensure people’s care and support is based on what matters to them and their individual strengths and needs as well as ensuring all medical records are made and shared in line with best practice. We will support people with long term conditions and disabilities to have more choice and control over how the funds for their health and wellbeing are spent and provide access to support for people’s health and wellbeing within their local communities
• People have expert support to make the care decisions that are right for them in partnership with professionals who are caring for them through shared decision making across the system
• We work as a system to deliver personalised care for all our population in SNEE that respects personal choice, addresses inequalities and increases independence and wellbeing

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

• an increase in personalised care and support plans either patient held or recorded in our system to 78,000 by 2027/28
• an increase in personal health budgets to 6,500 by 2027/28, linked to personalised care and support plans

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Quote: “We have listened to what people say about their health and care, and about services in SNEE. They want us to adopt a personalised approach and talk to how this will lead to better health outcomes and a reduction in health inequalities.”

Andrew Kelso, Medical Director, NHS SNEE ICB

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Public feedback:

“This is the key to all good quality services and should run through every element of the Plan”

“Personalisation is what every person accessing the NHS deserves and what all services should aim to deliver.”

Further details on the plans for Personalised Care are available in Appendix 8 – Be Well.

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Case Study: 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 nonmedical 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.

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5.7.3.3 Women’s Health

The key priorities we will achieve by 2028 are as follows:

• 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
• 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
• 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 system-wide 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 better understand women’s health inequalities
• We will also ensure we consider the differences experienced by women of different ethnicity culture and 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 can understand and spot the signs of abuse. We also want to ensure that survivors of abuse and violence have access to trauma-informed services and we will work with our partners to provide information for our local employers to support women and girls in and out of the workplace

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 oversight³³

Further details on the plans for Women’s Health are available in Appendix 8 – Be Well.

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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.”

Lucy Wightman, Director of Public Health, Essex County Council

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Case study: Case Study 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 more than 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 people such as 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 together with the organisation that employs these staff.’

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5.7.3.4 Oral Health

The key priorities we will achieve by 2028 are as follows:

• The provision of behaviour-management advice and techniques that reduce or prevent oral health problems will be provided to children, adults and older people through public health campaigns and 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 their nearest available NHS dentist is 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)
• Local training capacity for dental professionals (Training and Development)

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

• access to NHS dentistry available to all people within SNEE, with improved access to NHS dentistry for children and adults, including in residential settings by September 2024
• increases each year in the number of units of NHS dental activity delivered
• 10% 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

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Quote: “Access to dental services is complex and there are a multitude of challenges and barriers that influence an individual’s ability or willingness to access care. It is important to recognise that no single approach will improve access for all. The ICB’s dental plans are ambitious and we believe routine dental care should be available to all who want or need it.”

Richard Watson, Deputy Chief Executive, NHS SNEE ICB

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Further details on the plans for Oral Health are available in Appendix 8 – Be Well.

5.7.3.5 Eye Health

The key priorities we will achieve by 2028 are as follows:

• 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 and 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 to 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 Patient Initiated Follow Up (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 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 people know 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 signposted 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. 100% standardised pathways, contracts, and finances 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

Further details on the plans for Eye Health are available in Appendix 8 – Be Well.

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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 individual 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) – 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, 30% referred to Community Ophthalmology for glaucoma diagnosis
• Over 1,500 people with suspected glaucoma were managed within the community service which was 88% of the total referrals made for suspect glaucoma (12% went to hospitals). In terms of the 1500 community referrals, 61% of these were diagnosed with glaucoma and treatment initiated and 27% discharged

With this established glaucoma service, a minimum of 5000 outpatient appointments were saved.

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5.8 Stay Well – Supporting adults with health or care concerns to access support and maintain healthy, productive and fulfilling lives

Overall Outcome: Supporting adults with health or care concerns to access support and maintain healthy, productive and fulfilling lives

Overall Commitment: Access to care – We will support people to access the right support, at the right time and in the right place for their health and care needs

Early interventions – We will support adults with timely access to services to enable early detection and diagnosis of disease and risk factors to give people the best chance of maintaining a good quality of life.

5.8.1 What do we know about people’s local experiences?

Key factors and challenges noted include the following:

• Access to primary care remains one of the highest priorities for our communities. People can be frustrated by extended waits to access services. Many people recognise, however, that primary care is simply challenged by the level of demand being placed on it
• Location, convenience and familiarity of services is important to people; positive past experiences influence future decisions
• People are willing to travel to another hospital within the east of England to reduce their waiting time
• Honest, open communication is important to people, particularly surrounding wait time for treatment
• People find communication and information inconsistent. Appropriate, accessible information supports mental and physical wellbeing
• Our population have experienced significant delays in accessing urgent and emergency care with our hospitals not able to meet the required ED standards and ambulance response times also falling short
• Since 2010, the number of older people asking for council help has increased, but fewer now qualify for support in their own home or in care homes, with the average weekly cost of care being significantly higher in SNEE compared to the rest of England
• We know that the total number of people living with cancer is increasing in SNEE as it is across England. However, the percentage of people with cancer in SNEE is higher than the England average (4% vs 3.3%)
• In 2020/21, over 60,000 (7.1%) people registered to a GP practice had been diagnosed with diabetes in SNEE, with an estimated 12,600 people who have the condition who have not yet been diagnosed. The observed to expected ratios range from 77% for Ipswich and east Suffolk, to 92% for west Suffolk and 83% for north east Essex
• The percentage of people living with diabetes receiving all eight care processes in the SNEE ICS dropped from 70% in 2019/20 to 52% in 2020/21 and then recovered to 62% in 2021/22. The percentage of people living with diabetes achieving all three diabetes treatment targets in the SNEE ICS dropped from 42% in 2019/20 to 39% in 2020/21 meaning an estimated 27,700 people did not achieve their three treatment targets that year. HbA1c is consistently the least well achieved treatment target
• Respiratory diseases are also greatly associated with health inequalities. Someone from the most deprived section of society is two-and-a-half times more likely to have Chronic Obstructive Pulmonary Disease (COPD), and nearly twice as likely to develop lung cancer, as someone from the least deprived section of society
• Specialist fatigue management is important but access to the chronic fatigue service is variable and there is a long waiting list
• An individual personalised care plan is one of the most important aspects of supporting recovery for people living with long COVID. Actively listening to people and asking, ‘what matters to you?’ supports planning and shared decision-making based on what matters most to individuals
• Although standards are in place that describe good control of hypertension, it is estimated that only four in ten adults in SNEE with high blood pressure are both aware of their condition and are managing it properly
• In SNEE, there were 11,800 people with a Heart Failure (HF) diagnosis in 2020/21 (1.1% of the population). Only 31% of HF patients are receiving an annual review in SNEE (2020/21) though this is better than England average
• In SNEE, we have 2% of people registered with a GP recorded as having stroke or transient ischemic attack (TIA), this is higher than the England and the East of England region (both at 1.8%). At least one-third of stroke survivors will have some form of depression within the first year, which may be as high as 60% in all stroke survivors
• Data held by GPs across Ipswich and east Suffolk and west Suffolk, records a total of 3,376 individuals with a learning disability aged 14 or over, on their registers in 2022, (2,175 for Ipswich and east Suffolk and 1,201 for west Suffolk)
• Data held by GPs across north east Essex records a total of 2,284 individuals with a learning disability aged 14 or over, on their registers in 2022

5.8.2 How we plan to make a difference

Our priorities for Stay Well are broken down into elective and diagnostics, urgent and emergency care including community, cancer, diabetes, respiratory, cardiovascular disease, stroke and stroke rehab, ME and CFS, neuro rehab and learning disabilities and autism.

5.8.2.1 Elective Care and Diagnostics

The key priorities we will achieve by 2028 are as follows:

• People have the right treatment and support to prevent, treat and manage conditions by improving access to diagnostics and providing access to services that support maintenance and optimisation of health whilst waiting for treatment
• People have planned and non-emergency treatment and surgery when they need it, and in the place of their choice. We will enable this by reducing the time from referral to treatment and creating sustainable capacity to enable waiting times to fall and increasing our capacity by 30% from 2019/20 levels by 2024/25
• People have the best experience of planned and non-emergency care by reducing health inequalities and identifying clinical harm and taking appropriate action to develop a digitally driven proactive process for the delivery and management of clinical harm assessments. We will also continue to support mutual aid across our ICS

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

• 15 month waits from referral to treatment eliminated by March 2024 with the exception of patient choice and clinically complex patients
• 12 month waits from referral to treatment eliminated by March 2025 with the exception of patient choice and clinically complex patients
• diagnostic waiting times for 95% of people reduced to six weeks by March 2025
• theatre utilisation increasing towards the best practice levels of 85% throughput to reach 130% of 2019/20 levels by 2024/25
• no differences in the amount of time people wait for treatment between the most deprived 20% of our population and ethnic minorities to the rest of the population
• 10% reduction in on-the-day cancellations due to being unfit for surgery
• 5% reduction in length of stay for hip and knee replacements
• a reduction in complaints pertaining to extended wait times

Further details on the plans for Elective Care and Diagnostics are available in Appendix 9 – Stay Well.

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Quote: Following the challenges created by the pandemic we are committed to reducing long waiting times which we know are detrimental to health and wellbeing. We will do everything we can to ensure people can navigate the system easily and receive excellent care.

Paul Gibara, Director of Performance Improvement, NHS SNEE ICB

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Case study

In October 2022, WSFT implemented a clinical harm review pilot, utilising a methodology developed within the Norfolk and Waveney ICB. To test the pathway a questionnaire was sent to the 100 longest-waiting patients within General Surgery. Respondents were asked to provide detail on their current health, highlighting any deterioration in condition, as well as their general physical and mental wellbeing. They were also asked whether they had engaged with their GP or other health or social care providers whilst waiting for surgery. 46 responses (out of 100 questionnaires sent) were received of which 18of the 46 responses (39%) required clinical review.

The team is now working with informatic colleagues to determine which digital platform is most suited to host a further rollout to everyone experiencing prolonged waits for treatment.

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5.8.2.2 Urgent and Emergency Care including Community

The key priorities we will achieve by 2028 are as follows:

• People are signposted to the most appropriate service for their needs every time, by continuing to develop our Same Day Emergency Care (SDEC) model across all our acute providers to cover a minimum of 12 hours a day, seven days a week by March 2024
• People in need receive timely emergency ambulance care and conveyance, with minimal delays
• Within the ED, people with an emergency are managed in a timely manner with agreed professional ED standards in place by December 2023
• Clinical care and treatment is delivered on time and aligned with best practice. Safety is never compromised
• Staff are in the right place, at the right time with the appropriate skills to care for people and keep them safe
• People with urgent and minor ailments/illnesses are managed outside of the ED, by urgent care services, every time, first time. This will be supported by our Urgent Treatment Centres (UTCs) in Harwich and Clacton with plans to develop UTCs in west Suffolk and Ipswich
• We will work jointly with all system partners to strengthen and improve discharge processes. We will continue to develop the Trusted Assessor model to be a key link between our hospitals and care homes to ensure safe and timely discharge by March 2024
• ICBs take responsibility for oversight of urgent and emergency care recovery, improvement, and transformation through the implementation of robust governance arrangements across the ICS and place-based systems

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

• people experiencing an integrated single point of contact model of care, choosing which services are most appropriate for their immediate needs. This will be a single system-wide approach to managing integrated urgent care, to guarantee same-day care for people and a more sustainable model for services
• an improvement in A&E waiting times so that no less than 76% of people are seen within 4 hours by March 2024, with further improvement in 2024/25, building to 95% by March 2028
• an improvement to category 2 ambulance response times to an average of 30 minutes across 2023/24, with further improvement towards pre-pandemic levels in 2024/25 and work towards no one waiting more than 15 minutes by March 2028
• a reduction in adult general and acute (G&A) bed occupancy to 92% or below
• fewer people cared for in EDs as more are supported in Urgent Community Response Services and integrated urgent care services, with an increase of 10% each year in the number of cases seen by the urgent community response service
• fewer emergency admissions and a reduction in the rate of emergency inpatient hospital admissions for people aged 65 and over
• a reduction in the number of acute hospital bed days utilised by people without a criterion to reside that are discharged on complex pathways (1-3)
• an improvement in the quality and timing of ambulance responses, performance and patient handovers
• an increase in the capacity and quality of mental health support in emergency care 24/7
• an improvement in the quality, capacity and health outcomes of frailty assessments, therapy and social work services in emergency departments

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Quote: “The JFP outlines ways the SNEE ICB can develop and improve urgent and emergency care provision for our communities. It gives clear guidance on the advancements for 23/24 including reducing ambulance response times for the most urgent cases and ambitious targets for A&E waiting times. The plan brings together the many services already striving for patients to receive the right care, at the right time, in the right place, every time”

Neill Moloney, Managing Director, ESNEFT and Nicola Cottington, Executive Chief Operating Officer, WSFT

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Further details on the plans for Urgent and Emergency Care are available in Appendix 9 – Stay Well.

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Case Study: Co-ordination of Care for Mr A

Mr A, an elderly gentleman, who lived independently alone in his family home, called 999 after having a fall in his kitchen and was unable to get himself up. The ambulance call handler assessed his clinical needs and made a referral to the urgent community response team, who were able to respond quickly, with a therapist and a nurse attending Mr A. Using dedicated lifting equipment, he was picked off the floor and given a full holistic assessment.

In agreement with Mr A, it was deemed that there was no need for any further emergency treatment. As he would struggle with personal care for a few days, a support worker came in for the next week to assist him, as well as help with some exercises to regain his mobility. The team noticed that Mr A had been struggling to maintain his home and this was also the second fall he had had in a short period. Equipment to help around the house and prevent further falls was added, along with a digital device that he could wear around his neck to obtain help if he needed.

Mr A was referred to strength and balance classes at his local leisure centre and was visited by a social prescriber, who arranged some cleaning and shopping support from a local volunteer service. Once Mr A had recovered, a social care worker made a visit to discuss any ongoing support with care.

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5.8.2.3 Cancer

The key priorities we will achieve by 2028 are as follows:

• All communities are enabled to live healthy lifestyles, are aware of concerning symptoms and know how to seek appropriate help (Prevention)
• People have access to a wide range of high quality and timely services (including screening), which will lead to an earlier diagnosis (Access and Earlier Diagnosis)
• Workforce and infrastructure are in place to ensure faster diagnosis (Faster Diagnosis and Sustainable Capacity)
• Variation in diagnosis and treatment will be reduced by ensuring appropriate personalised support (Patient Focus / Personalised Care)
• A courageous approach to innovation and research will be taken to improve quality of life and survival (Innovation)

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

• delivery of the Faster Diagnosis Standard so that people are diagnosed or have cancer ruled out within 28 days from referral by the GP or via screening by 2024
• an increase in people diagnosed at an earlier stage so that 75% of people will be diagnosed at Stage 1 or 2 by 2028 in line with the NHS Long Term Plan
• increased responses from across all communities and increased scores for the National Quality of Life (QoL) Survey and National Patient Experience Survey (CPES)
• The current QoL response rate is 50% on average with a greater proportion of white people responding to the surveys. With data from a greater uptake across all communities and tumour sites, we will drive changes in our services
• For CPES we will demonstrate improvements each year until 2028 via annual review
• a reduction in the difference between under 75-year cancer mortality in deprived and less deprived communities. We will show improvements each year
• achievement of the national screening targets for breast, colorectal and cervical cancer across all the communities, considering deprivation and addressing pockets of worse performance. We will show incremental improvements each year until 2028

Further details on the plans for Cancer are available in Appendix 9 – Stay Well.

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Quote: “Building on the foundations in our 2018-2022 strategy, we want to utilise every practical prevention opportunity to minimise the avoidable risks of developing cancer. Similarly, when cancer is suspected or established, our goal is to deliver high quality, timely and person-centred care for the people of SNEE. Our workforce will be supported to deliver all elements of care in the most effective manner. We thank our current and past patients and people of SNEE in helping us to shape our approach going forwards.”

Dr Christopher Scrase, Macmillan Lead for Cancer

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Case Study: ESNEFT Pre-Diagnosis Cancer Service

The Pre-Diagnosis Cancer Service received a referral for a 79-year-old gentleman who had been delayed having a colonoscopy and gastroscopy for two months due to a chest infection. These tests were requested after his CT scan which showed a suspicious lump within his intestine which could have been cancer.

A referral was made to the Pre-Diagnosis Service to discuss with the patient the outstanding investigations and how important they were. He was also offered practical and emotional support to enable him to attend. He had been referred initially by his GP into to the colorectal team on a suspected cancer pathway because he had rectal bleeding and a change in his bowel habits. The GP had performed a blood test which showed he had iron deficiency anaemia.

The Pre-Diagnosis Cancer Nurse assessed the gentleman over the telephone and the conversation highlighted the following concerns: rectal bleeding requiring incontinence pads, ongoing weight loss, reduction in appetite, recent blood transfusion for anaemia, fatigue, low mood, reduction in independence and quality of life. The Pre-Diagnosis Cancer Nurse contacted the GP to raise concerns about the patient’s physical symptoms and general poor health. The GP subsequently made a same day home visit. The Pre-Diagnosis Cancer team also made immediate contact with the Colorectal specialty team to flag concerns regarding symptoms and a possible bowel obstruction. The Consultant requested urgent admission to hospital for symptom management and further tests. The patient was diagnosed with cancer.

Several factors contributed to the delays in the patient being able to access the specialist help he required in a timely way. Through the work of the pre-diagnosis nurse, the patient was able to access the support he required, the diagnosis was made, and he could start his treatment. Without this service it is likely he would have presented to ED and his cancer diagnosis would have been delayed.

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5.8.2.4 Diabetes

The key priorities we will achieve by 2028 are as follows:

• People at risk of diabetes are supported to prevent developing the condition, in particular those in high-risk populations such as ethnically diverse communities
• People living with diabetes have access to the best possible care and support they need to live well with diabetes, close to their homes, in community-based services.
• We will ensure people with diabetes are supported during their inpatient specialist care hospital stays and those living with type 2 diabetes have nutritional support to manage their condition or even achieve remission.
• We will also ensure children and young people with diabetes have access to high quality care and carers of people with diabetes have support to stay well
• People living with diabetes can monitor and self-manage their condition effectively. We will focus on providing support to people with diabetes to enable them to self-manage their condition as well as better enabling pregnant people with Type 1 diabetes to monitor their glucose levels more effectively
• We will reduce health inequalities for people living with diabetes and increase our use of PHM data to help us do this

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

• an increase in referrals to the National Diabetes Prevention Programme (NDPP) in-line with contractual requirements
• an increase in the diabetes diagnosis rate from 6.1% to 7.5% to support those living with undiagnosed diabetes
• a reduction in the rate of people developing type 2 diabetes
• an increase in the number of people putting their diabetes into remission via introduction of the planned Low-Calorie Diet programme
• a levelling up in the completion of national diabetes care processes to pre-Covid levels (60% completion by end 2024/25)
• a levelling up in the achievement of the diabetes treatment targets with an aspiration that all practices reach 45% achievement by end 2024/25
• improved access to and uptake of structured education classes by a further 10% from current baseline figures for both newly diagnosed and established patients
• improved access to glucose monitoring technology for:
  • pregnant type 1 people
  • adult type 1 people
  • adult type 2 people
  • type 1 children and young people
• fewer cases of type 2 diabetes in people of minority ethnic origin
• increased access to mental health services for people with long term conditions
• 5% reduction in diabetic emergency admissions and re-admissions (Hypo and Hyper) by 2025/26
• fewer diabetes-related amputations (above/below the knee – Major/Minor)
• a reduction in diabetes mortality rates
• all three alliances achieving their “outstanding” performance rating for diabetes services once again

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Quote: “All Alliances in our ICS have previously been rated as outstanding in the Improvement and Assessment Framework reports from NHSE. The ICS remains outstanding for delivery of the eight Diabetes Care Processes and Outcomes. We should rightly feel proud of this, however, we aim to do better as there is still so much more we can do. The proposals outlined in this JFP will deliver significantly better services for those of all ages and ethnicities, living with type 1 and type 2 diabetes in SNEE, as well as reduce the growing number of people developing type 2 diabetes. Our ultimate aim is to improve the lives of our population of people with diabetes and their families, as well as those at risk of the condition.”

Professor Dr Gerry Rayman, ICS Diabetes Clinical Lead Consultant Physician at the Diabetes and Endocrine Centre, East Suffolk and North Essex NHS Foundation Trust

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Case Study: Enabling patients to understand how to keep themselves healthy – structured education

Structured education improves outcomes by enabling people to understand what they need to do to keep themselves healthy. However, take-up among people newly diagnosed with diabetes is very low. As a system we were able to bid for funding from NHSE and the SNEE was awarded funds of £955k to transform Diabetes Management (including DESMOND and DAFNE selfcare programmes). We developed ICS-wide governance and appointed a clinical lead to provide steering and oversight. We have:

• recruited and trained DESMOND and DAFNE educators
• increased the number of DESMOND and DAFNE places and venues available
• implemented a central referral and booking service
• introduced a diabetes lifestyle navigator role in north east Essex
• developed and implemented the ‘Big Impact’ campaign
• commissioned a digital diabetes structured education provider to offer an alternative method
• promoted better glycaemic control.

As the full, expanded structured education service did not come into place straight away and year-end data is still not available, it is still early days in terms of fully evaluating the outcomes of the service. However, in the last three years the expanded structured education service has so far almost doubled the numbers of people attending the programme.

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5.8.2.5 Respiratory

The key priorities we will achieve by 2028 are as follows:

• People living with breathing and respiratory problems are diagnosed and detected earlier. We will maintain a clear focus on the delivery of a locally-accessible asthma and COPD diagnostic service and will ensure local access to diagnosis and monitoring of these conditions by 2026, aligned to the ambitions of the Core20Plus5 approach
• People with respiratory conditions are supported to live well by ensuring they receive the right medication to manage their condition. We will provide high quality support including high quality rehabilitation services and we will ensure people with respiratory conditions receive the best hospital and community-based respiratory care
• People at higher risk of respiratory infections have access to high quality care and support by ensuring people with respiratory conditions know how to prevent the risk of worsening health
• People with respiratory conditions or at risk of respiratory infections have awareness of the impact of air pollution on their health and are supported to reduce health deterioration associated with air pollution
• People with respiratory conditions and other long term conditions are empowered to make decisions to reduce the risk of worsening respiratory symptoms through a collaborative approach between prevention and population health management

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

• a reduction in emergency respiratory admissions in adults and children by 2027 to below the England average compared to the 2023 emergency respiratory admission rate
• 70% of respiratory patients have completed a pulmonary rehabilitation exercise programme as per the quality improvement national recommendation by 2027
• 85% of people with respiratory conditions are starting a pulmonary rehabilitation programme within 90 days of referral as per the national target
• an increase in the number of people who have switched to a dry powder inhaler, where clinically appropriate
• 78% uptake of flu and pneumonia vaccinations in people with respiratory disease including among groups with protected characteristics by 2027
• 100% of pulmonary rehabilitation (PR) services across SNEE accredited by 2027
• a reduction in business mileage and nitrogen dioxide and fine particulate matter (PM2.5) pollution levels by 2028 compared to 2023 and the England average
• increased public awareness of air pollution and practical strategies to improve health outcomes and reduce air pollution from 2025

Further details on the plans for Respiratory are available in Appendix 9 – Stay Well.

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Quote: “The West Suffolk Pulmonary Rehabilitation Service has been going through the accreditation journey for a couple of years and has recently had a site assessment, which was very successful. The accreditation process has enabled us to review our service and carry out a number of service improvements to both meet the needs of the accreditation and provide a gold standard service to our patients. Areas we have worked successfully on is the creation of our SuperSOP, with mini-SOPs embedded to ensure that our service is standardised across west Suffolk. We have re-designed our website to ensure that it is patient and carer friendly as well as appropriate for health care professionals. Embedded in this is our new self-referral platform. We have amended our patient and carer feedback surveys to ensure we capture feedback from the whole pulmonary rehabilitation pathway and have started to communicate to patients any service changes as a result of their feedback. We have started patient and carer involvement sessions at our local Breathe Easy group to ensure that we remain accessible to our patients and prospective patients.”

Jenny Steedman,
Pulmonary Rehabilitation Team Leader, West Suffolk NHS Foundation Trust

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Case Study: Coproduction – inhaler switching
“I was asked to join a group of clinicians as a patient rep to discuss how to promote the use of dry powder inhalers in place of MDI inhalers to reduce harmful emissions. I was extremely sceptical as my inhalers are critical to my wellbeing, especially “Fostair”.

Anyway, we discussed the design of a leaflet which shows a clear comparison of emissions between MDI inhalers and powder inhalers and that leaflet has since been published. After some deliberation I decided to try the powder inhalers and discussed with my consultant who was all for it as a trial meaning I could change back if I didn’t feel that the powder inhalers gave me as much relief. So back in August 2022 I switched from “Salamol Easy Breathe” to “Ventolin Accuhaler” and from “Fostair” to “Fostair Nexthaler” I have not noticed any detrimental effect and continue to use the powder inhalers.”

Phil Gladwell – Patient representative from Breathe Easy.

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5.8.2.6 Long Covid

The key priorities we will achieve by 2028 are as follows:

• People in all our communities can access the Suffolk and North East Essex Long Covid Assessment Service (SNELCAS). We aim to reduce health inequalities through close collaboration with VCSE teams, community pharmacy teams and social prescribers to ensure everyone can access the service
• People have access to a wide range of timely, appropriate specialist resources whilst they wait to be seen by the service (e.g. widespread access to Your Covid Recovery – Supporting Recovery for Long Covid NHS website)
• We take a proactive, courageous approach to innovation and research which could improve quality of life and self-management
• We will ensure people receive appropriate, personalised support throughout their entire pathway and have access to digital resources to review their progress
• We will consider the use of “one-off” personal health budgets to support personalised care choices linked to individuals’ personalised care and support plans by working closely with our personalised care team

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

• 80% of people triaged and seen within six weeks by 2025
• 100% of people continuing to be assessed within 14 weeks of referral as per the national target. In SNEE we have consistently met this standard
• 60% of people reporting improved outcomes from national quality of life tool EQ-5D-5L
• 70% of people waiting no longer than three months for inhouse rehabilitation support. As inhouse rehabilitation expands, we would expect a reduction in onward referral to specialist rehabilitation services
• over the next year the SNELCAS service will capture more activity and monitor this to ensure the whole offer of local services is tracked for continuous improvement

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Quote: “I would like to say a big thank you. This is the first time I’ve felt heard in a long time. It was so refreshing to see that we were talked to as individuals, and next steps catered to our individual requirements. Sarah couldn’t have been more perfect for this role!

“I felt heard, calm and for once didn’t waste my energy on having to get my thoughts and feelings heard. This is a big step, which is very much underestimated in preventing anxiety and depression. So thank you. I whole-heartedly wish this approach was taken for FND (functional neurological disorder), as there are a number of similarities in how patients can have similar or different symptoms. It was nice not to be labelled, put in a box and forgotten about. Thank you to all.”

Mel – Service user

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Further details on the plans for Long Covid are available in Appendix 9 – Stay Well.

5.8.2.7 Myalgic encephalomyelitis and chronic fatigue syndrome (ME&CFS)

The key priorities we will achieve by 2028 are as follows:

• Adults and children with suspected ME&CFS are diagnosed early within three months
• People with ME&CFS and their carers/families are supported to live well
• People with ME&CFS have access to high quality care that addresses health inequalities and inequity³⁴

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

• 60% of people with ME&CFS reporting improved outcomes from national quality of life tool EQ-5D-5L
• an increase in the number of people with ME&CFS diagnosed within three months as per the national guidance by late 2024
• an increase in the number of people/carers reporting satisfaction and confidence in their care plan as part of newly commissioned services by 2025
• the ME&CFS e-learning training programme established and accessible by health and social care professionals by 2024

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Quote: “Patient Groups would like to thank the NHS in Suffolk for their long-term support, together with the Local Authority Norfolk & Suffolk Health Overview Scrutiny and Joint HOSC Committees, who have been crucial to chances of resolution and success.”

Barbara Robinson and Tina Rodwell, Suffolk Youth and Parent support group ME&CFS

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Further details on the plans for ME&CFS are available in Appendix 9 – Stay Well.

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Case Study: Coproduction driving ME&CFS Service Redesign and Development

A robust feedback process is in place across Suffolk which empowers people to provide commentary via platforms such as ‘Let us Talk’ and ‘Have Listened’. In 2018, this coproduced approach resulted in a new consultant-led ME&CFS service for Suffolk people to better cope with the unmet demand for services.

The voices of the ME community are being listened to, enabled by the coproduction process that the SNEE has in place with our people and communities. We are now beginning to break down barriers, stopping stigma and bringing ME&CFS into the wider public lens.

Transformation Programme Manager, Alexis Johnys, has empowered this process and all those involved, so that clinicians, healthcare practitioners, social care professionals and local authority education staff can work together with the ME&CFS community.

Improving the understanding of complex unmet needs and current inequalities of care for those with ME&CFS and treating them according to their needs ensures the best, most cost effective and highest quality of life outcomes for people and carers. This also better enables health quality prospects for their future.

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5.8.2.8 Cardiovascular Disease

The key priorities we will achieve by 2028 are as follows:

• People have the information and support they need to reduce the risk of developing cardiovascular disease by providing prevention services based on best clinical practice and ensuring people routinely check their “ABCs” (AF, blood pressure and cholesterol)
• People with cardiovascular disease have the right treatment and support to manage and, where possible, improve their condition. We will ensure people experiencing breathlessness have better access to tests for heart failure and heart valve disease and people with heart failure and heart valve disease are supported by integrated community services. In addition, we will work in partnership with diabetes teams to support people to self-manage their condition
• People have the best possible treatment and care for survival and recovery from cardiovascular disease. We will ensure people who have a cardiac arrest have access to urgent treatment in their community, people receive high quality cardiac and vascular care based on best practice and provide the best chance of recovery from heart attack, surgery or procedure
• We will reduce health inequalities for people with cardiovascular disease

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

• more people with AF being detected (85%+ of expected by 2029) and having their condition managed (90% of detected with AF who are already known to be at high risk of a stroke to be adequately anticoagulated by 2028)
• more people with high blood pressure being detected (80%+ of expected by 2028) and managed (80% of detected to be treated to NICE guidelines target)
• 45% of people aged 40 to 74 identified in primary care as having a 20% greater ten-year risk of developing cardiovascular disease treated with statins by 2028
• a drop from the 10th (poorest) decile to at least the 8th lower decile by end 2025/26 in the use of high intensity statins over low/medium intensity statins resulting in more people having their lipids optimised
• a 5% reduction in acute admissions with a first presentation of heart failure
• a 5% reduction in deaths from cardiovascular related disease
• a reduction in the gradient in cardiovascular disease mortality across different levels of deprivation

Patients have told us: – “The cardiac service and intervention is excellent giving me complete peace of mind when I was dealt with immediately”

“This year was two years post heart attack. I received a letter from my surgery inviting me to see the practice nurse for my coronary heart disease annual check. I think it is an excellent idea for reassurance to have an annual check in the surgery, it was worthwhile having a BP, urine and weight check.”

Further details on the plans for cardiovascular disease are available in Appendix 9 – Stay Well.

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Case Study: Brian’s Story

Brian had a long history of heart problems, but had recently become significantly frailer, had lost weight and had fallen multiple times. Brian was very low in mood and frustrated that he was not improving and had stopped engaging in social activities. The Market Cross Frailty Project – a proactive approach to frail people living in their own home – carried out a Comprehensive Geriatric Assessment, a falls assessment and a medication review completed with Brian and his wife at home. As a result they changed his medications (which helped reduce his weight loss and helped his balance), obtained specialist advice from the local Bladder and Bowel service (which saved Brian an unnecessary visit), provided nutritional advice and information on domiciliary dentistry, arranged a personal alarm, helped Brian with welfare benefits and gave his wife information on Suffolk Family Carers.

Brian’s appetite is improved, he is walking more steadily, has had no further falls and has restarted physiotherapy. He has support from heart failure nurses and his mood is monitored through ongoing reviews.

5.8.2.9 Stroke Services

The key priorities we will achieve by 2028 are as follows:

• People know how to stay healthy and avoid a stroke, increasing awareness of the risk factors
• People are identified as being at risk of stroke by improving detection and treatment of the highrisk conditions: AF, high blood pressure and high cholesterol, working with other programmes such as cardiovascular disease and diabetes
• People receive the best quality treatment and care following a stroke
• People have access to the best possible stroke services in the community following discharge from inpatient care by implementation of the Integrated Community Stroke Service Model
• People have the best experience of recovery after a stroke, integrated care delivery in partnerships with voluntary and other care sectors to improve outcomes at six months and beyond

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

• an increase in the number of people returning to work post stroke by 2026
• an increase in access and the intervals offer for therapies, so that by 2025 all people will have access to 45 minutes of the appropriate therapy within an inpatient and community care setting. For 2023-2025 this will mean doubling our time periods
• a reduction in the mortality rates by 20% in SNEE in particular for the under-75 mortality rate
• more people discharged home and able to manage independently or with a carer
• we will have developed a flexible, future-proofed competency-based stroke workforce
• improved outcomes for the most complex Category A patients with a reduced risk of secondary complications

Further details on the plans for Stroke Services are available in Appendix 9 – Stay Well.

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Quote: “From stroke prevention through targeted detection of Atrial Fibrillation and case finding of those with high blood pressure to improving access to mechanical thrombectomy in order to save lives and reduce the disability stroke can give, we are committed to being ambitious for better outcomes. Not content with maintaining the quality of our acute stroke teams and the way in which our primary care teams manage risk factors, we want to use data and technology to intervene in early detection, optimising our prevention and challenge thinking that restricts access to high value interventions, saving lives at every opportunity. We also want to ensure that we have the right support for those who have sustained injury from stroke, including those who care for them, and be ambitious about what can be achieved.”

Nerinda Evans, Deputy Director Strategy and Strategic Programmes, NHS SNEE ICB

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Case Study: George’s Story

A 60 year old man had a left total anterior circulation stroke, he was thrombolysed and then discharged to the Early Supported Discharge team, then referred to Liveability Icanho with assessment 5 months later. He had moderate-severe aphasia and mild dysarthria, resolved dysphagia and limited use of a right upper limb (reduced muscle strength/dexterity). He had cognitive impairment – attention/memory, fatigue, depression and was avoiding social situations.

The team worked on his vocational rehabilitation to support his goals to improve right hand dexterity and writing, to get back to fishing, sailing and adventure sports. He needed to find strategies to manage fatigue, improve speech and be able to drive again and most of all to return to work.

The Therapy Plan involved physiotherapist 1:1 sessions, occupational therapist/vocational rehabilitation 1:1 sessions, speech and language therapist 1:1 sessions, clinical psychology advice/review, a social worker – available for support to partner too…and then COVID lockdown but this resulted in periods of rehabilitation being offered via remote channels, demonstrating that technology can help in continuation of care.

Getting back to work and life involved workplace assessment and liaison with company managers, analysis of duties/roles alongside capability with practical assessment with observation of work tasks/use of equipment. Reasonable adjustments suggested based on grading hours and duties, then very gradual phased return starting 2 hours twice a week on non-consecutive days to build strength and general work tolerance. The success was he went back to work and most importantly of all started to drive again.

5.8.2.10 Neuro Rehabilitation

The key priorities we will achieve by 2028 are as follows:

• People requiring rehabilitation have support as early as possible through early identification of their needs and better established networks for referral
• People requiring rehabilitation are supported to live well by increasing access and provision of vocational rehabilitation by 2026, establishing new Motor Neurone Disease (MND) clinics in north east Essex by 2025 and improving access for people with disabilities in developing knowledge and skills for self-help, care, management, and decision-making
• People requiring rehabilitation are better able to manage their condition through high quality support by increasing the level of provision of step-down rehabilitation provision and providing the best quality neurological services
• People with rehabilitation are better able to manage their condition through a more integrated model of care and cohesive workforce. We will focus on primary and secondary prevention to address health inequalities and equity and improve information sharing, joint working, and uncomplicated processes for interagency referrals. In 2023, we will identify any gaps in referral pathways and we aim to have a higher proportion of psychology/counselling staff by 2027/28
• People with rehabilitation requirements have access to technology and the appropriate level of care when needed

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

• patient centred rehabilitation tailored to individual requirements with a person-centred approach
• people with neurological disabilities having a greater degree of independence and confidence. Higher rates of people returning to employment, training or alternative meaningful activity
• a reduction in long term care and support costs as people achieve more independence
• a decrease in the numbers of people with acquired brain injury (ABI) coming into contact with the criminal justice system by 8% by 2027/28
• a reduction of 10% in the numbers of people with ABI within the homeless population
• fewer numbers of people with ABI finding themselves in crisis services
• a reduction in the number of later complications by 20% by 2026
• a reduction in the risk of re-admission to acute hospital or mental health services by 30% by 2027/28
• each person having a sharable, personalised care and support plan which records what matters to them, their outcomes and how they will be achieved
• timely and improved rehabilitation processes for the accurate assessment of individual needs and personalised goal setting to form the cornerstone of rehabilitation
• improved data recording, sharing and collation
• improved discharge planning and service integration across NHS, voluntary and charitable organisations
• increased availability and quality of rehabilitation services
• a reduction in disability levels in people with neurological conditions
• Patient Reported Outcome Measures / Patient Reported Experience Measures data indicating and assisting the involvement of the patient/carer voice at all stages of rehabilitation development

Further details on the plans for Neuro Rehabilitation are available in Appendix 9 – Stay Well.

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Quote: “Rehabilitation after stroke requires a multi-professional, multi-agency approach to move forwards and live well after the event. Stroke and Neuro Rehabilitation needs Specialist Rehabilitation delivered by
skilled team members seven days a week to regain meaningful activities, lessen ongoing care needs and provide psychological support for survivors and their carers within their home.”

Louise Dunthorne, Physiotherapy Clinical Specialist (Stroke)

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Case Study: Suspected Stroke, delayed discharge but returns to independent living

The patient was admitted to hospital with a suspected stroke but was diagnosed with autoimmune encephalitis. She had previously been completely independent as a family carer for her partner, attended a gym 3 times a week and spent time with her children and grandchildren. On admission she spent 2.5 months as an inpatient as there was no appropriate subacute discharge destination identified. She had poor sequencing of basic tasks, difficulty with planning and problem solving (cognitively and in terms of motor planning), a lack of problem-solving skills and was disorientated in time and place but once discharged with care in place she was walking independently and was mobile after three weeks. Staged discharge with afternoons at home with family was arranged prior to discharge.

She was discharged home with 24-hour care support (aided by social services) and twice weekly outreach by hospital therapy staff. Goals are now focused on getting the patient Mrs A more independent in accessing community resources and caring for her husband more independently. Support for fatigue management and involvement from Liveability Icanho and Headway is in place for ongoing therapy for the patient and extended family. What worked to facilitate rehabilitation and support to live independently again was the flexibility with rehab options, which is essential in truly patient-focused care. It was a great example for the team to accept neuro patients in their service model to allow neuro-specific rehabilitation within the home environment. There was recognition of the specialist support required to meet the demand identified in this case. If this was a more established
pathway, positive impact on the length of stay and reduce the significant time required to establish a discharge plan (reduced therapy time on the wards for rehabilitation).

5.8.2.11 Learning Disabilities and Autism

The key priorities we will achieve by 2028 are as follows:

• Primary and/or community-based services are provided to keep people healthy in the community
• High quality services are provided to adults with learning disability and/or autistic adults
• Good quality health and care services that work in an integrated way to optimise outcomes
• Action to tackle the causes of morbidity and preventable deaths in people with a learning disability and for autistic people
• The whole NHS will improve its understanding of the needs of people with learning disabilities and autism and work together to improve their health and wellbeing
• Increased investment is increased in intensive, crisis and forensic community support
• A focus on improving the quality of inpatient care across the NHS and independent sector

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

• a minimum of 75% of people aged 14 and over with a learning disability on GP learning disability register will have had an annual health check by 2023-24
• a continued focus on achieving Learning Disabilities Mortality Review reviews to ensure that 100% of in-scope reviews are completed in six months
• the ICB ensuring people who have been referred to an autism diagnosis service, will wait no longer than 18 weeks from referral to first appointment by 2024-25
• no more than 30 people in every one million adults with a learning disability and/or autism cared for in an inpatient unit by 2023-24
• all Care (Education) and Treatment Reviews (C(E) TRS) Standards are met

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Quote: “We are committed as part of the Suffolk Learning Disability Partnership Board and in partnership with the Southend, Essex and Thurrock Learning Disabilities Health Equalities Board to delivering through partnership and coproduction the ambitions set out in the JFP and NHS LTP.”

Lisa Nobes, Senior Responsible Officer for Learning Disabilities and Autism and Executive Chief Nurse, NHS SNEE ICB

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Case Study: Alice’s Story

Alice is a 63 year old diagnosed with a moderate learning disability and mood disorder. She lives in supported accommodation in a shared living placement. When unwell, Alice can display behaviours that present a challenge to herself, to the environment and to others.

In the past Alice has experienced frequent mental health crises resulting in admissions to hospitals under the Mental Health Act. Alice’s mental health began to deteriorate and through the dynamic support register, the system responded. A care education and treatment review took place which identified key actions for the local system to consider. The local system increased community support and health support through the Intensive Support Team. Unfortunately, remaining in her home became unsustainable so Alice became a resident of Lavenham Place admission avoidance service. She received individualised care, assessment and treatment from health and social care services. Following a short stay Alice was able to return home.

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5.9 Age Well – Supporting people and their carers to live safely and independently as they grow older

Overall Outcome: Supporting people to live safely and independently as they grow older

Overall Commitment: We will ensure that people who are ageing are able to live safely and independently, experiencing a good quality of life

5.9.1 Why is this important for people in Suffolk and north east Essex?

People in SNEE can now expect to live for longer than ever before – but these extra years of life are not always spent in good health, with many people developing conditions that reduce their independence and quality of life. We have a key role to play in helping older people manage these long-term conditions, making sure they receive the right kind of support to help them live as well as possible.

5.9.2 What do we know about people’s local experiences?

Key factors and challenges noted include the following:

• People in England are living longer than ever before and, as a result, the number of older people in England is growing significantly. It is projected to increase further over the next 20 years. The number of people living in SNEE aged 65+ is set to increase by 33% in the next twenty years (compared with 33% for England)³⁵
• Older people can have complex health and care needs. Long-term conditions and functional, sensory or cognitive impairment are the highest cost and volume group of service users. Dementia accounts for more expenditure than heart disease and cancer combined. Frailty is more common with increasing age, with 10% of those aged over 65 living with frailty. It is important to prevent frailty and deterioration in those already frail
• Over 33,000 people who are 65 and over provide unpaid care in SNEE³⁶
• Through recent consultation, we heard that adjusting to the role of carer and finding that you have less time for yourself is seen as a big challenge. However, carers also stated that the role of a carer can also be rewarding
• In 2021, carers in Essex reported being tired, feeling isolated and guilty, and having poor emotional wellbeing. It was also noted that carers often feel that others do not understand the responsibilities and pressures they face. Many carers would welcome more support from our clinicians, an improvement in social care assessments and reviews, and employers recognising their rights as carers

5.9.3 How we plan to make a difference

Our priorities for Age Well are broken down into ageing well, dementia and carers.

5.9.3.1 Ageing Well Programme

The key priorities we will achieve by 2028 are as follows:

• Enabling the ageing population to live a healthier life for longer in the person’s preferred place of residence by anticipating the health, care and wellbeing needs of the population by identifying people at an earlier stage and providing a multidisciplinary approach to their needs through the neighbourhoods model from 2023. We will enable this by supporting people to prepare for later life, supporting older people to stay healthy and ensuring older people do not face stigma, discrimination or disadvantage
• People with frailty are supported at home and unnecessary hospital admissions are avoided by achieving the 70% two-hour target for urgent community response to deliver care in people’s homes from 2023. We will enable this by ensuring older people are safe in their homes and closely monitoring their health to identify risks and prevent frailty, illness or injury. In addition, we will ensure older people have access to integrated physical and mental health support tailored to their health needs, can connect with their communities and have greater choice and control over their care
• To have an active ageing population by improving the number of referrals into the Strength and Balance programme and boosting delivery to more residents, including care homes from 2023. An active ageing population can reduce the impact of mental and physical health conditions resulting in a healthier and longer life

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

• an increase in disability-free life expectancy for our population at the age of 65 by 2028
• an increase in the number of people with severe frailty having advanced care plans in place by 2028
• fewer emergency hospital admissions due to falls in people aged 65 and over by 2028
• higher rates of people with joined-up mental and physical health services for the older population by 2028
• more carers identified, registered with their GP and supported into appropriate community pathways with support by 2028
• a reduction each year in emergency acute hospital bed use (bed days per capita) for those over 65 years old

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Quote: “Our new strategy for frailty will be based on our understanding that it is a chronic health condition which needs many specialist interventions, including medical and social. The strategy is being developed with all our system partners and in particular with neighbourhood teams. We know that frailty has a significant impact on many people and those close to them in our communities. It also is a major cause of increasing pressure throughout health and social care. Our new strategy and partnership work aims to address both.”

Angela Tillett, Medical Director, ESNEFT

Quote: “We are working to develop person-centred services to enable people to age well. Our frailty strategic framework focuses on embedding an end-to-end approach from prevention, earlier identification, support when frail and at end of life. We will embed this in all parts of the health and social care system, working with our partners supporting front line staff to develop and maintain the skills and have available to them the tools to offer this support well and consistently. Our work around anticipatory care and population health management are great examples of how we can strengthen our approach to prevention and provide early support to our most vulnerable population. Working with our community leisure providers and voluntary sector, we are beginning to see how proactive support can begin to change the way in which people can live their lives to the fullest, right into old age.”

Paul Molyneux, Medical Director, WSFT

Public feedback:

“It’s great to see ageing being acknowledged as an opportunity to get fitter and improve your health – it’s never too late”

Case Study: Strength and Balance Programme

Mr J is an 80 year old gentleman residing in a care home in Colchester. He has Insulin dependent diabetes mellitus, hypertension and vascular dementia. He moved to the care home in 2020 as he was having lots of falls at home and could not cope living independently. He relied heavily on his walker frame and was falling over at least once a week.

He completed all 12 sessions of his strength and balance course which was hosted at his care home. By the end of the programme he had stopped having falls altogether and has not had a fall since. Mr J continues to complete his Otago exercises with encouragement from the activities coordinator at the care home. He has his own booklet that he ticks off as he completes the exercises each day.

Mr J is feeling stronger and appears more confident. He is now completing short walks without his walker and is helping out at activity time at the care home by picking up the bowls equipment.

Further details on the plans for the Ageing Well Programme are available in Appendix 10 – Age Well.

5.9.3.2 Dementia

The key priorities we will achieve by 2028 are as follows:

• Achievement of the national 66.7% dementia diagnosis rate by October 2024 and an increase in dementia annual care plan reviews completed year on year until 2028
• The reduction of memory assessment backlogs and delivery of a timely dementia diagnosis in line with national standards by March 2025
• In line with transforming models of care within communities, individuals will be able to obtain a dementia diagnosis within primary and community care settings (where appropriate) by 2026
• Delivery of a seamless, integrated package of services linked to frailty services to respond proactively to those with dementia or suspected dementia and their carers in their own homes and community settings by 2027
• An ongoing awareness and information programme across the next five years focused on both health and social care professionals as well as wider community services with a focus on those hard to reach and from marginalised communities. This could include delivery of the Virtual Dementia Tour, the Dementia Infolink and general dementia awareness education across the system
• Continue working with system partners to derive dementia friendly communities, expanding community assets to support those living with dementia inclusive of family and carers via the relevant system governance including the SNEE Alliances and Essex and Suffolk Health and Wellbeing Boards

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

• delivery of the SNEE ICB diagnosis rate of at least 66.7% by October 2024
• every individual diagnosed with dementia, including their carer or family, offered and able to access support within communities to support later life modifiable risk factors by 2025
• evidence of dementia assessments/diagnosis taking place outside of specialist services and within community environments by 2026
• delivery of the diagnosis pathway that presents an average duration of referral to diagnosis for dementia within six weeks by 2027
• a year on year increase of annual care plan reviews being completed for those diagnosed with dementia up until 2028

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Quote: The prevalence of dementia is ever increasing and those who live with such diseases are still people. They have their own unique personality and character and are frequently capable of so much more than we can imagine. With the appropriate facilities to obtain a timely diagnosis and the right awareness and support, it is possible for people living with dementia to remain and live in communities happily and with a good sense of purpose and value. In SNEE we are committed to working in partnership with all agencies including those with dementia and their family/carers to improve and build networks and relationships across communities to enable better access to care and support that is compassionate, grounded and available in every facet of day to day life.

Georgia Chimbani, Director of Adults and Community Services, Suffolk County Council and Co-Chair of SNEE & Waveney Dementia Forum

Case Study: Anne’s Story

Anne has had a longstanding history of depression and anxiety due to a number of significant bereavements. Anne was given a community psychiatric nurse via the GP who she saw for monthly sessions to discuss her depression, and also paid for private counselling. By 2018 Anne’s memory loss began to become more prominent when her daughter received a distressed phone call when she had had a complete memory lapse. She could not remember where her daughter lived or how to get there by car. Her daughter took her to a GP who was very dismissive of her symptoms putting this down to her long history of depression and anxiety. The GP implied that her mother was articulate and because of this her daughter felt that her decline in memory loss was not taken seriously. A GP assessment of cognition was undertaken and the results were seen as ok, despite the concerns of her daughter.

At the end of 2019 Anne’s daughter paid for a private psychiatrist as they had seen 2-3 different GPs and a community psychiatric nurse who all appeared dismissive of the daughter’s concerns. The psychiatrist concluded that Anne’s memory loss was more than just anxiety and depression and wrote to the GP with the recommendation that Anne attend a memory clinic. Anne attended a memory assessment clinic in 2020, followed by CT and MRI scans and a psychology assessment. In November 2020 this resulted in a diagnosis of Alzheimer’s Disease, which was given over the phone due to the pandemic. Her daughter was left to have difficult conversations with her mother about giving up driving as she
was increasingly concerned that her mother’s ability and safety had further deteriorated over the diagnosis period.

Anne’s daughter felt that a carer’s concerns about the health of their loved ones should be taken seriously at the early stages as they know that person better than anyone else, despite continuing to flag with professionals she felt that her opinions was dismissed. Having a diagnosis has helped Anne’s daughter understand why she has behaved the way she has over the years, to understand the diagnosis and help find coping mechanisms to support Anne and prepare for the future. Anne has little understanding of her own diagnosis and frequently forgets that she has dementia, which has led to challenging conversations regarding her mother’s ability and safety.

Further details on the plans for Dementia are available in Appendix 10 – Age Well.

5.9.3.3 Carers

The key priorities we will achieve by 2028 are as follows:

• Carers are identified at the earliest opportunity
• Carers can easily access information, advice and support when needed
• Young and young adult carers’ health, education/life skills, choices and opportunities are not adversely affected by their caring role, and they are supported through transition in readiness for their adult caring responsibilities
• We have systems and services in place that work for and support carers, which are developed and influenced by our local carers
• Carers can enjoy improved health and well-being across SNEE

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

• an increase in the number of carers identified on GP systems from the 2023 level of 3.4% across SNEE, to 5% by 2028
• an increase in the number of carers registered with a contingency plan, year on year
• an increase in the number of GP surgeries attaining Carers Quality Markers developed by NHSE or equivalent, year on year
• increased referral and signposting of Carers across all healthcare settings
• carers telling us that they feel recognised, informed and supported via established surveys and provider feedback
• improved signposting to carers assessments with tailored support packages and ongoing review as required

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Quote: “It is encouraging to see that the JFP recognises the importance of family carers and has aligned its ambitions with the Suffolk All Age Carers Strategy and the Essex Carers Strategy. This will ensure that family carers are given due consideration within the context of the ICB’s priorities.”

Kirsten Alderson, Chief Executive Suffolk Family Carers and Chair, SNEE VCSE Assembly

Public feedback: “[Unpaid] Carers are an essential asset and should be protected and supported as a priority”

“Carers feel shame when they need to ask for help. How can we support carers to reach out and access what they need?”

Case Study: Shona and Brandon

Shona and Brandon care for each other. Shona, 51, supports her son Brandon with his learning and mental health difficulties. Brandon, 24, provides Shona with practical support to help her manage the symptoms of her kidney disease.

Shona said “Having someone there just to talk to if I need advice or somebody just to listen has helped me immensely as time progressed. I now feel supported which has really changed my caring role for the better. Being registered with Carers First in North East Essex has given me a sense of no longer being alone.”

Brandon said “Caring for mum can be quite difficult, it’s a big responsibility, especially as my mum doesn’t have anyone else coming in to support her, but she is worth it! Having the opportunity to go to different groups and events is a nice distraction.”

Further details on the plans for Carers are available in Appendix 10 – Age Well.

5.10 Die Well – Giving individuals nearing the end of life choice around their care

Overall Outcome: Giving individuals nearing the end of life choice around their care

Overall Commitment: We will enable people and their families to have high quality care and support from all health and care professionals involved at the end of their life

5.10.1 Why is this important for people in Suffolk and north east Essex?

End of Life care will impact most people in SNEE at some time, including those approaching the end of their lives, those that care for them and those who are bereaved. Over 10,000 people in SNEE are in the last year of their life and we wish to ensure that over this time they and those who care for them have the best and most equitable care and support from the resources we have available.

5.10.2 What do we know about people’s local experiences?

Key factors and challenges noted include:

• People are not always seen as an individual when at the end of their life
• Comfort and wellbeing are often something people are the end of their life value more than being kept alive
• People do not always get fair access to care when nearing the end of their life
• How families and patients experience the dying process is informed by culture and values

5.10.3 How we plan to make a difference

The key priorities we will achieve by 2028 are as follows:

• The timely identification of the people who are approaching the end of their lives, communicating this with them and those who are important to them with sensitivity and honesty
• The eliciting, recording and supporting of people’s preferences for care in the last phase of life, ensuring these are accessible to all parts of the health and social care system
• People at the end of life are treated equitably as individuals, with dignity, compassion, and empathy, controlling symptoms 24 hours a day We will know we are making a difference because we will see
• collaboration in this financial year to measure the baseline of how many people are being identified in the last year of life in SNEE
• incremental annual growth in the percentage of people known to be approaching the end of life
• an increase in the proportion of people passing away in their preferred place of death
• people’s satisfaction measured with the quality of the conversations by survey and show an annual improvement in the results
• the achievement of this priority measured by recording the number of people who have recorded an advance care plan, and the equity of access across the community as well as the access to these plans for health and social care professionals to support coordinated care. We shall ensure that residents of care homes are able to access advance care planning and care coordination services. We will demonstrate an annual improvement from the baseline figure identified in 2023
• the extent to which care was coordinated around people’s priorities by recording what proportion of people are cared for in their preferred place and by surveying people as to whether they received the right care for their needs and show an annual incremental improvement
• the dignity and symptom control that people experience measured by survey
• the patient and carer survey system currently running in north east Essex continuing this year and we will develop an equivalent survey system across Suffolk
• that we have made a difference by demonstrating annual improvements in outcome feedback results

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Quote: “This JFP gives us the opportunity to improve dignity and choice for people approaching the last phase of life in Suffolk and north east Essex. It focuses on what people have told us is important to them and allows us to build on what is working well, learning together to address inequalities.”

Dr Karen Chumbley, SNEE ICS, Clinical Lead for End-of-Life Care

Public feedback: “We need a better understanding of what palliative care is – it’s not just for cancer and the last few days of life?”

“If everyone has confidence to talk about dying we can honour choices and avoid crises.”

Case Study: Compassionate communities

Paddy was identified as likely to be entering the last year of his life. His GP matched him with a local compassionate companion volunteer who had been trained to support people by End of Life Doula UK. The companion supported Paddy to record his wishes for his end of life care and communicate this to his family and health care professionals. She also supported Paddy emotionally and practically. As a result of this, Paddy’s next of kin and health care partners were able to work together to support Paddy’s wishes and Paddy died in his own home. His family and health care professionals were reassured that his end of life wishes were respected.

Paddy was a great advocate of the Compassionate Companions and his legacy has continued with Paddy designing a daisy emblem which is now the logo brand for the scheme. The pins are given to all companions once they have completed the training. Paddy also had a starring role in an informational video for compassionate companions.

Further details on the plans for End of Life are available in Appendix 11 – Die Well.

6. How will we work differently to achieve our priorities?

6.1 Alliances

Our three ‘place-based systems of care’ are known locally as Alliances. They are ‘North East Essex’, ‘West Suffolk’ and ‘Ipswich and East Suffolk’ Alliance, each defined by the footprint of local health and care partners as well as natural geography. The alliances have distinct and shared population needs and assets. The alliances of NHS, local authority, independent, voluntary and community sector partners work together with common purpose to provide the focus for planning and delivering meaningful integrated care to their local populations.

Alliances provide the focus for:

• working with people to understand the wellbeing, social and healthcare needs of the local population and developing outcomes and solutions together
• producing and resourcing a detailed plan to deliver the overarching strategy
• ensuring clinical and professional engagement
• developing and managing partner relationships
• working collectively to identify improvements to individual services and across services
• delivering joined up (integrated) health and care
• ensuring the principles of good system governance are embedded
• understanding and reducing health and social inequalities across each alliance
• demonstrating accountability to alliance members, local people, stakeholders, and regulators
• ensuring continuous improvement and innovation in the quality and delivery of services
• ensuring the delivery of high quality, safe and caring services
• managing risk – finance, operational, quality and performance
• ensuring good financial management, financial governance and value for money

All three alliances have a dedicated committee with delegated decision-making for specific NHS services including primary care, community mental and physical health services, prescribing as well as children’s services and accountability for planning and delivery of a wider plan, as agreed by partners within each local alliance area.

They are supported by dedicated executive delivery groups, integrated quality groups and primary care groups. They may meet in common where it is appropriate to efficient and effective decision making and to share learning.

Each of our three alliances is developing its own local delivery plan for the end of June 2023. Each plan will demonstrate how the integrated care partnership strategy will be realised locally. The plans will be organised within the six agreed Live Well Domains aligned to the JFP.

Quote: “The alliance model gives us opportunities to improve health through partnership in so many ways. For example: improving prevention though exercise with our leisure services; taking a one public estate approach to our current and future buildings; communicating bringing together health and care providers and education networks to build the future workforce.”

Peter Wightman, Alliance Director, West Suffolk Alliance

6.2 Neighbourhoods

Neighbourhoods provide a focus for smaller, identifiable populations based on particular characteristics or needs, agreed within alliances. Without the need to meet the requirements of a fixed size or model, different areas can find different solutions for different problems. Alliances will play a key role in oversight and support of effective neighbourhood arrangements that deliver for local populations. These neighbourhoods might be based around GP catchment areas or local government ward boundaries, with local partners working together in networks, responding to the characteristics and needs of the local population.

Equally neighbourhoods may act in a three-dimensional way being defined by a school community or a virtual community, meeting needs through the use of social media. At neighbourhood level the role of district and borough councils and the voluntary and community sector are key.

Integrated Neighbourhood Teams and Care Closer to Home

The Integrated Neighbourhood Teams and Care Closer to Home teams bring together physical, mental health and social care practitioners that work with GPs and voluntary, community and social enterprise partners within a locality to provide a single coordinated care response for people, underpinned by prevention, selfcare, early intervention, reablement and rehabilitation (including people living in nursing and care homes).

There are four main objectives:

• Fewer people need unplanned care and support (reduction in crisis situations)
• Greater numbers of people have access to and are supported by activity outside of statutory services
• Resources in the delivery of community-based health and care support are used more efficiently
• The ongoing costs of supporting people are reduced as people’s independence is increased

In Suffolk, there is a focus on the Integrated Neighbourhood Teams identifying local issues that relate to their specific populations, and developing a joint plan as to how they, as a system, can begin to address these, with support of the respective alliance.

The Integrated Neighbourhood Teams work with wider partners in their locality, making sure that wider issues of health and wellbeing can be addressed. To support this work, named leaders have been identified for each area, with some functions picked up alliance wide where this makes sense, for example data analysis and training development. We now have the opportunity to closer align these teams with PCNs.

In north east Essex, work is underway to develop similar locality-based teams with an ambition to roll these out across the alliance during 2023/24.

Quote: “Our Integrated Neighbourhood Teams are leading the way in joining up care for patients in our communities; working across health and care and with community leaders to consider the most effective and efficient approaches to helping people to stay well at home. We will continue this journey with collective energy and clearly articulated delivery plans.”

Maddie Baker-Woods, Alliance Director, Ipswich and Suffolk East Alliance

6.3 General Practice (including Primary Care Networks)

Why is this important for people in Suffolk and north east Essex?

GP primary care remains the first point of contact for most people seeking health services in their local community; providing prevention services such as vaccinations and screening; urgent and emergency care; as well as complex long term condition management for people of all ages. GP primary care acts as a front door to secondary care and specialist services, when needed.

Professionals working in GP primary care respond to a broad range of physical and psychological needs; this means that GP primary health care is focused on caring for people holistically – delivering personalised care. Since primary care practitioners often care for people over extended periods of their lifetime; the relationship between a patient and general practice team is particularly important; with practitioners both acting as the patient’s advocate and co-ordinating their care.

Demand for health and social care services is rising – a quarter of the population experience long-term conditions, which may be related to age or circumstances associated with (or exacerbated by) stress, diet, activity levels, alcohol, smoking, air quality, poverty, isolation or poor housing. People with long-term conditions such as diabetes, COPD, arthritis and hypertension account for around 50% of all GP appointments. Whilst workloads for our health and care professionals are high and increasing; workforce recruitment and retention challenges have been deepening across primary care. Specific workforce challenges include:

• the number of primary care vacancies, specifically including GP, nursing and pharmacist roles with changing aspirations towards portfolio careers and working within more defined parameters
• imminent retirements with the loss of experienced staff
• the scale and nature of the estate required to meet current and forecast care needs and to enable education and training (crucial to recruitment and retention)

What do we know about people’s local experiences?

We know that access to GP primary care remains one of the highest priorities for our communities. Our local surveys tell us that most people make contact with GP primary care over the phone, although in some areas almost half make contact via a website or app. For those making contact via the telephone, the wait for a response can vary but we know that people would be willing to try more online options for making contact.

Based on the 2022 GP Patient Survey results, 97% of people said they were satisfied with the types of appointment offered. People have told us that they are being offered a range of appointment options, including telephone triage (e-consult) and same day appointments. 62% say they were satisfied with practice appointment times with options for enhanced or extended hours timings (before 8am or after 6.30pm on weekdays and/or at the weekend) and opportunities to see a range of healthcare professionals. The vast majority of people are offered a face to face appointment with someone at their practice. The survey results show that 79% of people had a good overall experience of their GP practice.

We know many praise the staff they meet as caring and kind but there are times when people’s experience falls below the standards. People can be frustrated by extended waits to access services. Many people recognise however that primary care is simply challenged by the level of demand being placed on it.

We have strong Patient Participation Groups (PPG) working alongside practices. Members of the PPGs are committed to supporting good quality care and better outcomes for patients; working with the practices to develop their approach. We have three PPG Networks in SNEE each supporting development and collaboration with their communities.

How do we plan to make a difference?

Our priorities are:

• to embark on an intense programme of work with primary care leaders to develop a clear forward strategy and action plan
• to facilitate delivery of the national contract changes for 2023-24, specifically as related to access, prevention and tackling inequalities and prepare for future contractual changes, as they become known
• to review Local Enhanced Services and the Suffolk Primary Medical Services to ensure they are effective in their outcomes and support vibrant and sustainable primary care
• to work with our Primary Care Networks (PCNs) and Integrated Neighbourhood Teams/Localities to further join up care for patients as close to home as possible
• to embed primary care workforce as an integral part of system thinking, planning and delivery
• to develop plans alongside local people and communities and review outcomes relating to their population

We are now embarking on an intense programme of work with primary care leaders to develop a clear forward strategy and action plan.

The purpose is to enable sustainable GP primary care, which responds to patients’ needs and supports the workforce’s confidence, capacity and career aspirations. The plan will include the following actions which will be delivered within 2023/24:

• Model demand and capacity for GP primary care services to ensure same-day, urgent care and continuity of planned care models are supported
• Include approaches to managing integrated urgent care and same-day care for patients – considering models within groups of practices or PCNs to manage demand effectively and safely
• Ensure continued Enhanced Access provision for all patients, maximising capacity and utilisation
• Support access to practices and clinicians in appropriate and timely ways, via a variety of methods including digital pathways and enhanced telephony
• Further review pathways to community and secondary services in the most streamlined way
• Ensure integration with 111/Early Intervention Team/Ambulance Service responses

We will further review Local Enhanced Services and the Suffolk Primary Medical Services to ensure they are effective in their outcomes and support vibrant and sustainable primary care.

We will do this in the context of our forward strategy and plan and national contract developments during 2023/24. We will give clear consideration to the opportunities for collaboration with other primary care providers and for the role of primary care within the whole health and care system.

We will work with our PCNs and integrated neighbourhood teams/localities to further join up care for patients as close to home as possible.

This will involve:

• exploring further co-location opportunities and mapping these with the PCN estates strategies to be completed by September 2023
• creating and actively using Place Based Needs Assessment and/or population health data sets for each locality/neighbourhood by October 2023 to enable improved local responses to needs
• devolving further local decision-making including resource allocation. These levels will be determined by the alliance committees and will vary depending on maturity levels of individual neighbourhood teams/localities by 2026
• mapping the opportunity and outcomes of the Primary Care Network Directed Enhanced Services and impact and investment funds with INT outcomes to ensure alignment by September 2023
• extending joint or hosted roles and training across INTs and PCNs to enable further integration where opportunities arise
• ensuring a local INT/PCN voice in place/alliance decision making, building better relationships with PCNs and INTs via executive delivery groups and Alliance Committees; adapting terms of reference to make this possible
• ensuring all PCNs have a health inequality lead who supports oversight and data, linking in with neighbourhood teams and partners to agree services linked to place based needs of the PCN’s local population
• mapping inequalities to existing service provision and reviewing resources to meet those needs on an ongoing basis

We will embed primary care workforce as an integral part of system thinking, planning and delivery. We will do this by:

• increasing capacity within the Training Hub to supply clinical supervision to more roles
• linking the Training Hub into the wider system workforce to align and ensure collaboration with all workforces and to ensure integrated planning by April 2024
• developing additional apprenticeship schemes to recruit into primary care from April 2024
• improving workforce data from primary care to provide up-to-date information that can be used for modelling and system planning
• continuing to mature the mental health community model; increasing practitioners in place by September 2023
• embedding the Health Education East Star methodology into transformation plans

We commit to work alongside local people and communities to develop plans and review outcomes.

This will enable a more holistic plan that supports outcomes matched to population needs, using real experience and people’s stories. This will be demonstrated by regular feedback from the engagement teams and PPG networks during 2024-2026.

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

Access

• By April 2024, all GP practices will have the digital capabilities in place to offer appointments
• Access to practices, measured by the GP Patient survey for the requirement ‘ease of getting through on the phone’ will be reported at above the England average for all practices by 2025
• No patient will experience a wait of more than two weeks for a routine appointment by April 2024
• 100% of all Enhanced Access slots will be provided and utilised by 31st March 2024
• Cloud based telephony will be in place in every practice by 2024/25

Prevention and health inequalities

• Prevention programmes effectively embedded into system working, ensuring appropriate presentations in primary care by 2026
• Progress will be made each year to improve prevention performance at practice level for Core20PLUS5 populations – a national NHS England approach to support the reduction of health inequalities at both national and system level – to include:
  • Long term condition identification and management (e.g. Hypertension)
  • Practice managed screening and immunisations

Quality assurance, workforce and resilience

• All practices will be rated as at least ‘Good’ by the CQC by 2025
• There will be no practice list closures by April 2024
• Practices will be more sustainable (evidenced by improved recruitment and retention rates and the primary care assurance framework)

Quote: Our aim as an ICB is to provide the commissioning environment to enable GP teams to adapt and thrive at the centre of our health care systems and communities, and thereby ensure Suffolk and North East Essex primary care is an attractive place for professionals to work and patients to register.

Dr Nick Rayner and Dr Freda Bhatti, Primary Care Partners, SNEE ICB

Case Study: Examples of PCN progress

Additional Roles Reimbursement Scheme is being utilised by all PCNs, bringing additional roles into primary care, allowing for more multi disciplinary team approaches to care, with a focus on personalisation and care planning.

All care homes have been aligned to specific PCNs providing a consistent approach and access to primary care teams – supporting education, personalised care planning and additional support.

A new enhanced access service is being provided by PCNs allowing patients to be able to access appointments every weekday evening from 6.30pm to 8pm and every Saturday 9am to 5pm – this is supporting increased access to appointments. Mental health roles are now within GP practices providing greater access to mental health support.

6.4 Collaboratives

6.4.1 ESNEFT and WSFT Collaboration

The two integrated community and acute trusts, WSFT and ESNEFT, are increasingly working together in order to provide the best care to the population of SNEE. This means bringing together the best of what each organisation can offer and collaborating where it makes sense to do so. This includes addressing health inequalities across the ICS and improving access to services.

Both during and following the COVID-19 pandemic, WSFT and ESNEFT successfully supported each other with elective care services including Orthopaedics, Urology, Ophthalmology, Ear, Nose and Throat (ENT) and Gynaecology. A joint elective care committee has been established, with co-chairs, and there has also been joint working in relation to procurement. The two trusts have agreed to establish joint governance for their collaborative work, and have set out shared principles for collaborative work:

1. We will work together to deliver the best quality and access to care
2. We will challenge and hold each other to account for the delivery of our vision
3. We will make shared decisions where this supports positive transformation, improves sustainability of services for our communities and reduces variation in quality. We recognise and respect our separate duties and accountabilities, acknowledging that we will need to act separately in other matters
4. We will support and empower our staff to work together, for the benefit our people and communities, through standardising care and reducing variation in quality
5. We recognise the importance of clinical leadership and governance in all our work, and the vital role of operational leadership in delivering high-quality, sustainable services
6. We will actively involve our staff, people, partner organisations and communities in our work
7. We will take shared responsibility for delivering agreed priorities and managing risks

The boards of the two trusts have been meeting regularly in “Board to Board” sessions to explore further opportunities for collaboration and agree the joint governance. The trusts have identified areas for future collaboration:

• Digital – working together on the implementation of an Electronic Patient Record (EPR) for ESNEFT. The aim is to enable standardisation of treatment, reduction of variation and integration of care
• Workforce development – including equality, diversity and inclusion as a priority for our people, staff and communities to ensure everyone is welcome and included and receives equity of treatment
• Virtual wards – building on the excellent work already underway in this development to provide care which would usually take place in an acute hospital, in people’s homes. Already an ICS-wide project, the integrated trusts are able to maximise the integration of community and acute services to embed virtual wards
• Elective care – moving beyond mutual aid between the trusts, there are opportunities to work together to improve services in a range of specialities to deliver high-volume, low complexity care and more specialised services
• Diagnostics – both trusts are part of the East Coast Pathology Network and the East 1 Imaging Network, which work over a larger geographical footprint to collaborate in procurement, quality and workforce planning. The two trusts are also working together to plan the Community Diagnostic Centre (CDC) at Newmarket, learning from the successful implementation of a CDC at Clacton
• Additional corporate services, including
  • Estates and Facilities
  • Procurement
  • Information governance
  • Organisational policies and procedures

Quote: Collaboration between West Suffolk NHS Foundation Trust (WSFT) and East Suffolk and North Essex NHS Foundation Trust (ESNEFT) has already delivered a number of benefits to patients as we recover from the pandemic. There are exciting opportunities for us to continue to work together so that all of our population receives the highest quality of care possible.

Ewen Cameron, Chief Executive WSFT and Nick Hulme, Chief Executive ESNEFT

6.4.2 Suffolk Mental Health Collaborative

Our comprehensive 10-year strategy for Mental Health and Emotional Wellbeing in Suffolk (#averydifferentconversation) was launched in 2019.

Built on the views of service users, the public, staff and stakeholders, our strategy sets out an ambitious programme of change to transform mental health support in Suffolk.

To accelerate the implementation of our strategy, we are now establishing a new Suffolk Mental Health Collaborative as a sub committee of the ICB. Our collaborative will bring together all the main partners from across Suffolk who have a role in funding, planning, delivering and receiving mental health services. This encompasses:

• Service users and the public representation
• VCSE
• SNEE ICB
• Suffolk County Council
• NSFT
• ESNEFT
• WSFT
• Suffolk GP Federation

As a result, there will for the first time be a single leadership forum in Suffolk that is focused entirely on mental health that has delegated authority to take decisions on how the available funding is used, how services are configured and who is best placed to deliver them. The Board will also have oversight of quality, operational and financial performance. We will mobilise the Collaborative from April 2023.

Quote: The 2019 Suffolk Mental Health and Emotional Wellbeing Strategy sets out a bold vision for a very different experience for our communities in Suffolk, a commitment, together, to transform mental health and emotional wellbeing. Building on strong foundations of partnership working, the establishment of our Suffolk Mental Health Collaborative I believe offers a genuine opportunity to create innovative models of integrated care, centred on evidence base and lived experience, putting the needs of our communities, service users and carers at the heart of what we do. Together, through collaboratives, we will improve the health outcomes of those children, adults and older people in Suffolk with mental health needs and the communities of which they are part. We believe there is hope for a brighter future, where collaboration to improve wider determinants of health, tackle inequalities, and intervene early when people experience ill health will best address population need, promote parity of esteem and transform lives.

Stuart Richardson, Chief Executive, Norfolk and Suffolk NHS Foundation Trust

6.4.3 Southend, Essex and Thurrock Mental Health Collaboration

We are working with partners across Southend, Essex and Thurrock (SET) to develop a refreshed five year all age mental health and emotional wellbeing strategy, informed by the views of service users, staff and stakeholders by the end of June 2023. The strategy lays out a programme of consolidation and change to continue the transformation of mental health support in SET.

To oversee and support implementation of the refreshed strategy, we are exploring development of a new SET All Age Mental Health System Implementation Group. This will bring together all the main partners from across SET who have a role in funding, planning, delivering and receiving mental health services. This encompasses:

• Service users and the public representation
• VCSE
• SNEE ICB
• Mid and South Essex ICB
• Hertfordshire and West Essex ICB
• Southend City Council
• Thurrock Council
• Essex County Council
• Essex Partnership University Trust (EPUT)
• North East London Foundation Trust [NELFT]
• Essex Police

The System Implementation Group will focus on coordinating and overseeing the existing work of pan SET groups and identify key priorities for joint work. Decision-making and overall governance will remain with the statutory organisations and three relevant health and wellbeing boards.

The implementation group involves a broad range of partners and will focus on promoting wellbeing and supporting people of all ages with mental health problems. The Group will also review the needs, models and outcomes across each place and locality in SET to identify and drive action around health inequalities, and to support collective learning.

Quote: “I’m proud of the work that has gone into The Southend, Essex and Thurrock All Age Mental Health Strategy. This is an important opportunity for us to raise the standard of care for local communities as well as taking steps towards tackling inequality of access, provision and outcome. We will only succeed in doing this if we act together across the sector, working with our partners – and this is at the core of this strategy. As the main provider of community and inpatient mental health services, as well as some physical health services, Essex Partnership University NHS Foundation Trust (EPUT) is in a unique position to deliver key improvements across this large and diverse area. We’re committed to consolidating our psychologically informed approach to delivery of care, partnering with those who use our services, as well as their carers and families, so that together we can shape the future of our services. We’re also working to create a culture where our staff and patients are encouraged to provide constructive feedback so we can learn and continuously improve. We will continue to collaborate creatively with our system partners to ensure that care is focussed on the needs of our communities to enable maximum support at an early stage, reduce the risk of mental health crisis and help people home in a timely and safe manner. I am optimistic for the future of mental health services in Southend, Essex and Thurrock with sustained improvement in the care we offer to the communities that rely on us.”

Paul Scott, Chief Executive EPUT

6.5 Specialised Commissioning

Specialised services support people with a range of rare and complex conditions. They often involve treatments provided to people with rare cancers, genetic disorders or complex medical or surgical conditions. They deliver cutting-edge care and are a catalyst for innovation, supporting pioneering clinical practice in the NHS.

Although ICBs have assumed responsibility for commissioning most NHS services, responsibility for some, often low-volume, high-cost, services and drugs currently remains with NHS England (NHSE). NHSE has stated that specialised commissioning functions and budgets for some specialised services will be delegated from NHSE to ICBs from April 2024.

SNEE ICB is part of a regional working group, together making progress on the arrangements for transition of responsibility from the East of England (EoE) Direct Commissioning Programme Board and the EoE Joint Commissioning Committee for Specialised Commissioning and Health and Justice to ICBs. In 2023/24, the intention is to have a ‘shadow’ year, where NHSE will set up a statutory Joint Commissioning Committee (JCC) for specialised services, which will require ICB leadership, engagement and representation in the committee.

Through 2023/24, the statutory JCC will manage either the full or more likely a nationally agreed portfolio of specialised services before transfer expected in April 2024.

6.6 Population Health Management (PHM)

We already have access to many sources of data and intelligence that tell us about the health, care and wider needs of our population. The Joint Strategic Needs Assessments (JSNAs) for Suffolk and Essex bring these published data sources together to highlight key health and care strengths, needs, and risks for our local populations, as detailed in Appendix 1 of the JFP.

However, the data used in JSNAs are mostly held separately by individual services and their commissioners. This limits the information that can be provided and the questions that can be answered. Showing the entirety of an individual’s care allows a better understanding of which factors have the largest influence on health and care outcomes within the local population. This is where PHM comes in to play.

PHM is about using linked data to provide new insight, and then taking linked action to improve the social, physical and mental health outcomes and wellbeing of people within and across a defined population, while reducing health inequalities.

PHM will mean that:

• health and care services are more proactive in helping people to manage their health and wellbeing
• more personalised care is provided when it is needed
• local services work together to offer a wider range of support closer to people’s homes
• solutions which may already be available become easier to access, improving outcomes, reducing duplication and using our resources more effectively
• care and support is designed and delivered to meet individual needs, ensuring the right care is given at the right time by the right person
• greater and more holistic understanding of the health and care needs of the local population enables commissioners to commission accordingly and ensure health and care providers work together to achieve maximum benefits

Our focus will be to understand the health and care needs in our population, and use key enablers such as workforce, IT, appropriate estate and PHM to build and deliver health and care services to meet those needs and deliver benefits that we know improve health and care outcomes, including:

• people having access to the information, tools and support to stay well and prevent ill-health
• people benefitting from earlier diagnosis
• people with long-term conditions being better supported to manage their condition well and prevent complications
• people with complex co-morbidities benefitting from tailored individual support that meets their unique needs
• reducing demand for reactive care services so we can use those resources to provide better proactive care for more people
• people identified as being at the end of life receiving coordinated personalised care
• power to evaluate complex interventions across organisational boundaries
• critical gaps in data, or areas where data quality is poor, being identified and addressed, improving the usefulness of that data
• helping to design effective interventions, which need to be multi-factorial, are not within the control of any one partner in the ICS, and which may need to be much wider, more creative, and more localised than traditional commissioned interventions or pathways
• tracking the progress made through these interventions against the key priorities for the ICS

Our PHM Strategy has been developed over the past three years and has now been approved by both our ICB and ICP Boards in late 2022³⁷. We have procured a dataset to cover the whole of our SNEE ICS population by April 2023 and are currently creating a dedicated PHM team. Our next step is to develop our 2023/4 delivery plan which will be in place by June 2023.

Quote: Population Health Management offers new and powerful approaches to improving health and care outcomes, and to reducing inequalities. We are looking forward to the insights that our new PHM data will bring, and on working with teams across the SNEE ICS to design, develop and implement new interventions in response to these new insights which will improve outcomes.

Laura Taylor-Green, Alliance Director, North East Essex Alliance

6.7 Medium Term Financial Plan

As spenders of public money, we have a duty to taxpayers and the Treasury to use the funding available as efficiently and effectively as possible, maximising the improvement in health and care which can be gained from each pound spent. Public sector organisations, including the NHS, have a statutory duty to break-even and are held to account for failure to deliver that target.

The system now has statutory financial duties both applicable to individual organisations and collectively through the delivery of system financial balance for those organisations within the system control total; NHS SNEE ICB, ESNEFT, WSFT and East of England Ambulance Service NHS Trust.

The key statutory duties are:

• to at least break even individually and collectively
• ensure both capital and revenue resources do not exceed the limit set by NHSE

In addition, SNEE ICB is required to:

• achieve the Mental Health Investment Standard which requires the investment in mental health services to increase at a higher percentage than the overall rise in allocation from NHSE each year
• ensure expenditure on running costs does not exceed the limit set by NHSE

In addition, as part of the move from the Covid-19 financial regime NHSE requires all organisations to:

• improve recurrent efficiency
• fully engage in national savings initiatives
• reinstate pre pandemic financial controls
• improve compliance against national standards for improving financial sustainability

We have agreed the following principles that will underpin our approach to achieving system efficiency:

• We will focus on management of financial risk through the four lenses of efficiency improvement – cost reduction, cost avoidance, income generation and service productivity improvements
• We will develop a medium-term financial plan for the system which is underpinned by realistic and deliverable plans at an organisational level as well as cross-system transformation
• We will develop plans to include a balance of system transformation and transactional opportunities, supporting existing programmes of work rather than starting new. We will partner and work with stakeholders to reduce overall system cost, enhance productivity, strengthen partner integration and improve experience and population health outcomes
• Short term measures that result in long term pressure will not be pursued
• To further strengthen system governance and support development of a financially astute culture, the system will adopt a recognised approach to forecasting and evaluating Return on Investment
• We will avoid shifting activity and costs from one area of the system to another – instead identifying and supporting a range of different options to achieve savings
• We will seek to avoid making the mistake of spending new money in ‘old ways’ – we will instead explore ways to use money differently in the future
• We will listen to the ideas of frontline staff, test out their ideas and scale up what works
• We will help frontline staff to better understand how their work impacts budgets and resources
• We will use technology to operate more efficiently and effectively
• We will use buildings more effectively, sharing spaces and resources
• We will take a regional approach where appropriate, achieving alignment and consistency across borders

Our focus is on opportunities to:

• reduce cost
• avoid cost
• improve productivity
• increase system funding

Quote: “Delivery of our objectives as set out in the Joint Forward Plan goes hand in hand with a system wide focus on improving our cost efficiency, productivity, and therefore in ensuring we can demonstrate value for money in all that we do. At its heart this is about delivering a sustainable NHS for the population of Suffolk and north east Essex.”

Howard Martin, Director of Finance, SNEE ICB

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6.8 Quality and Safety

6.8.1 Current Picture

The ICB must be able to prove to people in SNEE that services are safe and of high quality, and that all the different organisations that provide health services have systems in place to check the quality and safety of care provided.

The ICB has agreed how it wants to achieve this and has described this in the “SNEE ICS Quality Improvement Strategy”. As well, this JFP provides more detail on how it will happen in real life.

We will improve the quality and safety of health services for people in SNEE and create a health service that people and staff are proud of by:

• sharing and getting better at what we are good at (“Strength Based Approach”)
• working closely with the public and our communities (co-production)
• clearly describing how we will improve and monitor quality (our “Quality Management System”)
• working closely together to share responsibility for our work (“Collective Accountability”)

6.8.2 Why is this important for people in Suffolk and north east Essex?

The people providing health services in SNEE already perform an outstanding job every day. Due to a lack of available trained staff, financial strain, relentless pressure from infectious diseases, cancer, trauma and long-term conditions (like diabetes and high blood pressure), and a growing list of people waiting for operations and other non-urgent care, sometimes it can be difficult for our staff to provide the quality of service that they would like to. From time to time, despite rigorous safety checks, people come to harm, and sometimes that harm might have been avoided if we had worked in a different way.

It is because of this that all health and care teams need to check that the work they do is high quality and safe. The best way to do this is to create a “system” – a way of doing things that means that we can be alerted to problems as soon as (or even before) they happen, so that we can learn from our mistakes and stop them from happening again. Our quality management system is set out in figure six below.

Figure 6: Quality Management System

This figure is described directly below the image.

Quality Management System: text description

The Quality Management System is a structure model.

The overarching concept is that Quality Planning (understanding our priorities for improvement) is informed by three universal processes:

• Quality Control (maintain quality and know when it slips)
  • Embed mechanisms into teams/services so they can detect variation from agreed standards/desired quality
• Learning System
  • Measurement system that enables learning about what is and isn’t working (qualitative and quantitative)
  • Processes in place that support the appropriate use of evidence
  • Individuals and services working on similar challenges are enables to learn together (learning networks)
  • System for identifying the bright spots and assessing the generalizable learning
• Quality Improvement (deliver the improvement)
  • Ensure staff and teams have the skills to improve what is in their control and escalate those issues that aren’t (microsystem improvement)
  • Systems to support prototyping
  • Systems for spreading learning that enables adaptation for local context

All of the above are underpinned by Co-production and co-design, Relationships, Leadership culture and behaviour.

Quality Assurance take place and is informed by all of these functions and also feeds up to ensure Quality is central to Planning.

Measuring quality and safety

Using our quality dashboard, we will measure how safe we are and have picked things to measure that will help us to work out where problems might happen before they harm people. We will make this information available to everyone that is responsible for improving quality.

Developing how we work

We will take advice and continue to pay attention to how we are with each other, to improve our working relationships, so that we can make the biggest difference to the health of the people that we look after. How we work with each other is closely linked to safe treatment and care (safety culture), and we will invest in our colleagues to make sure that they can be honest, talk about and learn from their mistakes, without being frightened about discussing
when things go wrong.

Figure 7: Quality Assurance Maturity Framework

Quality Assurance Maturity Framework: text description

The Quality Assurance Maturity Framework is a step wise maturity framework designed to illustrate four levels of maturity. Each level has an overarching category and additional narrative to provide more detail as to what this means. The level increases from 1-4 in order of increasing maturity.

• Level 1 is Clarify governance – This is the first step on transformation with opportunity to test new ways of working.
• Level 2 is Improve governance – This is the next step on transformation and opportunity to test new ways of working.
• Level 3 is Quality assurance integration – This level of maturity is based on trust and transparency, improving working relationships, reduces burden on providers, focus on improvement.
• Level 4 is Quality Assurance Excellence – This is the final step and based on Radical change ideas, Improve QA expertise across the system, Combination of teams.

Treating people fairly

Not everyone in SNEE has access to the treatment and care they need, and not everyone’s treatment is as effective as it might be, i.e. health inequalities exist. We will make sure that we look for inequality in all of our work, whether that is caused by poverty, ethnicity, sex, religion, or address, and will work hard to reduce inequality.

Listening to the right people

People and communities know what good quality health and care looks like and can describe what’s important to them. We want to improve the right things. Through a regular meeting (People and Communities Quality and Safety Forum) we will share what we know about the quality of care we are providing and listen to people when they tell us what is important to them.

Working on the right things

At the start of every year, we will agree what our priorities are going to be, based on what is important to people and communities, and then focus on improving them.

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

Evidence that we are working more closely and better together

• By the end of 2023 we will produce documents that describe how our committees work together that are understood and accepted by all members (terms of reference, agendas, agenda planning meetings)
• By 2025 we will conduct joint visits to assess quality in local hospitals and clinics (peer review schedule) and reports will be brought to Quality Committee
• We will also be working with other counties to improve quality and safety in the same way (Inter-ICB Service Level Agreements)
• We will be running educational events to teach people how to create better quality and safety together (System Quality Assurance Masterclass)
• By 2028 we will have people working to improve quality and safety in more than one hospital/clinic (joint appointments)

Evidence of reduced harm to people

Using a clinical quality dashboard to review our performance, by 2028 we will:

• reduce the rate of haemorrhage after childbirth (post-partum haemorrhage, PPH) to the national target of 3.3% for a vaginal birth and 4.5% for a caesarean birth
• reduce all categories of infections (hospital and community attributable infections, HCAIs) and hospital-associated outbreaks. Detail on how much we will improve varies from infection to infection, and is described in our infection control strategy

Those who inspect our services will agree that they are safe

• We will work together to support our hospitals, GP practices, optometrists, community pharmacies and dental surgeries to improve their safety
• By 2028 the CQC will have given a minimum of a Good rating for Safety in all of our hospitals
• By 2028 the CQC will have given a Good rating for Safety in 85% of our primary care services, and we will have firm joint plans for improvement where there are concerns about safety
• At our next inspection (expected in 2023) the CQC will give SNEE ICS a minimum of a Good rating for Safety

Our leaders will know that our health services are high quality and safe

We will give our health and care leaders the right information about quality and safety of healthcare, and they will be confident that they have access to the right information at the right time. We will start taking stories from people to our ICB and use these in our internal papers immediately (from 2023). We will assess this by commissioning a peer review of our ICB’s Quality Assurance maturity in 2024.

We will develop a healthy safety culture

By 2026 our staff will be able to talk about and report quality and safety concerns freely without fear of being criticised – 65% of staff will feel safe to speak up about anything that concerns them in their organisation, as measured by the NHS Staff Survey. By 2028 this number will be 70%.

Our people will tell us

By 2023 with our people and communities we will have co-designed a meaningful measure of quality and safety and an improvement target for the subsequent five years. We are doing it this way so that we can make sure that we are measuring something that our people and communities want us to measure.

Quote: “Being involved in the Quality Committee allows us to ensure patient voice and lived experience are central to the decisions made. The ability to directly share experiences to the committee and providing the role of critical friend ensures scrutiny and integration. The opportunity to keep focus on the citizen throughout clinically led decisions enables safe, well led, compassionate care to be prioritised.”

Sam Glover, Chief Executive Healthwatch Essex

6.8.5 Case Study

EPUT Psychological Therapies Team has been using three new initiatives to support young people in their care.

They have set up groups for young people to learn specific skills to manage their emotions, distress, and relationships more effectively.

Individual positive behavioural support plans help best support young people when they are distressed. These are put together by the young person, their parents and carers, and our staff.

The team are also working with young people to identify alternatives to prescribing medicine to manage their emotional distress, such as weighted animal and fidget toys.

6.9 Clinical and Professional Leadership

‘Health Equality for Everyone’ requires that our health and care professional leaders work together as partners to achieve services which meet the distinct needs of our people in localities and place and that our innovations and improvements encompass the expertise of our health and care professionals who represent:

• all sectors of health and care, including social care, voluntary and charitable organisations, integrated neighbourhood teams, mental health services, primary, secondary, and tertiary care
• a broad range of health and care professions, social workers, GPs, community pharmacists, acute consultants, nurses, and physician associates for example
• a vibrant and diverse community with varied ethnicity, age, gender, sexuality and disability with an ability to represent all
• the broad geography and the distinctions this encompasses including urban areas, rural areas, and seaside towns

Our ICS draws on the wide range of expertise, knowledge, and experience of our health and care professional leaders to shape better prevention and outcomes for our people and inform innovations and future plans. Our leadership team aim to work together with one collective voice and a culture of shared learning.

Leadership in Practice

End of Life care will impact most people in SNEE including those approaching the end of their lives, those that care for them and those who are bereaved. Working together with the community they serve, health and care professional leaders aim to deliver personalised and coordinated care centred around what is important to each person. Within each service,
they address each priority, focussing on equality of access across all parts of our community. This ensures that care is personalised and equitable regardless of age, ethnicity, diagnosis, gender, mental health condition or level of deprivation.

Work is on-going with carer support networks, hospices, GPs, social care, hospitals, voluntary sector, community teams and health and care professionals across sectors and areas, making collective decisions to improve support for carers and those who are approaching end of life. An approach of co-production like this with the needs and considerations of the local population at its heart, means better quality of care and outcomes for our people as well as best use of available funding and resource.

Our health and care professional leaders in turn require support with leadership skills and their own health and wellbeing. The ICS currently offers the high impact One Team leadership development programmes for clinicians, managers, nurses, social workers and allied health professionals.

These programmes are expressly designed to build a network of effective leaders who can together address the key challenges in the wider health and social care system. The programmes focus on skills but also on mindsets. They enhance mutual respect, highlight how our clinical skills complement each other and show how transferable those skills are to
managing change in the teamwork environment, as well as in people’s lives.

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“One of the greatest compliments given to the programmes was that participants felt that when they walked in the room with their colleagues there was not a sense of who they worked for organisationally, but that they were working together as one to improve their own working lives, that of their teams and that of their patients.”

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6.9.1 How we Plan to Develop the Health and Care Professional Leadership Program

In February 2023 we held a Health and Care Professional Leadership workshop with invited attendance across SNEE from all sectors. We asked questions and collected outcome themes.

Two of the questions discussed and key themes included

1. What does a high achieving leadership culture look like?

• There is visible collaboration
• Leadership is earned through modelling positive behaviour
• There is a culture of psychological safety
• There is a shared commitment to do right by people
• Opportunities for leadership training and progression are offered and invested in
• A variety of voices are heard equally
• There is a more collective model of leadership
• There is diversity in leadership
• Staff are supported
• There is transparency and communication

2. What needs to be in place to ensure that health and care professional leaders are included and listened to, so that the right decisions are made?

• A dedication to building an inclusive culture
• Psychological safety to speak up and to support others to speak up
• Staff being motivated to contribute their views
• People can work flexibly to enable collaboration across boundaries
• Investment of funds, space to talk and time to listen
• Mechanisms to ensure that the right people are included in the decision making
• Forums and communication mechanisms for people to be heard
• Space for new joiners to share ideas and different perspectives
• Hierarchy is flattened
• Critical thinking about how programmes of change are best delivered

Further events will focus on how we take these outcomes forward into actions and deliverables.

Quote: “Integrated care requires that professional leadership, both for health and social care has leaders that can understand both aspects to be well informed and understand the needs of our population. We need to ensure that all leaders understand what is happening at neighbourhood and place in both care and in health and that there is a golden thread of understanding, aspirations, and actions.”

Sarah Nasmyth-Miller, Assistant Director, Mental Health, Learning Disabilities & Autism & Access, Suffolk County Council

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6.10 Voluntary, Community and Social Enterprise

6.10.1 Context

Like our public sector, our VCSE organisations are driven to address need and provide opportunities to create the best lives for our population. The VCSE in Suffolk and north east Essex is largely made up of a diverse network of small and medium sized organisations.

Suffolk

• 2,943 registered charities are active, with an estimated 12,000-18,000 other small community groups and organisations too small to register
• Over 1,000 not for profit organisations registered with other bodies
• 88% have turnover of less than £100,000 and the majority of these will be volunteer only organisations

Colchester

• 186 active charities are registered in Colchester, plus other national and regional charities and faith and sports groups
• Of those registered, 52% have an annual income of under £25,000 and so are likely to be volunteer led
• Another 73 have an income of under £500,000

Tendring

• Estimated 900 voluntary groups with 20,000 volunteers including trustees
• There are almost no large charities based in Tendring or Colchester
• Most Tendring VCSE groups’ income is below £50,000

Suffolk and Essex Community Foundations are independent charities, part of the UK Community Foundation network of 46 Foundations across the UK. Together, the network members are the fastest growing charitable foundations in the country.

The Community Foundation model aligns and channels funding from public sector, other trusts and foundations and local philanthropy, to provide grant funding to support local charitable and community groups.

6.10.2 Strategy

Our local VCSE infrastructure organisations see a range of opportunities to increase the impact of our sector and build on the commitment to the VCSE
sector being an equal partner within the ICS. These opportunities include:

• more effective engagement between VCSE and public services on key challenges and solutions to maximise reach into communities and manage demand together. This starts with a principle of how the VCSE sector can be a delivery partner not whether they should be
• embedding our VCSE Resilience Charter, including a more consistent approach to grant funding and commissioning by local and national funders, and an approach which: identifies and supports what is already working; makes best use of assets and partnerships; and focuses on tackling unmet need across SNEE
• committing to a greater proportion of funding being spent on the VCSE sector to support delivery of the priorities set out in the JFP
• supporting individuals to engage in wider and more varied volunteer and social action and providing parity to volunteers in our programmes of work
• developing more effective business/employer volunteering and social mobilisation to include time credits, local giving and other forms of engagement
• supporting VCSE organisations to improve their sustainability through effective financial planning, marketing, support for training and development and supporting 21st century fundraising and income generation opportunities
• developing digital solutions to provide efficiencies, resilience through new forms of income generation and smarter tracking of impact and outcomes

The ICB fully endorses these opportunities and is committed to turning them into a reality.

Quote: “We welcome the commitment to responding to lived experience and working differently that is so central to this Joint Forward Plan. The Suffolk and North East Essex system clearly understands that our local charities and community groups are a vital and equal part of our health and care services, so often reaching the most vulnerable in our community, and there for people, at the most difficult of times. These groups also understand and share the voice of those with lived experience, which can be harder for those delivering public sector services.

Delivering such joint working will be challenging but vital if we wish to avoid costly duplication and to increase impact.”

Andy Yacoub and Wendy Herber, CEO and Chair, Healthwatch Suffolk CIC

7. Enablers to Success

7.1 Working in partnership with people and communities

In July 2022 NHSE published new statutory guidance for how NHS bodies should support effective partnership working with people and communities³⁸. In response to the guidance, SNEE ICB developed a strategy³⁹ which outlines its principles and approaches for working with people and communities so that they are involved in priority setting and decision making.

The SNEE People and Communities Strategy recognises that outcomes are better when communities, partners, providers and commissioners work together to shape the delivery of our health and care. Understanding how people experience health and care support is a fundamental part of learning how to improve quality and safety. Engagement and co-production will underpin and guide all activity of the ICB, working at neighbourhood, place and system level to lead change.

Moving from understanding how people experience the care and support of single services or providers, to partners listening together to learn how they can provide better joined-up care – acting as a system – will enable us to develop a clear and concise vision for the future. We have developed strong relationships with existing networks and community assets. Working together, we identify collective priorities, common themes and opportunities and agree a system response which draws on the skills and experience within the partnership.

7.1.1 What are our principles?

The guidance sets out ten principles upon which our work with people and communities should be built. They provide ways of working, culture and best practice. We collaborated with people and communities in SNEE to identify what they would mean to us locally;

1. Ensure people and communities have an active role in decision-making and governance
2. Involve people and communities at every stage and feed back to them about how it has influenced activities and decisions
3. Understand your community’s needs, experiences, ideas and aspirations for health and care, using engagement to find out if change is working
4. Build relationships based on trust, especially with marginalised groups and those affected by inequalities
5. Work with Healthwatch and the VCSE as key partners
6. Provide clear and accessible public information
7. Use community-centred approaches that empower people and communities, making connections to what works already
8. Use co-production, insight and engagement methods so that people and communities can actively participate in health and care services
9. Tackle system priorities and service reconfiguration in partnership with people and communities
10. Learn from what works and build on the assets of all partners – networks, relationships, and activity in local places

7.1.2 How will we work with people and communities – what approaches will we take?

Involvement and collaboration with the public relies on developing strong relationships with local communities and individuals, building trust and respect. We are committed to a set of values which will underpin all our involvement and collaboration activity:

• Collaboration – working together and creating partnerships to understand people’s experience throughout all parts of the organisation
• Respect – building trusted relationships between people, organisations and communities based on inclusivity, mutual understanding and accessibility so that everyone feels they belong in the conversation
• Listening – taking every opportunity to hear people’s experience, paying attention and being curious about what local people say and acting on what we are told
• Equality – we will ensure that a diverse range of voices are heard and that people who are seldom heard are able to take part in every opportunity
• Transparent – we will be open and honest about our activity, be clear about parameters and decision making
• Meaningful – activity will be relevant and purposeful
• Influential – all activity will seek to have impact and lead to positive change, QI or better decision making

Developing strong and enduring relationships with our diverse people and communities relies on an equally diverse range of ways to collaborate and work with people. We will take an asset-based approach to community involvement. Investing in bespoke approaches in communities, creating a culture of transparent decision making and open discussions. Often this will mean taking a narrative-based approach to understanding experience, utilising storytelling, creative expression, or content analysis.

7.1.3 How will we support online involvement?

We already know that meetings, forums and face to face collaboration is not right for everyone. Many people want to collaborate with us at times and circumstances which suit them. Consequently, we have developed an online engagement platform to support engagement and collaboration with communities which can be found at www.letstalksnee.co.uk.

Each of our three place-based alliances have their own hubs on the platform, reflecting their own priorities and programmes of work. Details on strategic programmes which work across the ICB are also shared on the platform. This platform enables forum discussions, quick polls, sharing news and information, surveys and idea development. Where possible these pages will be codesigned with local people to maximise accessibility and engagement.

7.1.4 How will we work in partnership across Suffolk and north east Essex?

Good health relies on more than NHS services and the ICB cannot do this alone. Wider determinants of health – for example, poverty, discrimination, educational attainment, employment and housing have just as much influence on our health and wellbeing. By working collaboratively with our partners to understand the wider determinants of health, gathering a system wide view of equality and working with communities on joined up solutions we stand a better chance of improving the health outcomes of people in SNEE.

We are working with partners from across the wider ICS to jointly lead work with people and communities. These partners include local people, Healthwatch, the VCSE, acute and community trusts, foundation trusts, local government, public health and social care. Working together we have
committed to:

• identify collective priorities and common themes and identify opportunities for system responses
• identify areas of concern and issues being raised across different parts of the system (organisation, neighbourhood, Alliance) and bring these to the attention of the ICB Board
• respond to system priorities identified at the ICB Board with insight and voices of experience, drawing on the range of expertise and experience of the committee partnership
• look ahead at potential issues or areas of work and work together with people and communities to influence strategy and decision making
• understand collective feedback loops and system communications about engagement, making sure opportunities are transparent and open and outcomes shared widely

As the wider ICP develops, we will continue to review our approach and how we work in partnership with people and communities. In particular we will focus on the communities identified through the CORE20Plus5 (children, young people and adults) to make decisions collaboratively on how to address their specific health and care needs, agree ambitions and plans to improve health outcomes through commissioning and service delivery. Adopting the CORE20Plus5 approach we will work alongside the place-based Alliance partnerships to identify local communities experiencing significant health inequalities or worse outcomes and those who would benefit most from a tailored approach.

For example, the fishing community working out of our large ports, migrant agricultural workers working in our rural communities and transgender people. We will work with our strategic programmes to support specific clinical areas to ensure we have an inclusive and equitable approach to working with people and communities.

7.1.5 What are the governance arrangements?

The governance structure for involvement and co-production with people and communities ensures that insight and collaboration with people and communities happens at all levels across SNEE. We have worked with local people to design and develop the most effective governance route for people to come together, reflect on insight and experience, contribute to decision making and raise important issues. The work of the People and Communities Strategy is therefore required to report through quality governance processes at both system and alliance level.

People have identified that building on existing work in localities and neighbourhoods and working in partnership at neighbourhood level is the most effective and appropriate approach. This work will be brought together at place level to form part of the alliance delivery plans and local quality groups.

Finally, all place-based and system programme work will be heard in the ICB subcommittee to provide assurance and deliver oversight to the ICB. We will be working closely with alliance committees, the ICB Board and strategic partnerships to embed the people and communities narrative so that it is seen as an essential part of the infrastructure.

7.2 Workforce

Strengthening our health and care workforce is the key enabler to delivering the benefits to the people living in SNEE described in this plan. We will enable this to happen by following the four pillars of the NHS People Plan:

• Looking after our people – with quality health and wellbeing support for everyone
• Belonging in the NHS – with a particular focus on tackling the discrimination that some staff face
• New ways of working and delivering care – making effective use of the full range of our people’s skills and experience
• Growing for the future – how we recruit and keep our people, and welcome back colleagues who want to return

We recognise that many of our solutions will crosscut all four pillars. We have adopted an integrated approach to workforce, working closely with
performance and finance to make sure our workforce plans are realistic and meet the needs of our local population.

Our ambition for our population is to have an integrated workforce that delivers care at the right time, in the right way, in the right place, by the right person. We will adopt an integrated approach to workforce with system partners which will allow us to think differently and develop a collaborative workforce strategy, to achieve local ambitions and the aspirations set out in national policy. The triangulation of workforce, activity and finance, and the alignment with the digital and estates strategies are intrinsically linked to system integration.

Our plan needs to address our greatest challenges highlighted below:

• At this current time there are significant issues being faced to recruit, support, develop and retain our workforce
• Coming out of the pandemic staff survey responses and increasing turnover show that we have a workforce tired and burnt out from responding to Covid-19
• These feelings have been heightened by increasing inflation and rising cost of living. As such, staff are looking for opportunities with independent providers or alternative sectors and geographical locations, in particular administrative, IT and physiotherapy staff
• We have an ageing staff profile, particularly within key primary care services

7.2.1 Workforce Planning

Working closely with system partners in health we will have a numeric long-term view of the workforce which will be aligned to activity and finance. This will be shared with system partners so that we can align our workforce plans as the system identifies areas of need throughout the ICS, allowing us to produce operational solutions in a co-ordinated strategic collaboration. This will be triangulated with finance and activity. We seek to improve service delivery and inform action plans and strategic direction, by linking strategic (workforce), operational and financial planning with population need. In addition, we will:

• quantify workforce needed for both our supply lines and activity levels, that is financially costed for the next five years
• have a system approach to workforce planning
• have the right staff levels through the health and care system to meet demand without one area negatively impacting on the other
• have one integrated strategic plan for the system

7.2.2 How we plan to meet the needs of our changing workforce profile to in turn meet the needs of our local population

Growing for the future – how we recruit, retain and welcome back people who want to return.

The system has shown a 27% growth in the workforce over the course of the last six years. The latest national figures available showed vacancies within social care of 7.5% and in secondary care at 4.7%. Within this, there are particularly prevalent professions, including care workers, midwives, occupational therapists, physiotherapists and diagnostics staff.

The system is exceeding its target for growth relating to nurses, although this has predominantly been due to a reliance on international recruitment. This has created greater disparity between care and health following the UK’s departure from the EU.

Organisations primarily operate independently to recruit staff, but there is appetite to apply learning and best practice across the sector. The system’s Health and Care Academy and Talent Academy has provided support through advertising campaigns and career guidance to local communities and are managing the system’s work experience offer.

We have ambitious targets for transferral of staff from agency and bank to substantive roles. We have been successful in recruiting good numbers to the reservist model in our system.

Looking after our people – with quality health and wellbeing support for everyone

The system’s staff turnover rates are particularly concerning – within secondary care our 12-month rolling turnover rate is over 14% and within social care it is 31.4%. There are particular concerns relating to care support workers and allied health professionals.

The cost of living challenge is becoming the key area of concern for retaining our workforce. Currently organisations are adopting individual responses to this issue and sharing best practice. However, it is acknowledged that we will need more radical solutions, particularly with the additional financial incentives available within other sectors and geographic areas.

Over the next five years we want to:

1. improve our staff engagement and morale scores from the 2022 staff survey
2. reduce the 12-month rolling turnover rates
3. develop innovative action plans to ensure those most affected by increased inflation and cost of living are supported and improve access to affordable housing
4. ensure our staff can work safely and improve their working lives
5. deliver a compassionate working culture at all levels
6. ensure that all staff are able and know how to access appropriate wellbeing and psychological support

New ways of working and delivering care – making effective use of the full range of our people’s skills and experience

Over the next five years we want to:

1. work with the Integrated Care Academy to lead and support our new ways of working
2. enable collaboration and integration of the VCSE workforce and volunteer base
3. support system colleagues in exploring new models of delivering care
4. embed a culture of training and progressive development across the system and in all roles
5. develop and deliver a system-oriented career and leadership pathway
6. increase the use of apprenticeships
7. work with educational institutions to develop training and placement opportunities to address key skills gaps, identified by workforce planning

Belonging in the NHS – with a particular focus on tackling the discrimination that some staff face

During the pandemic we became more critically aware of the need for enhancing social justice, equality, diversity and inclusion. Our workforce is predominantly female (72% in secondary care), although these figures drop when looking at senior pay grades within secondary care. 20% of our workforce is from an ethnic background, with 28% of Band 5 staff from an ethnically diverse background, but with few signs of progression to more senior roles.

There are clear barriers to progression, as recognised by our Workforce Race Equality Standard (WRES) and staff survey results including more ethnically diverse staff being in performance management and higher levels of bullying and harassment. A range of additional information on our equality and diversity initiatives is hosted on the SNEE ICB website⁴⁰.

For our detailed approach please see section 5.3: Equality, Diversity and Inclusion in the Workforce.

Over the next five years we want to:

1. create an open culture, where the principles of EDI are embedded as the personal responsibility of every leader and member of staff
2. ensure staff have equity of opportunity across the system by developing understanding and reducing unconscious bias
3. improve representation of staff with protected characteristics in senior leadership positions across our system
4. reduce experiences of bullying and harassment across our system

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

• improved staff retention rates
• more providers’ CQC ratings as ‘Well Led’
• reduced vacancy rates across all staff, both clinical and non-clinical
• reduced sickness absence rates
• positive annual NHS Staff Survey feedback
• greater numbers of apprentices
• more young people recruited into health and care career pathways
• improved supply and quality of pre-qualifying student placements
• implementation and effectiveness of e-rostering system
• closing of the gender and race pay gaps in partner organisations
• increased diversity of employees with protected characteristics at all levels
• improved support to NHS Boards to review their WRES and Disability Equality Standard and develop relevant implementation plans across their workforce

Quote: “The future of the workforce in the NHS is a great responsibility. Although we have great challenges, we also have great opportunities. We are looking at the future health needs of the population and what new and old skills and technologies our workforce will need. By ensuring that we are creating and communicating relevant and sustainable career pathways we can attract the next generation of the NHS workforce. We will continue to strive to improve the working lives of our current NHS heroes, so that they feel truly valued
and can continue to give the care they are so rightly known for. We are a constantly evolving workforce but some things do not change and that is the skill, dedication, compassion and care of those that work in the NHS.”

Amanda Lyes, Director of Workforce and People, NHS SNEE ICB and Senior Responsible Officer for Sustainability

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7.3 Estates

Where services are located, the choice of services offered and the environment in which care is delivered can enhance or reduce people’s personal health and wellbeing. Creating an estate where more people can access services at the right time, in the right place and be seen by the right person therefore supports people to improve their lives. Our priorities include:

• providing ease of access to services that maintain health and wellbeing including acute, primary, community, mental health, VCSE and leisure as close to home as possible
• providing treatment in environments that ensure privacy and dignity are protected
• taking views into account when an estates scheme is being developed
• being confident that as our population increases over time, our estate can meet the population needs
• ensuring that our buildings are safe, efficient and well-maintained
• enabling appointments with health and care professionals in a timely manner using a method of their choice

We are adopting an integrated approach to estate development, use and planning, working closely with workforce, finance, sustainability and digital teams to ensure our estate plans and solutions meet the needs of the growing local population. Adopting this approach allows us to think differently and creates a unified and collaboratively produced approach for the development of a system Estates Infrastructure Strategy (EIS).

7.3.1 Estates Objectives

Our ambition for our population is to have an integrated estate that allows the delivery of care at the right time, in the right way, in the right place, by the right person.

Our EIS will address our key challenges as highlighted below:

• Complex and fragmented estate management arrangements
• An ageing estate across the system which will require investment info mitigating the high levels of backlog maintenance over the coming years
• High levels of planned population growth across the system over the next 15-20 years, with clusters of significant growth in a few specific localities
• High demand across the system for limited amounts of capital investment
• Significant pressures on current and future revenue budgets to support ongoing and future estate development
• The desire to move services from the acute sites where these can/should be delivered within a community setting

7.3.2 Estate planning

The ICB Estates Committee has a strong membership and leadership and is directly accountable to the ICB. The Committee has access to and uses a wide range of data and information to understand the use, condition and planned development of the system estate.

Whilst areas of data collection have improved, particularly across primary care, the collective review, analysis and development of a system prioritised strategy is yet to be undertaken. Therefore, it has not been possible to develop a true system view of how, where and when to develop the estate. To do this requires a system, regional and national approach. The SNEE ICS EIS, once completed, will inform this discussion to construct a system wide ‘data bank’ and planning system to be used by all partners and overseen by the ICB.

Where we want to be:

• To develop effective and efficient estate management arrangements through increased coordination and collaboration between individual estate and facilities management teams and consolidated estate ownership within the ICS area
• Have a consistent but appropriate and proportionate methodology for collecting, reporting and presenting data relevant to the system estate, ensuring we have a fuller understanding of the entire system estate
• Work to develop a system EIS which will look to create a prioritised delivery pipeline of system estates development schemes as well as optimisation of existing premises and opportunities for disposals
• Demonstrate value for money in the design, construction and operational management of the system’s estate through collaborative working between system partners
• Optimise, through collaboration with One Public Estate, the utilisation of public buildings and infrastructure for the health care benefits of the population we serve
• Development of a collaborative, highly skilled Estates and Facilities workforce with all system partners able to access the right expertise in the right place through the potential establishment of integrated Estates and Facilities services
• Achieve the targets contained within the SNEE ICS Green Plan and the overall NHS net zero ambitions, as noted in Section 7.9
• Create an estate infrastructure to deliver transformational models of care, supported by system wide technological innovation and enhancements
• Have a ‘Single source of the Truth’ in Estates data and information for the entire ICS Estate to inform and enable accurate planning of the Healthcare Infrastructure System from this JFP

7.3.3 How we plan to make a difference

Development of Primary Care Estate Strategies

Historically, estate development with primary care has been considered at individual GP practice level. However, there will be a growing demand on primary care and wider community estates due to the growth and expansion of services which will be delivered through PCNs via the ARRS as well as the migration of services from acute hospital sites to the community. Therefore, estate planning must be collectively undertaken at PCN level taking account of GPs as well as community and wider public and VCSE sector estate opportunities. Services have been commissioned for the development of PCN estates strategies across each of the three alliances.

Development of a System Estates Infrastructure Strategy

Through the work of the ICB Estates Committee progress is being made on developing the first SNEE ICS EIS. The strategy will include the current costs, location and condition of the existing estate and consider the changes required to enable successful delivery of the JFP and SNEE ICS strategy. The document also includes extensive links into the ICS workforce and digital strategies recognising the importance of both in the delivery of a patient focussed, technology enabled environment.

The EIS will provide a comprehensive assessment of the current and entire estate across the ICS, along with a strategy of what the estate solution requirements will look like in the future (10years+) and how the ICS will develop that solution.

Over the next five years we want to:

• develop a single infrastructure strategy which prioritises and aligns infrastructure development projects across all system partners to the system and national priorities
• support system and organisational finance leads to develop finance plans and budget allocations which align to the delivery of system infrastructure priorities
• support the development and delivery of care closer to home and in locations most appropriate for service and people’s needs
• deliver the short, medium and long-term outputs from the EIS

Future Systems

WSFT sits within the New Hospital Programme as a cohort four scheme to deliver a replacement for the current West Suffolk Hospital Reinforced Aeriated Autoclaved Concrete (RAAC) building before 2030. With outline planning permission secured and the Outline Business Case being submitted in 2023, WSFT is on-target to achieve this goal. This will provide a fantastic new facility for the population of west Suffolk and work continues with stakeholders to deliver a successful project. Development through co-production is key to minimise risks.

The Future System Programme can support WSFT’s credentials as an anchor organisation and ensure the best economic benefit to the west Suffolk area; maximising positive impact and minimising negative impact in a sustainable way is a key driver to not only how we operate estates and facilities now but also for the future.

The next five years of the management of the estate and facilities services are focused on ensuring we keep an appropriately high level of compliance on the estate to be demolished ensuring safety and quality, but not to over-maintain this estate beyond its operational life. For WSFT, the ongoing investment to support the RAAC building through the failsafe programme will see c.£74m invested over a four year
period, this does not extend the life of the asset but supports the mitigation of risk whilst the building continues to be used.

Supporting the drive to bring care closer to home, the Estates and Facilities Strategy must work alongside Workforce Planning and Digital Strategies to ensure these are aligned. Supporting investments at Newmarket such as the Elective Surgery Unit (under development) and Community Diagnostic Hub (agreed) are part of that programme while ensuring there are appropriately trained and skilled staff to
safely provide that service.

Over the next five years we want to:

• ensure a successful new WSFT hospital estate is well underway
• work as a system to ensure the system’s infrastructure underpins new ways of working
• work alongside and ensure our strategies are aligned with other key enablers including workforce planning and digital
• align estate intelligence and planning to our activity, performance, and finance planning, to create a sustainable estate to meet health population needs

Developing Centres of Excellence

The new Dame Clare Marx Building at Colchester Hospital will provide a three-storey building on the southwest of the site using modular construction and will open in August 2024. It will include eight theatres, a 16-bed Post Anaesthesia Care Unit (PACU) Stage 1, three 24-bed inpatient wards (67% ensuite single rooms), a diagnostic imaging suite and associated facilities including receptions, waiting areas and outpatient rooms.

Key benefits of the new elective orthopaedic centre for patients and staff include:

• shorter waiting times for surgery and shorter stays in hospital
• minimal risk of cancellation of surgery in a pandemic resilient surgical facility
• better clinical outcomes from the standardisation of care
• improved patient and staff experience of the physical environment
• new opportunities for training, education, research, and innovation
• delivery of clinically and financially sustainable acute services
• support the transformation of health and social care across the ICS

One Public Estate

Within SNEE ICS we have a strong relationship with the three One Public Sector Estate Groups (one per alliance). Through these relationships the system has developed some key initiatives including the co-location of NHS and local authority services.

Over the next five years we want to continue to engage with and support key initiatives through the one public estate framework to promote and develop co-location and integration of key public, health and voluntary sector partners where possible.

Meeting the future demand from an increasing population

We continue to develop excellent relationships with the six local planning authorities across the ICS, enabling the development of a collaborative working arrangement. This will ensure that sufficiently detailed strategic infrastructure delivery plans are in place to
support the mitigation that the effects of housing growth will continue to have on the local health infrastructure.

The ICB has identified that it is important that developers’ contributions support the whole healthy economy and therefore the ICB Estates team continue to coordinate system wide responses to planning applications, local plans, infrastructure delivery plans and neighbourhood plans. This approach looks to ensure that people are not disadvantaged though population growth, whilst also ensuring the increased
population has adequate access to a fit for purpose health system.

Over the next five years we want to:

• work with the local authorities to understand, plan for and mitigate the proposed housing growth planned within each district, borough and City’s local plan to ensure health care provision is adequate for increased population
• work to secure adequate and appropriate mitigations from housing developments to support the development and expansion of health and wellbeing services to meet the growth in population
• consult with the local population on major changes to the estates infrastructure to ensure the future estate is patient focussed, increases social value to the population it serves and is flexible to adapt to new practices, technologies and increasing activity
• improve patient and staff experience by providing high quality, technologically enabled estate to enhance clinical service delivery and aid health outcomes

Ownership and management of properties

The ownership and management of the NHS estate can directly and indirectly impact on the delivery of services to the population and therefore needs to be managed in such a way that maximises the benefit to people’s care. Changes in the Department of Health and Social Care policy over the last few years have meant that NHS trusts can apply to transfer the ownership of assets from NHS Property Services to
themselves if it can be shown that there is benefit to care through management of the premises at a local level.

The Health and Social Care Act 2022 enables ICBs to hold estate, which has not been possible since the abolition of Primary Care Trusts in 2013. Whilst national policy and financial controls are yet to be developed to support ICBs in holding estate, this change presents the system with an opportunity to plan, develop and manage their estate for the benefit of the system and patient population at a local level.

Over the next five years we want to work as a system to ensure assets are owned by the most appropriate system partner to benefit the delivery of care.

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

• improved estate optimisation and greater integration with One Public Estates partners in the use of the public estate
• a rationalised and prioritised capital pipeline
• a single system delivery plan with organisations and partners working towards the same system objectives and priorities
• wider sharing of estate across the system for the benefit of service delivery
• reduced backlog maintenance
• improved efficiency and effectiveness of estates and facilities services through closer collaboration to support clinical delivery
• services located in the right place to meet the demands of the population
• disposal of redundant or non-viable estate
• improved staff recruitment and retention through improved estate
• demonstration of clear value for money for the public purse

Quote: “Our ambition is to have an integrated estate that allows the delivery of care at the right time, in the right way, in the right place, by the right person. This means an estate which is in a good condition, is functionally suitable, and is flexible, accessible, and affordable. Our Estate Infrastructure Strategy will respond to the needs of this Joint Forward Plan, not vice versa, by delivering an estate which is focussed around the needs of the population we serve.”

Paul Fenton, MBE, Chair of the SNEE ICB Estates Committee and ICB Strategic Estates Advisor

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7.4 Digital

Out of the 12 core functions of the ICB, two focus on digital:

• Leading system-wide action on data and digital: working with partners across the NHS and with local authorities to put in place smart digital and data foundations to connect health and care services to put people at the centre of their care
• Using joined-up data and digital capabilities to understand local priorities, track delivery of plans, monitor and address unwarranted variation and health inequalities and drive continuous improvement in performance and outcomes

It is therefore the responsibility of SNEE ICB to create and enable the levers that make this happen. A key ambition is to provide more joined up care that better enables information to flow across the system in a consistent and coherent manner. Ensuring that we join up data from multiple systems in real time will ensure that we can deliver safer, better quality care.

This will in turn lead to improved health outcomes and a more positive experience for people, staff and carers.

The SNEE ICS Digital, Data and Technology (DDaT) Strategy 2022-2025 and corresponding Strategic Delivery Plan are aligned to the ICS Strategy and Live Well Outcomes, The Design Framework and Suffolk and Essex Health and Wellbeing Strategies, What Good Looks Like and our ICS Core Values. The DDaT Strategy can be found in Appendix 12.

Priorities over the coming financial year and beyond for the ICB DDaT Project Management Office through this transition stage are to:

1. foster professional leadership throughout the ICS, and implement a Strategic Delivery Plan that aligns to the annual investment cycles to make best collective use of public money and assets
2. establish Smart Foundations for projects, procurements and services that free up time to care and implement systemwide delivery models, e.g. shared care records and personalised care planning
3. build our multi-disciplinary approach to safe practice, and communities of specialists to enable this across the ICS
4. enable support for our health and care community to ‘thrive in a virtual world’ by embracing a culture of continuous learning
5. develop a common digital front door for our people and actively improve channels that support our most vulnerable
6. enable an approach to digital care technologies and remote care to increase capacity that may empower our provider collaboratives
7. enable a linked data set platform that will provide data insights for a range of purposes
8. form and operationalise provider collaboratives, and support health and wellbeing alliances to adopt capabilities that enable integrated care

Figure 8 – SNEE ICB Digital Principles

Figure 8 text description

The above graphic shows the eight digital principles typed out below.

• Well Led (leadership and governance): How we lead, and how we work
• Smart Foundations (including ShCR): Getting the right basics right
• Safe Practice (assurance, cyber, information governance, safety and ethics): Safe practice in an innovative world
• Support People (digital workforce): Supporting our workforce in a digital era
• Empower Citizens (enabling digital channels): Digital channels and support that addresses inequalities
• Digital Care (enabling transformation): Digital care pathways, remote monitoring and virtual care enabling care closer to home
• Enabling Insights (healthy populations): Timely, data driven insight for care delivery and coordination, for planning purposes and for research
• Sustainable Change (shared capabilities and pooled resources): Simplification, convergence, consolidation and value

7.4.1 Delivering digital transformation

We are currently undertaking an appraisal and baselining exercise of options to make the best use of our existing collective resources and programmes/projects to mitigate duplication. The DDaT Project Management Office team will work with partners to develop our ICB digital approach by following eight key principles which stem from the success measures of the What Good Looks Like framework⁴¹. These serve as our overarching direction to align our priorities in the context of the wider DDaT landscape and such priorities will develop over time in both shape and pace of delivery.

Key principles and corresponding priorities of the strategy are noted below:

• Be Well Led – Goal: Lead and enable our strategy
  • Agree a strategy for digital transformation and collaboration that drives ‘levelling up’ across the ICS and is underpinned by a sustainable financial plan by July 2023 which will be responsive to our people’s health and care needs over the next 3-5 years
  • Develop the DDaT Strategic Delivery Plan and the resources to progress by September 2023
• Smart Foundations – Goal: Invest in core digital technologies and ‘levelling up’ whilst establishing convergence pathways
  • Support organisations to progress to minimum digital foundations, including digitising social care, electronic patient records (EPRs) and shared care records as part of the ongoing programme of investment scheduled for 2023/24 and 2024/25
  • Establish a data strategy that encompasses all the ICS partner organisations by Q3 2023/24
  • Develop and recognise digital skills embedding continuing professional development and recognising DDaT professions within our continued programme of work in 2023/24
  • Secure investment in EPR and diagnostics to stabilise and improve infrastructure for partners and providers in 2023/24
  • Enhance systemwide governance for Shared Care Records and Care Planning (Personalisation) starting in Q1 2023/24
• Safe Practice Goal: Maintain trust, transparency, security and resilience
  • Develop a specialised team to work across the system, bringing together considerations around Cyber and Standards, Information Governance and Policy, Clinical Safety and Data Management and Ethics in 2023/24
  • Support local communities of practice, enable programme progress across other principles and their delivery plans, and develop cross-organisational governance, policies and processes in 2023/24
• Support People – Digital Workforce Goal: Support our workforce to thrive in a digital world and develop our DDaT professionals
  • Baseline DDaT skills and knowledge across the system as well as the current available assets at national, regional, ICS, place and organisational levels which will follow the baselining of our resource options in Q2 2023/24
  • Develop our skills development network, with a focus on analytics, cyber and core capability skills during 2023 across the ICS and established links in the EoE and nationally
  • Develop a repeatable and sustainable approach to digital skills adoption for the frontline with a focus on digital care and integrated team working by 2025
  • Developing support models for hybrid working by 2025
• Empower People Goal: People at the centre of digitally enabled care, which ensures Equality and Equity
  • Develop a system-wide digital inclusion strategy and ICS Equality and Equity Toolkit across key digital services in 2023/24
  • Enable the use of NHS login with our key local digital services in 2023/24
  • Enable people with advance care needs for end of life to contribute to their co-produced record by December 2023
  • Begin to further test the process of people having access and contributing to their healthcare information and taking an active role in their health and wellbeing
• Digital Care Goal: Digitally enabled care closer to home that is clinically led, unified and resilient
  • Form a systemwide Digital Care Delivery Board by the end of Q1 2023/24 to coordinate digital options including remote care, virtual consultations, remote monitoring and virtual wards
  • Enhance our programme of work to enable virtual wards and ‘Hospital at Home’ models to develop further from the progress in 2022/23
  • Facilitate and enable clinically led, virtual wards and other digital care; aligning operating models to support staff in 2023
  • Establish a delivery plan to scale these capabilities throughout the system, whilst decommissioning those capabilities that become obsolete or remain siloed by June 2023
  • Baseline our digital decision support and establish our strategic plan by July 2023
• Enabling Insights Goal: Make best use of the information assets we hold
  • Develop a system-wide data strategy in 2023/24
  • Revisit the Data Management Maturity model with providers in 2023/24
  • Supporting the Intelligence Function in developing capacity and tools in 2023/24
• Sustainable change shared capabilities and resources Goal: Enable sustainable change
  • Form and operationalise provider collaboratives and support health and wellbeing alliances to adopt capabilities that enable integrated care in 2023/23
  • Start creating digital exemplar hubs in the community in 2023/23
  • Explore strategies to achieve a SNEE people portal in 2023/24

Quote: “Shared care records, where the whole of our personal medical history is available to each of the medical parties seeking to help us, should be a fundamental foundation in creating effective integration. Being asked for the same information several times is both wearing for the citizen and creates the potential for inconsistent understanding.”

Cllr John Spence, Co-Chair of the SNEE ICP and Chair of the Essex Health and Wellbeing Board

7.5 Intelligence

7.5.1 Background

Aligning with national guidance and to further progress our approach to PHM, SNEE ICS is developing an ICS Intelligence Function.

The vision for the Intelligence Function is to develop shared, cross-system intelligence and to use information to improve decision-making at every level. The Intelligence Function will be a shared analytical resource that will work on cross system priorities. It will use linked data to help design and deliver improvements to population health and wellbeing, making best use of collective resources, and will ensure that insights from data are used to improve outcomes and address health inequalities.

In particular, the Intelligence Function will undertake modelling to improve our understanding of future demand across the system over the longer term to inform strategic, workforce and financial planning.

7.5.2 Our Priorities

• We will develop a SNEE Intelligence Function to provide additional analytical skills and capacity and ensure intelligence from data informs strategic decision making
• We will develop the data infrastructure and supporting information governance processes to enable the Intelligence Function to operate effectively and lawfully
• We will ensure ICB committees are supported by high-quality Business Intelligence (BI) to ensure there is an up-to-date understanding of activity and performance
• We will co-develop our intelligence plans with partners, exploiting opportunities to work across boundaries to join up data and expand our insights into the drivers of health
• We will work to the highest standards in how we use, share, and store data, adhering strictly to appropriate information governance processes as well as security, ethical, and quality standards

7.5.3 Progress to date

Our Intelligence Function has been co-developed with partners across the ICB. It will address gaps in analytical capabilities, ensuring the ICS is well served by a sophisticated and high performing analytical function. We are diversifying and broadening our intelligence capabilities, by investing in skills such as health economics, impact evaluation, and data science. This will enable us to maximise the utility and value of our data and ensure that intelligence from data informs decisions on prioritisation, change, and operational planning.

We have developed a modern cloud-based integrated data and analytics platform to give our analysts the opportunity for shared access to linked data with modern analytical tools.

From this data, we are developing a PHM intelligence platform that provides system-wide insights on our population’s health, from person to system. This gives clinicians and operational managers across the ICS access to intelligence on population health, including at-risk cohorts and trends in long-term conditions, enabling the identification of appropriate proactive interventions.

We have developed a suite of dashboards which cover a wide variety of activity, resource and performance metrics. The localised monitoring of
System Oversight Framework and national priority metrics has been developed and aligned to the Making Data Count approach. These reports are made available to partners across the system and are aligned to the ICB Committee structure.

Substantial quantitative analysis has been undertaken to ‘model’ services and establish statistically robust demand projections given assessments of population need and service activity. This takes into consideration demographic and non-demographic drivers of demand. We will continue to use this analysis to identify what we must do as a system to sustainably meet our population’s health and care needs.

7.5.4 Our partners

The Intelligence Function is a collaboration of statutory health and care organisations across the ICS but will also seek partnerships with wider
organisations within the ICS and beyond.

It will also work with the Offices for Data and Analytics in Suffolk and Essex, important enablers for undertaking analysis on linked datasets across health and care and wider determinants of health including education, housing, welfare, and environment.

The Suffolk Office of Data Analytics (SODA) is a collective endeavour between Suffolk public service organisations to make better use of data to generate new insights into public services and the needs they serve, and to apply these insights to improve policy and service design and delivery. SODA achieves this through analysing data from multiple sources and linked datasets and by applying robust analytical techniques to generate insight. The SODA partners are the SNEE ICS, Suffolk’s six Local Authorities, and Suffolk Police. Going forward, SODA will focus on bringing together partnership datasets, while also continuing with longer-term evaluations of the Suffolk Criminal Exploitation Programme and the Suffolk Tackling
Poverty Strategy.

The Essex Centre for Data Analytics is a partnership venture between Essex County Council, Essex Police and the University of Essex that seeks to promote the use of data sharing and analytics to improve outcomes for local people. It focuses on having system-wide impact by enabling partners to work together to generate new insights on a range of topics that support strategy development, targeting of early intervention, service design and outreach. Future work includes developing a holistic view of vulnerabilities amongst the residents in north east Essex and assessing disparities in waiting lists and using joint data to inform an action plan on how best to manage this to reduce inequalities.

Quote: “Data has tremendous utility, and our aim is to translate data into rich insights that will inform decisions on how we work now and
in future and how we can deliver our priorities such as meeting the growing demand for health and care services or health inequalities.”

Alex Royan, Deputy Director Strategic Analytics, SNEE ICB and Suffolk County Council

7.6 Procurement/Supply Chain

Procurement is the act of obtaining or buying goods or services and covers all spend undertaken within the ICB. Spend within the ICB is wide ranging, from the purchase of information technology hardware and legal services to healthcare services or human resource. Every element of spend is regulated by the internal standing financial instructions, internal policies and external regulations and guidance.

The principal aim of procurement undertaken by NHS organisations is to deliver essential goods and services and improve outcomes, while increasing value from every pound spent by the NHS.

Procurement across the ICS is moving towards working more closely in collaboration to procure common items together. To start this integration the ICB and partner Trusts have started to align standing financial instructions to ensure approaches to procurement are more aligned. The integration will develop once the ICB and its partner trusts are able to share common spend categories across the spectrum of procurement.

Working as Anchor Organisations, the ICB and its partner trusts are jointly responsible for procuring for social benefit, by embedding social value into procurement activities to ensure positive environmental, social and economic impacts are realised through commissioning and purchasing goods and services⁴².

Aligned social value commitments will be agreed between procurement teams and the wider system to support the delivery of the benefits and achievements of the ICS Green Plan (as discussed in Section 7.9).

To achieve the above commitments, strategies and policies the ICS is working to further develop and integrate the use of a single e-commercial system which enables NHS organisations to have visibility of each other’s sourcing and contract management systems. The adoption of the Atamis Health Family System across the ICS will allow greater sharing of data, processes, spend analysis and market intelligence, allowing joint procurement to be developed with greater ease.

7.7 Communications and engagement

7.7.1 Context

The fundamental change the ICB brings is that all organisations and services, across physical, mental health and social care, will work together to create seamless services and joined up working. Effective communications, public relations and engagement is pivotal to this.

Engagement refers to engaging with people and stakeholders about significant service change. Any approach should be discussed and agreed beforehand with Healthwatch as the system’s lead on public involvement and engagement and Health Overview and Scrutiny Committee (HOSC) in Suffolk and Essex.

Getting the right messages to our people, stakeholders, staff and communities through the most appropriate channels at the right time is central to effective communications and engagement. The ICB will continue to inform and share information as well as listen to the views people have about the services they receive or any proposed changes to the way these services may be provided in the future.

7.7.2 Public relations and engagement

Our communities and people have frequently told us that the complexities in the way our health and care system has previously worked is too confusing and has added to their levels of stress when they or their loved one is experiencing ill health. For:

• People, this means a local health and social care system that they are able to navigate with ease and take an even greater role in managing their own health and wellbeing
• Patients/service users, this means local services that work seamlessly together to meet their individual needs and values their time
• Staff, this means an environment in which they are able to work together to deliver the very highest standards of care under effective leadership
• Organisations, this means genuine collaboration and organisations equally value their own success and that of the wider local health and care system

7.7.3 Aims and objectives

A detailed set of aims and objectives will be co-produced with partners such as Healthwatch, local service provider organisations and the charitable sector that will seek to achieve outstanding communications and engagement in 2023. However, at the very least, the ICB communications and engagement teams will seek to ensure the following aspirations are achieved:

• Stronger stakeholder and partner relationships
• Greater levels of trust among staff, patients and the public
• Better solutions and outcomes for people based on feedback
• Influence behavioural change among patients and the public concerning the correct use of services
• Feedback to people on how engagement has influenced decision-making – ‘you said, we did’
• To position the organisation as a leader of the NHS

The objectives are to:

• build credibility and trust in the NHS in SNEE so the ICB can maintain a reputation with partners, stakeholders, patients and the public as a high performing, responsive organisation
• build continuous and meaningful engagement with the public, patients and carers to influence and support us in our commissioning decision making process
• ensure member practices feel fully informed about the work of the ICB, are ambassadors for the ICB and advocates for their patients
• establish robust and effective mechanisms to gather feedback relating to significant service change
• work closely with Healthwatch Suffolk and Essex and other independent sources to understand additional feedback from communities

7.7.4 Key messages

Our key messages will be coproduced with our local stakeholders. This will be achieved through a separate workshop that will be independently facilitated. However, the following messages will be used in most communications produced by the ICB, until this workshop takes place, where appropriate:

• We are committed to ensuring that the public voice is at the heart of the ICB’s work to ensure everyone has an opportunity to influence our decisions and co-design NHS services
• We fund quality services to meet the health needs of communities across SNEE
• We work with our partners in the NHS, local authority, community and voluntary sector to support people to manage their health and remain independent, whilst avoiding unnecessary hospital admissions
• The ICB is committed to exploring innovative approaches to support people with their health needs, such as social prescribing and advance care planning for end-of-life care
• Through partnership, the ICB will seek to deliver care close to people’s homes and enable a more personalised approach to meet their health needs
• The ICB will work to educate and support people to better understand the importance of prevention and early diagnosis

7.7.5 Communication tools and approaches

• Social media: The ICB has three Twitter and three Facebook accounts which were a legacy from the previous CCG organisations. The ICB kept these accounts to maintain the high volume of followers it has gained and will seek to further increase good quality, locally relevant and engaging content on all its digital platforms. The Communications team will develop a robust social media plan which will explore additional channels and platforms most relevant for target audiences to keep our communications relevant
• Media relations: The Communications team will continue to work closely with local, regional and national media to get the ICB’s messages across. We will also work with the media to explain why we make decisions and provide an honest and transparent response when we are scrutinised or challenged about any aspect of our commissioning role
• Campaigns: Throughout the year, the Communications team will contribute to and promote various healthcare or seasonal campaigns, that link to our priorities. We will adopt a creative and targeted approach to campaigns, based on clinical evidence. We will evaluate our campaigns to ensure learning is captured for future work and continue to amplify public health messaging
• Websites: The Communications team maintains content on www.sneevaccine.org.uk (the SNEE Vaccination Service website) and on www.sneewellbeing.org.uk (a site which supports people to stay well – one of the main channels for the ICB’s winter campaign). It also recently launched a new ICB site which contains corporate information about the organisation – www.suffolkandnortheastessex.icb.nhs.uk and is currently developing a SNEE wide ‘tolivewithdying’ website which offers support and advice to people affected by bereavement or end of life issues
• Parliamentary briefings: The ICB will respond to urgent parliamentary briefing requests and queries from local Members of Parliament (MPs) in a timely manner. The ICB will actively engage with local MPs to ensure they are aware of our plans and to hear the voices of their constituents as well as continue to share the monthly ICB briefing with them
• Internal communications: The ICB will continue to communicate and engage effectively with its staff. It will continue to deliver virtual staff briefings and identify agenda items to share with staff. The ICB will also promote the work of its staff networks within the organisation and, where appropriate, will increase awareness about the work of the networks that exists within its partners too. This is to highlight the breadth of diversity and support that exists within our system area
• Different ways to involve diverse groups: We aim to use a range of communication and co-production methods to reach our diverse population to ensure we are including groups that are potentially excluded and can be seldom heard. The pandemic allowed the Communications team to develop and strengthen relationships with local community leaders and groups and we will continue to explore new and innovative ways of reaching these groups. Through the ICP and Healthwatch, we will continue to build on and create new links with VCSE groups
• Accessible information: The ICB will ensure all public facing information is accessible; our public documents and campaign materials will be produced in Easy Read and film versions when required. Other formats such as languages other than English can also be provided as required and on request. We will also ask patient groups to review documents such as leaflets and surveys to help ensure we communicate effectively
• Working with partners: We aim to work with communication and engagement partners, operating across organisational boundaries and building a coalition of advocates to achieve our aims. Our partners will include local authorities, NHS foundation trusts, PCNs, VCSE organisations and groups, local Healthwatch, neighbouring ICBs and patient groups

Quote: “Working together with our patients, partners, public and communities is central to everything we do as an Integrated Care Board. The overarching aim of our communications and engagement work is to support this Joint Forward Plan’s vision to deliver the best possible health outcomes for the one million people living across Suffolk and north east Essex. A key aspect of this work will be to generate understanding about these aspirations. We are committed to doing this in the most effective way possible which requires ongoing co-production with our communities and health and care providers. It is vital we share our vision, plans and progress in a way that local people can fully access, understand and respond to. As such, using the most appropriate channels and platforms of communication to reach our different audiences will be crucial.”

Simon Morgan, Communications Lead

7.8 Research and Innovation

Our ambition is to build a culture of research and innovation across our ICS that is responsive to those in most need in the communities that it serves. We recognise that there is a continuum to research and innovation and we will align the innovation priorities with the research strategy and aims to ensure timely translation of research into practice for our
people. We will embed coproduction in research and innovation with our people and communities to ensure the patient voice is integral to our work.

Our ICS will encourage research and innovation by organisations, communities, health and wellbeing alliances and as a whole system that improves the design, delivery and outcomes of health and care services. We will develop a peer network of researchers and innovators to offer a range of opportunities to meet, learn, collaborate, share and review research and innovation. Building and strengthening these partnerships gives opportunities to identify and develop ideas, and apply for funding to support research and innovation, at a system wide level. We will share learning within our ICS and more widely, to help promote best practice regionally and nationally.

Individual partners across SNEE have a strong track record of delivering and collaborating on research and innovation. In collaboration with all our system partners, we will research and deliver innovative solutions that address our key local challenges and that make a positive and lasting health impact for our people.

7.8.1 Research

Our ICS regularly delivers research, collaborates on studies between organisations, and has a strong history of research across our trusts and primary care. We have established a five-year research strategy in order to develop our system wide research infrastructure and create a research rich environment which aims to:

• build a flexible, system-wide approach to research across our ICS
• build on our academic partnerships to develop research ideas and achieve research funding
• empower research teams, services, service users and carers to work as partners to help deliver, develop and support high quality research
• work towards embedding a culture of research, innovation and use of evidence across the ICS
• make research both meaningful and accessible

We have established strong connections with our local academic partners. The priorities of the Integrated Care Academy at the University of Suffolk purposefully align with those of the ICS. Academic links are also established with the University of Essex, and the University of East Anglia Health and Social Care Partnership. In order to build on our existing collaborations, we will in the short term undertake a systematic mapping of our current research, the identification of research need and understanding of opportunities for research funding, which will enhance the future resilience of our local research collaboration infrastructure.

We will also map the ways in which the system engages with our population around research, for example existing Public and Patient Involvement groups. This will support the initiation of conversations with our population about research and the many ways they can be involved.

In the medium term, we will explore joint appointments between ICS partners focussed on the generation of research ideas and competitive applications for research funding. We will explore and provide appropriate training to support co-produced research for staff, service users and carers, working with the Integrated Care Academy’s co-production hub at the University of Suffolk. We will also support applications for externally funded fellowships.

We recognise the importance of making research accessible to everyone. Therefore, we will increase communication and visibility of research in a format that is accessible and inclusive to support the development of a research culture within our ICS. We will hold annual ‘celebration of research’ events to raise awareness, celebrate progress and disseminate
findings with our staff and population.

In the next two years, we also aim to develop a digital platform for sharing research and innovation activity and support across the ICS.

By 2028 we will have achieved:

• research grant success centred on SNEE priorities
• investment in local structures to support the ICS to work with academic colleagues and developed a centre of excellence located within SNEE
• development of fellowship opportunities and embedded researcher models of practice across the different ICS partners
• development of dedicated posts centred on research and evidence use across the ICB/ICS
• the use of evidence in policy documents embedded at an ICS level e.g., key part of commissioning documents
• an agreed programme of work across the ICS to communicate about research and research opportunities with our population and our workforce

7.8.2 Innovation

Our ICS recognises the importance of innovation as a key driver of improved outcomes and efficiency. Innovations in health and care may include a process, service, product or technology, which represent a step change on what has gone before, that when implemented results in better health and care. We have built strong foundations for the innovation programme, including the adoption and spread of many noteworthy innovations that have already made a difference.

We have developed a two week wait skin cancer pathway that has an integrated teledermatology approach that has improved people’s experiences and reduced the average time to their first appointment by five days (as discussed in the case study later in this section). This was supported following a successful innovation exchange developed to horizon scan and identify future innovations in this area.

As we look ahead our priorities include:

• creating a culture of innovation readiness and collaboration across our system:
  • develop an innovation partnership group with stakeholders to provide innovation oversight to drive and coordinate activities, by the end of 2023
  • identify mechanisms by which to maximise investment in innovation within and between organisations, by 2025
  • embed innovation to support cross-cutting priorities including but not limited to: reducing health inequalities; enabling and supporting our workforce; working to net-zero, by 2028
• maximising public and patient engagement in health and care innovation:
  • co-produce our approach to innovation with our people, by 2024
  • share information and learning between regional and local patient and public involvement partners, by 2028
• accelerating the prioritisation, development and uptake of innovation that addresses the needs of the NHS and partner organisations, based on input from people, staff and key stakeholders:
  • coordinate an ongoing series of innovation exchanges that support system partner engagement with innovators, by 2023
  • develop landing zones for innovation to maximise communication and engagement with both internal and external innovators, by 2024
  • in partnership with Eastern Academic Health Science Network (AHSN), provide a clear framework to work openly and transparently with healthcare industry partners, by 2023
• increasing system capacity so innovations that can be developed, tested and evaluated in real world settings in our ICS:
  • a clear communication strategy to share innovation best practice, to loop learning back into the wider system and to increase engagement in innovation, by 2023
  • develop open access-training to upskill staff to be confident to develop, adopt and implement innovations at the front line, by 2025
  • identify collaborative funding opportunities that will support research and innovation, by 2028

We will work in partnership with Eastern AHSN to undertake horizon scan activities and innovation exchanges to find innovations that meet our specific challenges and develop a clear approach to working with wider health care industries, e.g. pharmaceutical, health and care technology, digital and analytic. We will engage with innovators to support the early development of innovations in our system which meet our known challenges.

We will support the adoption and spread of proven and successful innovations from elsewhere. We will focus on innovations shown to have had the highest impact to influence our priorities moving forward, as well as ensuring rapid adoption can be achieved, thus benefiting people more quickly. We will deliver innovative solutions to challenges to transform systems, ensuring evidence-based outcomes, and reducing inequalities.

Together with our strategic priorities and areas of focus, then on looking back from five years’ time we will have achieved the following:

• Recognition as system leaders in the development and delivery of high-impact innovations
• A programme of horizon scanning and pipeline of innovations to support our approaches to the most pressing challenges
• Significant growth in our portfolio of innovation programmes in partnership with industry and Eastern AHSN and increased investment in innovation into our local system
• Established and embedded system-wide knowledge and expertise in innovation, and developed innovation fellowships
• Increased capability to provide real world evidence to validate the impact of innovations that will be shared regionally and nationally

Quote: “We have a growing ambition to realise the enormous potential innovation can bring and we are committed to working together to ensure that the best new innovations reach our patients and clinicians faster than ever.”

Caroline Angus, Head of Innovation, SNEE ICB

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Case Study: Skin Cancer Innovation

There continues to be an increase in the number of skin cancer referrals both nationally and locally. To address this issue, WSFT set up a skin cancer assessment service using innovative artificial intelligence (AI)-driven technology (machine learning tools to identify skin cancer based on (dermoscopic) images of skin lesions). People attend a ‘photography clinic’ where images are taken and uploaded to the Tele dermatology AI service.

The digital platform provides an immediate opinion with images also reviewed by Trust Dermatologists virtually. Those with benign skin lesions are discharged and those with possible skin cancer are sent an urgent appointment to attend a clinic at the soonest opportunity. The AI technology has supported improvements with faster detection and treatment of skin cancers. This technology is now being adopted in other areas in SNEE.

Feedback from people is positive and they have commented that a second visit to the hospital has not been an issue with the speed and professionalism of staff noted. One patient praised how quick and efficient the service was. They saw their GP with a suspected skin cancer and within a few days attended the photography clinic. Three days later they were informed that they did not have skin cancer. They were relieved at how quick the service was and their anxiety greatly reduced.

7.9 Sustainability

7.9.1 Sustainability and Health

Environmental protection, tackling climate change and restoring nature are intrinsically linked to the health of our communities. Sustainability therefore not only supports the delivery of the JFP, but it also underpins its overarching needs. For instance, if the UK hits its climate change targets, we could save up to 144,000 lives per year⁴³ through more active lifestyles, less vehicle pollution and healthier carbon friendly diets, thereby improving outcomes in population health.

These outcomes alone tackle an array of health issues we face including obesity, diabetes, cardiovascular disease, respiratory disease, cancer and mental health and wellbeing ⁴⁴. Tackling inequalities in outcomes, experience, and access through digital models of care reduces travel and inconvenience. As such, we view sustainability actions as preventative health and wellbeing actions.

Social prescribing teams utilise green and blue models which link people to nature-based interventions and activities thereby accessing and improving nature and green spaces and supporting mental health and wellbeing. Actions to reduce air pollution will help our respiratory patients (as noted in Section 5.7.3.5) and is a preventative health measure that will reduce incidences of heart disease, cancer, stroke, dementia and childhood asthma⁴⁵. Being more resource efficient, wasting less, reducing reliance on pointless/single use plastics and embracing circular economy principles in all our activities will save money, time and natural resources thereby enhancing productivity and value for money.

Delivering social value to our communities through supporting broader social and economic development will also maximise taxpayers’ investment in the NHS, it is also intrinsic in how healthcare has been repositioned following the Health and Care Act.

7.9.2 Sustainability in action in Suffolk and north east Essex

Embracing sustainability has inspired our Medicines Management team to deliver an award-winning training programme and approach to reduce the carbon emission impact of inhaler use. As noted in Section 5.7.3.5., inhaler switches and optimisation improve respiratory health. Safe disposal of canisters through our pharmacies has also been established.

These projects tackle the biggest carbon issue within primary care, delivering cost savings and reducing waste.

Our HR team established a staff salary sacrifice scheme for low emission and electric vehicles thereby reducing air pollution. Our trusts are embarking on energy efficiency projects, assessing renewable energy sources, reducing waste, providing electric vehicle charging and reducing greenhouse gas emissions by changing anaesthetic practices.

In partnership with Suffolk County Council, we have secured a Department of Transport social prescribing fund to support more walking and cycling which will have huge health and wellbeing benefits linked to developing active travel infrastructure.

With Essex County Council, the Sustainability team has championed developing the retrofit agenda to make buildings carbon positive. Upgrading infrastructure to deliver carbon reduction targets is also an opportunity to develop local green based jobs and investment for our local economy. Retrofit also helps address the cost-of-living crisis through tackling fuel poverty via building improvements.

7.9.3 Sustainably supporting our staff and communities

Despite all the benefits, the links between climate change and health are not commonly realised. Therefore, one major objective of our forward plan is to engage with our staff, system partners and communities to overcome this barrier to change; this is the building block of all future activity. This aligns with our Green Plan. Our JFP will provide targeted focus on areas within the ICS Green Plan where the ICB is best placed to be a lever for change. This means our role as commissioners, contract managers and key partner will all play a part.

Partnerships are critical and our role within the wider ICS working with our system partners will provide a cumulative benefit to our communities. Addressing areas such as air pollution and being members of the Suffolk Climate Change and Energy Board and Essex County Council Anchors networks reduces duplication and integrates public sector health and sustainability impact and outcomes.

A Green Plan⁴⁶ for 2022 to 2025 for SNEE ICB has been agreed, detailing our current sustainability goals:

• Tackling the causes and effects of health inequalities and poverty
• Reducing the impacts of air pollution on health
• Reducing and mitigating the impacts of climate change on the system and population health
• Delivering the NHS LTP (value for money, staff development, embracing digital and doing things differently)
• Providing leadership through actions, partnerships, engagement

The Green Plan also supports the four core purposes of the ICS formation following the Health and Care Act further re-iterating its importance to supporting the overall JFP.

• The adoption of activities and interventions which slow the associated health impacts of climate change, which can improve population health, e.g. reducing the number of heatwave-related excess deaths and pollution-related respiratory illnesses
• Supporting action to address poor air quality, which disproportionally affects vulnerable and deprived communities in the UK through prevalence of respiratory illnesses, therefore tackling existing inequalities in outcomes, experience, and access
• Enhancing productivity and value for money, by planning to improve energy efficiency and switching to renewable energy sources across NHS estate across an ICS footprint, reducing long-term energy bills for the NHS
• Driving broader social and economic development by ensuring all NHS procurements include a minimum 10% net zero and social value weighting and adhere to future requirements set out in the NHS Net Zero Supplier Roadmap

Through the JFP, we will continue to work closely with our partners across health, VCSE and public sector organisations. We will use our position to provide leadership and identify, share and integrate resources and expertise. This will allow us to target future innovation, investment and resource allocation thereby ensuring we provide value for money and deliver greater health and sustainability outcomes.

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

• carbon footprint reduction
• transport-related air pollution emissions reduction
• waste reduction
• increased green spaces and supporting biodiversity through environmental stewardship
• system partners’ and suppliers’ carbon footprints reduced
• measures in place to be more climate resilient as a system
• our actions inspiring the public and our staff to adopt more sustainable and healthy lifestyles

Quote: “The climate emergency is often described as a health emergency. Climate change is recognised as the greatest threat to healthcare in the 21st Century by The Lancet. Our approach is to treat the climate and health emergency as an opportunity. It is an opportunity to improve how we deliver care, how we work with our partners and communities to prevent illness and be more sustainable in our day-to-day business.”

Amanda Lyes, Director of Workforce and People, NHS SNEE ICB and SRO for Sustainability

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8. Managing delivery of the Joint Forward Plan

8.1 Communication and explaining the plan to key stakeholders

SNEE ICB is committed to ensuring an open and transparent exercise is conducted in the development of the JFP to incorporate public and stakeholder views in planning arrangements. The first part of this has been the stakeholder engagement and community liaison activities during January and February 2023 to ensure such feedback is gathered, considered and ultimately reflected in the plan in its final draft in March 2023.

8.1.1 Approach

From December 2022 to January 2023, the draft JFP was separated into manageable and meaningful sections to enable effective engagement and comment on the work. The aim of this process was to share the JFP in an accessible, creative and inclusive way to encourage interaction and discussion. This method helped ensure all people and communities had the opportunity to comment on the JFP, either on the sections most important to them or the whole document.

A mixed methodology was used to enable the ICB to reach a wide audience through both online and in person discussions. Clear, transparent and honest information about the purpose, governance and accountability of the JFP was shared during these sessions.

Online

In January 2023, key components of the JFP were published on the www.letstalksnee.co.uk platform to reinforce the approach taken. Each Live Well domain was given an individual page/section on the site, setting out key priorities. People and communities from SNEE were then asked to comment on sections and the people reported outcome measures. A full stakeholder mapping exercise was also undertaken for dissemination and involvement.

In-person

In February 2023, three hour in-person workshops were held in each health and wellbeing alliance area in addition to one online workshop. Key priorities of the Live Well domains were discussed during these sessions and an overview of feedback to date was also shared. The adopted approach, reflections and ideas will be considered by stakeholders. These workshops also enabled the ICB to use quick fire ‘ideation’ and creative curiosity techniques to generate conversation about each domain and section area. Attendees included a broad range of individuals including members of the People and Communities Groups and Patient and Public Group (PPG) Networks.

Quality considerations

Whilst the people and communities engagement took place, a supplementary conversation was held about the development of the Quality Dashboard. As part of the programme of meetings about the JFP, a fourth meeting will be held to develop the quality dashboard to enable the ICB to better
understand what good looks like and how best to collect that data.

Communication and formal engagement with stakeholders

During February, a programme of engagement with stakeholders commenced. The ICB asked strategic external audiences for their view on the JFP to date (which also incorporated feedback from the public groups). Strategic stakeholders were asked to consider the content within the JFP, its vision and core priorities.

The following groups are identified as key strategic stakeholders:

• ICB staff
• GPs / PCNs
• ESNEFT
• WSFT
• EPUT
• NSFT
• ISCRE
• Hospices
• MPs
• Suffolk County Council
• Essex County Council
• District and borough councils
• Community Action Suffolk
• Community 360
• Community Voluntary Services Tendring
• Healthwatch Suffolk and Essex
• Carers organisations
• Councillors including HOSC and the Suffolk and Essex HWBs

To communicate with these strategic stakeholders, the ICB produced:

• a one-sided crib sheet to support staff in communicating key elements/overview of the plan with stakeholders. This was shared with Health Overview and Scrutiny Committee (HOSC) prior to any patient and public engagement work
• a shortened summary document for stakeholders, taken from the plan’s Executive Summary, which highlights key messages / aspirations from the plan with details of milestones and timeframes
• a story for inclusion in the ICB stakeholder briefing which outlines the purpose of the plan
• a recorded video message for the ICB website so the core information is available in audio format
• a PowerPoint slide deck for presentations with stakeholders if needed so senior ICB colleagues can share details of the plan in meetings with partners

In addition, the ICB regards its staff as important internal stakeholders. To ensure they are aware of the purpose and contents of the plan, the Communications team:

• produced an item for inclusion in the Buzz (internal newsletter)
• uploaded the full version of the document as well as summarised versions on the intranet
• gave an overview of the plan during a future virtual staff briefing

A full report outlining the outcomes of our engagement exercises on the draft JFP can be found at Appendix 2. Section 3.6 sets out the main themes which then influenced the final version of the JFP.

8.2 Managing and reporting progress

SNEE ICB will manage and report on its statutory duties and aim to:

• improve quality of services for those at home, in the community, seeking secondary care and those with long term conditions (LTCs). This is discussed in Section 6.9
• address health inequalities by understanding the demographics of those most in need. This is discussed in Section 5.2
• promote involvement of each person in their care by expanding the choices and control that people have over their own care. This is discussed in Sections 5 and 7.1
• ensure that needs of children and young people are met and they have the best start to life. This is discussed in Section 5.4
• address the needs of victims of abuse by ensuring that the proper systems are in place to help. This is discussed in Section 5.5.3.4
• promote innovation by leveraging the benefits of innovation to enable positive change in the way that health and care is delivered. This is discussed in Section 7.8
• support and encourage contribution to national research by increasing the number of people participating in health research and promoting opportunities for people to register. This is discussed in Section 7.8
• promote education and training, enabling career development. Strengthening our health and care workforce is a key priority. This is discussed throughout the JFP, in particular in Sections 7.2, 7.4 and 7.9
• promote integration by working with system partners to align and integrate service delivery across sectors to create efficiencies in practice and improve outcomes for the local population. This is discussed in Sections 6.1 to 6.6 and throughout the JFP
• help the fight against climate change by supporting national efforts to reduce the NHS’s carbon footprint. This is discussed in Section 7.9
• have regard to the wider effects of decisions or the ‘triple aim’. This is discussed in Section 5 and throughout the JFP

SNEE ICB has established several committees to assist it with the discharge of its duties and functions, including the delivery of the key priorities and goals set out in the JFP. The ICB Board remains accountable for all functions, including those that it has delegated to committees and subcommittees and therefore, appropriate reporting and assurance arrangements are in place and documented in terms of reference. All committees and subcommittees that fulfil
delegated functions of the ICB, will be required to:

• submit regular decision and assurance reports to the Board
• submit minutes of committee meetings to the Board
• ensure that the committee Chair or designated deputy attends meetings of the Board as necessary
• comply with internal audit findings and committee effectiveness reviews

The ICB will undertake a continuous appraisal of the position, performance, and delivery of the key priorities and goals set out in the JFP via the ICB committees. The committees will monitor the performance and delivery and agree plans to mitigate any concerns regarding underperformance or under delivery, where necessary reporting these to the Board through exception reporting or if appropriate via the Board Assurance Framework (BAF).

8.3 Escalation and remediation

Our BAF provides the ICB Board with a simple but comprehensive method for the effective and focused management of risk. Through the BAF the ICB Board gains assurance that risks are being appropriately managed throughout the organisation.

The BAF identifies which of the organisation’s strategic objectives may be at risk because of inadequacies in the operation of controls, or where the ICB has insufficient assurance. At the same time, it encompasses the control of risk, provides structured assurances about where risks are being managed and ensures that objectives are being delivered. This allows the ICB Board to determine how to make the most efficient use of resources and address the issues
identified to improve the quality and safety of care.

8.4 Assurance and accountability

The ICB will publish an Annual Report in accordance with any guidance published by NHSE that sets out how it has discharged its functions and fulfilled its duties in the previous financial year. The annual report will:

• explain how the ICB has discharged its duties
• review the extent to which the ICB has exercised its functions in accordance with the plans published including achievement of the key priorities and goals set out in the JFP
• review the extent to which the ICB has exercised its functions consistently with NHSE’s views about how functions relating to inequalities information should be exercised
• review any steps that the ICB has taken to implement any joint local health and wellbeing strategy

The ICB has also put in place arrangements that will effectively facilitate and support NHSE’s annual assessment of how effectively the ICB has exercised its functions. The ICB has established effective arrangements via the delegation to Committees and subsequent reporting cycles to enable the Board of the ICB to provide an effective and timely account of its performance to key internal and external stakeholders and the public.

The ICB will seek reports and assurance from directors and managers as appropriate, concentrating on the delivery of the key priorities and goals set out in the JFP including the systems of integrated governance, risk management and internal control, together with indicators of their effectiveness. Reports will have consistent foundations based on underlying assurance processes that indicate the degree of achievement of the priorities and the effectiveness of
the delivery and performance.

The System Oversight and Assurance Committee (SOAC) has been established by the Board to support managing improvement, development and performance at ICS (system) level. SOAC is a data-driven, evidence-based and rigorous committee that provides focus on supporting the spread and adoption of innovation and best practice between partners.

The SOAC will:

• oversee the development of a dashboard of key outcome, performance, and quality and transformation metrics for the ICB, linking with the system Data and Intelligence function
• take an overview of performance and transformation at whole system, place and organisation levels in relation to the key priorities and goals set out in the JFP, specifically those where primary responsibility for taking remedial action lies with other components of the system, thus ensuring the ICB has effective levers available to enable remedial action should it be necessary
• create links with external organisations
• lead the development of a framework for peer review and support for the ICS and oversee its application
• make recommendations to the ICB Board on the deployment of improvement support across the ICS, and on the need for more formal action and interventions
• receive reports from ICS priority programmes and enabling workstreams on issues which require escalation

8.5 Integrated Care Board performance

SNEE ICB is held to account by NHSE for performance through the NHS Oversight Framework which sets out a broad range of measures. In addition, the ICB has set out local performance priorities that are important to the system’s population. Together these metrics form the ICB’s performance framework.

The performance framework will continue to be developed as priorities are expressed and refined by our population, informed by our partners, and shaped by data intelligence.

The ICB will monitor and seek to improve performance by delegating responsibility through its locality, transformation and corporate committees. These committees will be responsible for improving all areas of our commissioning responsibilities.

Each committee will have detailed datasets which are summarised in a data dashboard. The committees will report on their dashboards each month to the SOAC where performance will be scrutinised to form a judgement on whether the ICB is assured that controls are in place to maintain or improve performance, or not assured in which case a remedial action plan will be required from the committee.

We aim to maintain or recover performance against our statutory responsibilities, further information on these is outlined in the specific sections in this document, in particular Section 5. Over time the ICB intends to increase the number and breadth of outcome measures, experience measures and quality measures informed by feedback from patients, the public and clinicians. The ICB intends to further develop a culture of continual improvement and person-centred healthcare across all areas.

9. Supporting information

9.1 Glossary of Terms Show Content Hide Content

A glossary of terms used throughout the JFP is provided below.

ABI: Acquired Brain Injury
ACE: Anglian Community Enterprise
ACTs: Alcohol Care Teams
ADHD: Attention deficit hyperactivity disorder
AF: Atrial Fibrillation
AI: Artificial Intelligence
AHSN: Academic Health Science Network
ARMS: At Risk Mental State
ASD: Autism Spectrum Disorder
BAF: Board Assurance Framework
BI: Business Intelligence
CAS: Clinical Assessment Service
CCG: Clinical Commissioning Group
CHC: Continuing Health Care
CHRIS: Crisis Help and Risk Intervention Service
COPD: Chronic Obstructive Pulmonary Disease
CPES: Cancer Patient Experience Survey
CQC: Care Quality Commission
CRHTTs: Crisis Resolution and Home Treatment Teams
CRtP: Clinically Ready to Proceed
DDaT: Digital, Data and Technology
DMS: Discharge Medicines Service
DSR: Dynamic Support Register
EACH: East Anglia’s Children’s Hospices
EAHSN: Eastern Academic Health Science Network
EAU: Emergency Assessment Unit
ECG: Electrocardiogram
ED: Emergency Department
EHIIAs: Equality and Health Inequalities Impact Assessments
EIP: Early Intervention in Psychosis
EIS: Estates Infrastructure Strategy
ENT: Ear, Nose and Throat
EoE: East of England
EoL: End of Life
EPR: Electronic Patient Record
ESNEFT: East Suffolk and North Essex NHS Foundation Trust
FeNO: Fractional Exhaled Nitric Oxide
FH: Familial Hypercholesterolaemia
GP: General Practitioner
HALOS: Hospital Ambulance Liaison Officer
HF: Heart Failure
HOSC: Health Overview and Scrutiny Committee
HWB: Health and Wellbeing
IAPT: Improved Access to Integrated Therapies
IBA: Identification and Brief Advice
ICB: Integrated Care Board
ICOPE: Integrated Care for Older People
ICP: Integrated Care Partnership
ICS: Integrated Care System
IMD: Index of Multiple Deprivation
IP: Independent prescriber
JCC: Joint Commissioning Committee
JFP: Joint Forward Plan
JLHWS: Joint Local Health and Wellbeing Strategy
JSNA: Joint Strategic Needs Assessments
KWF: Key Working Function
LA: Local Authority
LD: Learning Disability
LD&A: Learning Disability and Autism
LeDeR: Learning Disability Mortality Review
LMNS: Local Maternity and Neonatal System
LPNs: Local Professional Networks
LSOA: Lower Super Output Areas
LTC: Long-Term Condition
LTP: Long Term Plan
MASH: Multi-Agency Safeguarding Hub
ME&CFS: Myalgic Encephalomyelitis and Chronic Fatigue Syndrome
MHIS: Mental Health Investment Standard
MP: Member of Parliament
NDD: Neuro-Developmental Delay
NHSEI: NHS England and NHS Improvement
NICU: Neonatal Intensive Care Unit
NIHR CRN: National Institute for Health Research Clinical Research Network
NMS: New Medicines Service
NSFT: Norfolk and Suffolk Foundation Trust
OHID: Office of Health Improvement and Disparities
ONS: Office of National Statistics
PCN: Primary Care Network
PHB: Personal Health Budgets
PHM: Population Health Management
PPG: Patient Participation Groups
PREP: Pre Exposure Prophylaxis
QoL: Quality of Life
RAAC: Reinforced Aeriated Autoclaved Concrete
REACH: Race, Equality and Cultural Heritage
ReSPECT: Recommended Summary Plan for Emergency Care and Treatment
SALT: Speech and Language Therapist
SAU: Surgical Assessment Unit
SDEC: Same Day Emergency Care
SEND: Special Educational Needs and Disabilities
SET: Southend, Essex and Thurrock
SMI: Severe Mental Illness
SNEE: Suffolk and North East Essex
SNELCAS: Suffolk and North East Essex Long Covid Assessment Service
SOAC: System Oversight and Assurance Committee
SSS: Stop Smoking Services
T&O: Trauma and Orthopaedics
TIA: Transient Ischaemic Attack
UCR: Urgent Community Response
UTC: Urgent Treatment Centre
VCSE: Voluntary, Community and Social Enterprise
VLCD: Very Low-Calorie Diet
WHO: World Health Organisation
WRES: Workforce Race Equality Standard
WSFT: West Suffolk Foundation Trust

9.2 Appendices Show Content Hide Content

Appendices are available upon request:

• Appendix 1 – Essex and Suffolk Joint Strategic Needs Assessments
• Appendix 2 – Joint Forward Plan Engagement Report
• Appendix 3 – Our Partners’ Aligned Plans
• Appendix 4 – National Five Priority Areas for Tackling Health Inequalities
• Appendix 5 – SNEE ICB Equality Diversity and Inclusion in the Workforce Plan
• Appendix 6 – Start Well
• Appendix 7 – Feel Well
• Appendix 8 – Be Well
• Appendix 9 – Stay Well
• Appendix 10 – Age Well
• Appendix 11 – Die Well
• Appendix 12 – Digital, Data and Technology Strategy 2022-25

References Show Content Hide Content

1. The SNEE ICB covers the whole of Suffolk except Waveney which is part of the Norfolk and Waveney ICB
2. Guidance on Developing the Joint Forward Plan December 2022
3. Patients registered at a GP practice (March 2023) NHS Digital
4. Source: Shape and ONS data 2023
5. Source: Place-based approaches for reducing health inequalities: main report
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7. Policies page on the NHS Suffolk and North East Essex ICB website
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9. The SNEE ICB covers the whole of Suffolk except Waveney which is part of the Norfolk and Waveney ICB
10. Guidance on Developing the Joint Forward Plan December 2022
11. Policies page on the NHS Suffolk and North East Essex ICB website
12. Patients registered at a GP practice (March 2023) NHS Digital
13. Source: Shape and ONS data 2023
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17. Fuller Stocktake Report
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19. Suffolk Transitional Joint Health and Wellbeing Strategy 2022 – 2023
20. Place-based approaches for reducing health inequalities: main report
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24. Kline, R and Prabhu, U (2015). Race inequality of NHS staff is putting patients at risk. HSJ
Accessed at: https://www.hsj.co.uk/leadership/race-inequality-of-nhs-staff-is-putting-patients-at-risk/5082766.article
25. Stonewall’s 2018 report on the health of LGBTQ+ People in Britain. Accessed at: https://www.stonewall.org.uk/resources/lgbt-britain-health-2018
26. Trevena, L (2023). The Diversity Dividend. The Podiatrist v26 (1)
27. McDermott, E. Nelson, R and Weeks, H (2021). The Politics of LGBT+ Health Inequality: Conclusions from a UK Scoping Review. Int J Environ Res Public Health v18 (2) 826.
Accessed at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7835774/pdf/ijerph-18-00826.pdf
28. Katikireddi SV, Lal S, Carrol ED, et al. (2021). Unequal impact of the COVID-19 crisis on minority ethnic groups: a framework for understanding and addressing inequalities. J Epidemiol Community Health v75:970–974. Accessed at: https://jech.bmj.com/content/jech/75/10/970.full.pdf
29. Elwell-Sutton, T. Deeny, S & Stafford, M (2020). Emerging findings on the impact of COVID-19 on black and minority ethnic people – COVID-19 chart series.
Accessed at: https://www.health.org.uk/news-and-comment/charts-and-infographics/emerging-findings-on-the-impact-of-covid-19-on-black-and-min
30. NHS England (2020). NHS People Plan. Accessed at: https://www.england.nhs.uk/wp-content/uploads/2020/07/We-Are-The-NHS-Action-For-All-Of-Us-FINAL-March-21.pdf
31. Available: https://ahauk.org/resource/commission-on-alcohol-harm-report/#:~:text=on%20Alcohol%20Harm-,’It’s%20everywhere’%20%E2%80%93%20alcohol’s%20public%20face%20
and%20private%20harm%3A,the%20harm%20caused%20by%20alcohol
32. Note: As at February 2023, we have reached the end of the NHSE Five Year Mental Health Long Term Plan covering 23/24. Further targets will be agreed during 23/24 covering 24/25 to 27/28 and will be included in the subsequent refresh of the JFP
33. 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
34. NHS Long Term Plan: Stronger NHS action on health inequalities
35. Source: https://fingertips.phe.org.uk/profile/healthy-ageing/data
36. Source: https://fingertips.phe.org.uk/profile/healthy-ageing/supporting-information/carers
37. Further information on the SNEE PHM Strategy and additional PHM Flip books are available on the SNEE ICS website.
38. Source: Working in partnership with people and communities: statutory guidance
39. Suffolk and North East Essex ICB People and Communities Strategy
40. suffolkandnortheastessex.icb.nhs.uk/about-us/equality-and-diversity/
41. Directed at all NHS leaders, this framework sets out what good looks like at both a system and organisation level. It describes how arrangements across a whole ICS, including all its constituent organisations can support success. Further information is available via the NHSE website
42. Source: Procurement Policy Note 06/20 – taking account of social value in the award of central government contracts – GOV.UK (www.gov.uk)
43. Source: https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(20)30249-7/fulltext
44. Sources: https://www.rcplondon.ac.uk/projects/outputs/every-breath-we-take-lifelong-impact-air-pollution; https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/904146/gear-change-a-bold-vision-for-cycling-and-walking.pdf
45. Source: https://www.gov.uk/government/news/new-tool-calculates-nhs-and-social-care-costs-of-air-pollution
46. https://www.sneeics.org.uk/can-do-health-and-care/creative/environmental-sustainability/#:~:text=As%20an%20ICS%20we%20are%20already%20working%20with,transport%20
patients%2C%20staff%20and%20materials%20to%20reducing%20waste”