3. Our goals

As individual organisations within the partnership, we have priorities that we need to achieve. However, we know that only by working together will we accomplish our individual goals and deliver better outcomes for the people of Leeds. At the centre of our approach is working with people and our Team Leeds health and care workforce to support the partnership. Together we can identify ways to achieve our goals, working better together to identify areas of improvement, and ensuring people and staff feel empowered to make a difference. In developing our collective goals, we believe that:

1. People will be equal partners in their care, ensuring high quality, personalised care services are delivered focusing on what matter to people – we will need to define outcome frameworks based on ‘what matters to me’.
2. The population’s health overall will move from being sicker and more dependent on services, to living, ageing, and dying well. To do this our Health and Care Partnership will need a much clearer focus on specific goals.
3. For the population’s health to improve equitably and for us to reduce health inequalities, our partnership will need to ensure services are more inclusive and better targeted for those who are socially and economically disadvantaged or at higher risk of poor health – our goals must include a focus on reducing inequalities.
4. To achieve our ambition, we will need to shift more resources into prevention and personalised, proactive care – often meaning more activity and care taking place in community settings and people’s homes – we will develop measures of how activity levels will change (for some people with a complex physical or mental health condition, the most proactive approach is to have access to specialist care as quickly as possible, which may be delivered from hospital).

Given this, the Leeds Health and Care Partnership has agreed to focus on two collective system goals:

• Goal 1: Reduce preventable unplanned utilisation across health settings.
• Goal 2: Increase early identification and intervention (of both, risk factors and physical and mental illness).

These goals will focus on the 26% of the population in Leeds who live within the 10% most deprived areas nationally. Taking a person centred preventative and proactive approach – working with people and staff to co-design solutions.

The indicator to measure a reduction in preventable unplanned utilisation within Leeds comprises of four parts:

1. Unplanned acute admissions (bed days)
2. A&E attendances including walk-in and Urgent Treatment Centres (number of attendances)
3. Access to specialist mental health crisis services (number of attendances)
4. Mental health inpatient admissions (bed days)

Preventable unplanned utilisation refers to access or admissions to services where there was scope for earlier or different action to prevent an individual’s health or wellbeing deteriorate to an extent where unplanned care services are required. Accessing the right care at the right time, in the right place is what patients, carers (paid and unpaid), families and staff have told us is important to them.

A focus on two goals will help us drive improvements that include:

• Better outcomes for people: Patient insight has indicated that people would prefer to access care in a planned rather than an unplanned way. Our data shows that people admitted to hospital in an unplanned way have a longer length of stay compared to those admitted in a planned way. Episodes of unplanned care can also be disruptive for other areas of life such as caring arrangements, work, and education.
• Better use of resources: Within Leeds we know that a considerable amount of financial and operational resource is utilised by unplanned care. Given the current financial challenges faced by Leeds and other health systems, resources spent on prevention and early intervention are also likely to reduce costs and increase efficiency.
• Addressing health inequalities: Those living in the most deprived neighbourhoods are more likely to utilise healthcare in an unplanned way and less likely to access care in a planned way. We also know from our JSA that the number of people living in IMD1 is expected to grow the fastest in the future.

National and international evidence supports this focussed approach. For example, Staten Island adopted a similar methodology:

Case Study: Staten Island Performing Provider System

In 2014, Staten Island Performing Provider System created an integrated network of providers to improve population health outcomes, reduce costs and reduce avoidable hospital use by 25% over five years. It is comprised of more than 75 provider organisations covering mental health, social care, and community services; 22 population health practices; over 20 community organisations, and 3600 primary care practitioners.

Approach

Staten Island Performing Provider System model utilised a data-driven approach that focussed on a ‘System of Care’ methodology. The Staten Island Performing Provider System created an advanced population health management ecosystem that monitored outcomes of care at an individual, practice, and population level. The platform’s geomapping and hot spotting capability made it possible to correlate geographic areas with services, health outcomes and social determinants of health. The analysis was used to understand risk factors, target interventions and measure success of various projects.

Priority work programmes

The data and insight from the analysis informs the potential programmes of work. Staten Island Performing Provider System, on an annual basis, work with people, local communities, and professionals to review the information and narrow down the potential programmes to a number of focus areas for that year, identifying and co-producing the solutions together. One area of focus was children with asthma. The data indicated that within specific geographic areas there were high numbers of children attending the Emergency Department, longer inpatient stays and much less planned activity compared to children in other areas.

The programme worked with these communities to understand the root causes linked to the higher numbers of children attending unplanned services for asthma. Several solutions were identified which included home visits and working with families and children at higher risk (risk stratification of the population), family hubs within local communities and a focus on eliminating triggers such as pest and mould, including the purchasing of vacuums and mattress covers. The programme resulted in a reduction in the number of Emergency Department attendances and inpatient stays as well as a reduction in the number of lost school days.

Overall achievements of the Staten Island Performing Provider System

The approach used by Staten Island Performing Provider System has delivered significant improvements including, but not limited to:

• 62% reduction in preventable Emergency Department visits, saving $15m
• 61% reduction in preventable mental health Emergency Department visits, saving $6.2m
• 51% reduction in preventable readmissions, saving $6.5m

The Staten Island Case Study shows how starting with a health-based goal has led to numerous examples of improving outcomes and quality of life for people. The success of their paediatric asthma programme resulted in children and their families’ lives being less disrupted by not having to frequently attend hospital in an unplanned way.

These focussed goals will help the partnership to target resource, prioritise work and make tangible improvements in the health and wellbeing of people in Leeds, identifying and reducing areas of unmet need in a targeted and systematic way. Concentrating on areas of high cost will also support financial sustainability and allow us to invest further in the upstream, preventative areas that we want to as a system.

Analysis of preventable unplanned utilisation will help inform and understand where, as a system we need to increase early identification and intervention. Therefore, goal two and its supporting measures will be developed at a later stage during 2023 / 2024.

Contents – Explore the Healthy Leeds Plan

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