4. Population health infrastructure

The Healthy Leeds Plan sets out the health and care contribution towards achieving this vision. The plan outlines our five year strategic vision and focuses on equitable access, excellent experience, and optimal outcomes for people living in Leeds, ensuring we get the best value from Leeds public money.

The Leeds Segmentation Model

As a system we are developing robust population health infrastructure, designed to put the diverse needs of our population at the heart of everything we do and move decision-making closer to the people using our services. This infrastructure will help the Leeds Health and Care Partnership to achieve its goals.

Within Leeds we have described the different needs of the Leeds Population using nine mutually exclusive population segments. These nine segments are :

  • Children and young people
  • Maternity
  • Healthy Adults
  • People with a learning disability and / or neurodiversity
  • Serious Mental Illness
  • Cancer
  • Long-term conditions
  • Frailty
  • End-of-life.

Grouping people into segments of similar needs allows us to look at how we use our resources to best meet these needs.

Everyone in Leeds fits in to only one segment at one time reducing the risk of double counting or misrepresenting changes in health outcomes over time. This does not mean we cannot consider population needs across segments, but it does help us to understand the value and impact the partnership has on each segment.


The Leeds Data Model

The Leeds Data Model is our pseudonymised, person level, linked dataset bringing together data from a range of partner organisations delivering health and care to the people of Leeds. The model enables us to identify specific cohorts through our population segmentation model to which we can compare service utilisation, prioritise services and help to plan existing or new services. The Leeds Data Model provides the system with the capability to cross reference utilisation with demographic and geographic information enabling the partnership to plan and deliver initiatives in a targeted and systematic way. Outputs from the Leeds data model was instrumental in the selection of our nine mutually exclusive segments.


Population and Care Delivery Boards

A key element of the Leeds Health and Care Partnership governance structure are the nine population boards that mirror our segmentation approach. These boards have the responsibility for advising and guiding the Partnership on the best way to allocate NHS resources to improve value and reduce health inequalities for its defined population. They have an important role in identifying how to meet local priorities, national priorities and contribute towards narrowing the financial gap.

In addition, two ‘care delivery boards’ work across all population segments to understand needs and effectiveness in two critical city-wide areas: Planned Care (elective secondary and community activity); and Same Day Response (same-day urgent and emergency services).

Population and care delivery boards are clinically led and consist of members from each organisation in our partnership. We are also establishing an approach to involving the people of Leeds in the decisions of the boards. Understanding the needs, health outcomes, spend, activity and contracting associated with each population is fundamental to a boards capability to make recommendations.


Population Outcomes Frameworks

Each of the population and care delivery boards have developed an outcomes framework, which clearly sets out what they are working to achieve for their population and how this achievement will be measured. Outcomes have been developed based on insight from people in Leeds as well as wider stakeholder and people engagement. Each board has an insight report that summarises what people have told us about their experiences of care and have been jointly produced with our partners through a series of public involvement workshops (more information here: https://www.healthandcareleeds.org/have-your-say/shape-the-future/populations/). Outcome frameworks continue to be reviewed and revised as further insight is received and the work of the boards evolves. Having clear and measurable outcomes, at a population level, enables us to track outcomes over time and develop an increasing, collective focus on how efficiently or effectively public resources are consumed across all organisations to improve health outcomes.


Local Care Partnerships

Local Care Partnerships bring together a range of partners within Leeds to champion coordinated holistic person-centred care and address community priorities within the context of a wider health and wellbeing partnership. Local Care Partnerships are central in understanding people-voice, insight, and data to help inform decisions and delivery of person-centred care and have a vital role in supporting the wider partnership to achieve our system goals. The 15 Local Care Partnerships focus on their local communities and implementing solutions to meet the needs of the local community. Local Care Partnerships support the Population and Care Delivery Boards, as well as the Primary Care Board, in achieving the outcomes for their population at a local level.

The work Forum Central has undertaken with the LCP team has ensured that there is a strong third sector presence in all LCPs, connecting communities (both geographical and communities of interest) to local health and care partners.


Health Inequalities – Tackling Health Inequalities Group and Communities of Interest Network.

The Tackling Health Inequalities Group is an expert advisory group that was established to demonstrate our commitment to achieving our Health and Wellbeing Strategy ambition that the poorest improve their health the fastest with a particular focus on health and care. The Tackling Health Inequalities Group acts as an expert advisory group to the health and care system providing advice, expertise, and challenge to ensure we are taking effective action to reduce health inequalities ensuring a consistent approach and sharing best practice. They have helped the Leeds health and care system to develop its Tackling Health inequalities Toolkit that provides an evidence based and community informed framework for partners to use when addressing health inequalities.

The Tackling Health Inequalities Group has oversight of delivering the requirements of the national Core20PLUS5 (adults) and the Core20PLUS5 (Children and Young People) programmes which are in place to inform action to reduce health inequalities at both a national and system level.

Whilst the Population and Care Delivery Boards are accountable for addressing health in equalities for their populations, The Tackling Health Inequalities Group has a role to ensure that the health and care system remains focussed on the 26% most deprived population within Leeds as well as the wider communities that are seldom heard / underrepresented.

In addition, the Communities of Interest Network (COIN) helps to highlight and address the needs and challenges faced by groups and communities which experience the greatest inequalities. A key focus of the network is to understand and raise awareness of the importance of intersectionality, where people’s overlapping social identities may mean they experience multiple disadvantages or discrimination.

Collectively, our Population Health infrastructure forms a central part of the Leeds Health and Care Partnership governance arrangements. The Population and Care Delivery Boards bring key partners in Leeds together so that they can work collaboratively to improve the outcomes, experience and value derived from NHS spend for their defined population. They are supported by the city’s expert advisory groups and enablers. Population and Care Delivery Boards provide assurance to the three sub-committees in Leeds that the city is delivering the triple aim of healthcare; improving outcomes, improving experience for people; and ensuring effective use of resource and reporting on performance against the system priorities. These three sub-committees in turn provide assurance to the Leeds Committee of the West Yorkshire Integrated Care Board and subsequently the West Yorkshire Integrated Care Board.

The Partnership Executive Group in Leeds will have oversight of the delivery of our two system goals, with support from the Delivery Sub-Committee, which will have responsibility for monitoring implementation and delivery. The Partnership Executive Group is accountable to the Health and Wellbeing Board and members include the Chief Executives from the NHS in Leeds, Leeds City Council and Public Health, and advocates from the third sector, General Practice and Clinical Senate.

Expert Advisory Groups provide high support high challenge to the boards in areas that are a particular priority for the system:

Person-Centred Care Expert Advisory Group was established through a collective and system commitment to implementing the “Leeds Person Centred Principles”. The role of the group is to advise, influence and support implementation of best practice for services which communicate effectively, are compassionate and are coordinated (the Leeds 3 Cs). Within Leeds we support the West Yorkshire vision for everyone to be able to access high-quality health and care services that have been co-designed to take account of lived experiences and personalised through shared decision-making. The care will be responsive to health inequalities, trauma informed, and respectfully delivered, resonating with what matters most to the individual, their family and unpaid carers, and in support of the community connecting them.

The Leeds Carers Partnership champions the needs of the estimated 61,500 unpaid carers in Leeds and aims to influence service design and delivery in response to the needs of carers. Unpaid carers are crucial both to our communities and to the sustainability of health and social care in Leeds. Without unpaid carers, individuals and communities would be worse off and the NHS, social care and community services would be overwhelmed. To achieve our ambition to be the best city for health and wellbeing we need to ensure we can identify and support our unpaid carers, recognise, and value the contribution that unpaid carers make. Alongside this we need to promote unpaid carers’ own health and wellbeing, putting unpaid carers at the heart of everything we do, as described within the Leeds Carers Partnership Strategy.

The Tackling Health Inequalities Group, as described above, provides advice and expertise as well as challenge to the health and care system to ensure we are focussing and taking actions to reduce health inequalities across Leeds. See Health Inequalities section of this plan for more detail.

The People’s Voices Partnership brings engagement and involvement leads from partner organisations together to share their work. Their common aim is to improve the way we hear the voices of local people, particularly those living with the highest health inequalities. The People’s Voices Partnership are working together to understand what matters to people in Leeds. Projects like the Big Leeds Chat have helped senior leaders to listen directly to local people and staff from across the city. The People’s Voices Partnership is an expert advisory panel and was instrumental in pulling together the insight reports that our Population and Care Delivery Boards use to understand what matters to the people of Leeds. We have a number of public groups and involvement activities across the city that will help us work together with local people and staff. These groups and activities will enable us to continue listening to people and to use their feedback to shape our services. We are also committed to feeding back to people about how their stories and experiences help us to improve services in Leeds.


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

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