Delivering our priorities for 2024-2026

2024-25

Implement our new clinical pathways, including revised staffing model to reduce diagnostic waits and ensure the right people are offered assessments through improved multi-agency support built around the child and family. These changes will initially focus on Hertfordshire, as in west Essex they have made significant service improvements and developments but there are plans for west Essex to be incorporated into the second phase of developments.

The digital patient interface for referrals into west Essex community healthcare was launched and we are working across the Essex Southend and Thurrock Transforming Care Partnership to progress and deliver a pilot around accelerated autism assessments for children and young people at risk of admission.

2025-26

Undertake an evaluation of Autism Spectrum Disorder Psychoeducational Resource pilot across Essex, Southend and Thurrock and monitor and review pathways and support offered in line with changing needs and demand.

Progress indicators

Reduction in waiting times for a diagnosis (% of patients waiting less than 18 weeks, July 2024: East and North Hertfordshire NHS Trust (ENHT) – 16.9%, HCRG (Health Care Resourcing Group)19.6%, Hertfordshire Community NHS Trust (HCT) – 39.3%, Hertfordshire Partnership University NHS Foundation Trust (HPFT- ADHD only) 17.6%)

2024-25

Complete phase 1 of the Family Hub Service model delivering universal and targeted support for children, young people and families, including support with: parenting, helping parents and carers to manage their child’s behaviour and respite support. It will also support adults with challenges that impact on children, including support with parental substance misuse, mental health, physical disabilities or domestic abuse.

We will mobilise this new service with strong partner and community links within the Voluntary, Community, Faith and Social Enterprise (VCFSE) sector, schools, Hertfordshire County Council and districts/borough councils. We will work with these partners to drive a preventative approach with holistic whole family support, making every contact count and reduce duplication between our services.

2025-26

Complete phase 2 of the Family Hub Service model expanding the hub further to encompass support for 0–25-year-olds and increase collaboration with partners and other services.

Progress indicators

• An increase in the proportion of children accessing early help support.
• An increase in the number of children accessing mental health support.
• A reduction in the proportion of 0–4-year-olds attending Emergency Departments (ED). An increase in the proportion of children under 5 years old who have had the required immunisations.

2024-25

Improve detection and control of hypertension (high blood pressure) through awareness raising (communications campaign) and community engagement events, increased access to blood pressure measurements in general practice, community pharmacy, outpatients and other community settings, as well as adopting a ‘Making Every Contact Count’ campaign across NHS providers and working with wider non-NHS organisations to use every opportunity to achieve health and wellbeing.

Restore performance of local stroke services to pre-pandemic Sentinel Stroke National Audit Programme (SSNAP) standards and begin implementation of the Integrated Community Stroke Service specification (ICSS).

Development of a local integrated lipid service and improving the delivery of core care for people with raised cholesterol in primary care.

Including integrated heart failure services with shared objectives and improve delivery of core care in primary care for people with heart failure. Primary care will continue to be funded to deliver core care processes and manage the health needs of people with heart failure atrial fibrillation and high cholesterol proactively.

2025-26

• Continued monitoring and improvements to hypertension detection and treatment, with a specific focus on tackling inequalities.
• Implementation of a community lipid clinic.
• Working towards full implementation of an integrated community stroke service (ICSS).
• Development and delivery of integrated care models across the ICS for people with heart failure.

Progress indicators

• Increased identification of hypertension.
• Increased proportion of people with hypertension who are treated to age specific thresholds.
• Increase in the identification of hypertension among people living in the 20% most deprived communities.
• Reduce the waiting time for Echocardiogram (ECHO).

2024-25

We will continue to maximise use of nationally and locally commissioned weight management services for children and adults, ensuring all commissioned capacity is utilised.

We will support the mobilisation and integration into local system of a new Herts-wide, integrated tier 2 and tier 3 weight management service for adults.

We will embed early weight management support into clinical pathways (e.g. sleep apnoea, non-alcoholic fatty liver disease, diabetes) and optimise appropriate access to new anti-obesity medications. Whilst continuing to explore options for addressing unmet needs where people have been unable to achieve weight loss with tier 2 services.

In west Essex we plan to work with Essex County Council to review all weight management tiers including arrangements in Hertfordshire.

2025-26

Continue to embed early weight management support into additional clinical pathways (e.g. elective surgery, cardiology, fertility). Utilise a Population Health Management approach and the Core20PLUS5 model to identify priority groups for targeted intervention.

Progress indicators

An increase in the number of people referred to and accessing weight management services who go on to lose weight.

2024-25

Reducing the harm from medicines prescribed:

• System wide plan to reduce overprescribing and medicines waste.
• Sharing best practice across the system.
• Develop effective communication methods at place and within Integrated Neighbourhood Teams.
• Empower patients to know about the medicines they take, the expected outcome, potential side effects and the criteria for discontinuation.

2025-26

Embed a culture of shared decision making.

2024-25

To complete the building work and mobilise the Community Diagnostic Centre (CDC) spoke site at St. Albans City Hospital (SACH) offering additional capacity for MRI and CT scans.

Outpatients: embedding the Shared Decision Making campaign and to reduce the number of people who do not attend appointments without prior notice (DNAs). Continue to increase the number of people on a patient initiated follow up pathway and work towards supporting people through the functionality of the new patient portals. Increase the use of triage, specialist advice and guidance, implement ‘Get it Right First Time (GIRFT), through:

• standardisation and streamlined clinical pathways
• increasing our capacity to undertake elective care, support the reduction in variations in access time
• improved clinical outcomes and overall waiting times in accordance with the national standards by March 2025.

Increase specialist advice activity and scope potential opportunities for one stop clinics, to support the backlog of people waiting for their first outpatient appointment including optimisation of remote consultations and reduce variation in pathways and processes. Increase Multi-Disciplinary Team (MDT) working (utilising the different workforce skill mix accordingly), to enable a single outpatient appointment with multiple healthcare professionals, to reduce pressure on estates and increase capacity. Increase Patient Initiated Follow Ups (PIFU).

2025-26

Diagnostics: To complete the building work and mobilise the endoscopy unit at St Albans City Hospital and complete and mobile Clinical Diagnostic Centre (CDC) hub in Epping offering a range of diagnostic tests.

Progress indicators

• Reduce the size of the elective waiting list.
• Theatre utilisation equal to or greater than 85%.
• Day case rates equal to or greater than 85%.
• By March 2025; 95% of patients needing diagnostic tests seen within six weeks.

2024-25

Identify and quickly acknowledge people’s frailty at the front door of ED so that they can be swiftly referred to alternative services closer to home if most appropriate to meet their urgent care needs. If they require emergency care, we will endeavour to provide this on the same day, either through same day emergency care (SDEC) or acute frailty services with swift comprehensive geriatric assessment and frailty expertise to turn patient’s diagnosis and treatment around promptly and avoid unwanted or unnecessary admission to hospital.

To support the ambition to provide greater same day emergency care, efficient direct referral pathways between our ambulance service and acute trust SDEC services will be developed with a focus on increasing the proportion of frail patients seen and treated on the same day. We will develop direct referral pathways from primary care and NHS 111 and continue to develop pathways between SDEC and hospital at home and other community services supporting frailty.

2025-26

We will continue to make frailty everybody’s business and embed digitally enabled (direct booking) referral pathways to ensure SDEC is accessible across all parts of the healthcare system (primary care, community care and hospital at home, 111 and 999), including from a single point of access.

We will establish remote clinical support from senior clinical decision-makers in our acute trust to support ‘call before convey’ and direct access to SDEC.

Progress indicators

• Increase percentage of patients at risk of frailty (aged 85+ or over 65+with conditions) who have a clinical frailty score (CFS) recorded and accessing support.
• Increase proportion of frail patients who receive same day emergency care.

2024-25

Systematic identification of patients who are likely to be approaching the end of their life and support clinicians to undertake person-centred discussions about preferences and priorities for future care to develop advance care plans. Scope proposals for a digital advanced care plan with wide stakeholder engagement and implementation of the digital advance care plans in Q4 which will ensure consistent documentation that it is shared, and understood by all staff, across the health and care system.

2025-26

Continue to embed sustainable and robust digital advanced care plans accessible across the health and care system, use continuous quality improvement methodologies. Continue to strengthen our care coordination for those at end-of-life to facilitate care closer to home, learning from discharge facilitator pilots, and embedding end of life skills in our hospital at home workforce with clear pathways to specialist palliative support so that those at the end of their life who experience acute illness or exacerbation of long-term conditions can be supported and cared for closer to home.

Progress indicators

• Increase proportion of people who are routinely identified as likely to be in the last 12 months of life and who have an advance care that has been reviewed in the last 12 months.
• Reduce rate of emergency admissions for people on the End-of-Life register Increase proportion of palliative and end of life care (PEoLC) patients who die in their place of choice.

2024-25

Across HWE, map our falls prevention and rehabilitation services, and the pathways for people who have fallen and whose care and treatment could be provided in the community to avoid unnecessary conveyance to hospital. Identify opportunities to scope new, or maximise existing, commissioned services and clinical pathways to improve patient care.

A system-wide review by pharmacy and medicines optimisation team to identify individuals prescribed more than 10 medications and to identify those older people at risk of the cumulative effect of taking medications with anticholinergic activity (the ‘anticholinergic burden’ (ACB)) and support clinicians in assessment and deprescribing as necessary to reduce the risk of falls.

2025-26

Continue to develop our proactive approach to preventing falls, using continuous quality improvement methodology and learning from pilots, such as use of sensor devices in peoples’ own homes to predict falls or early decline in functioning.

Increase identification of those at risk of falls and promote self-referral into falls prevention services. Ensure patients at various falls risk receive best practice care and interventions, continue to develop strong links between community falls prevention services and the voluntary sector. Development of a fracture liaison service to identify those at risk of osteoporosis and proactively manage them to avoid falls-related injuries.

Progress indicators

• Reduction in prescribing for individuals on 10 or more medications.
• Reduce rate of emergency admissions for falls within the community for people aged 65+.
• Increase the proportion of people aged 75+ accessing falls services within the community.
• Reduce hip fracture rate in people aged 65 and over.

2024-25

A consistent high-level model of ‘Care Closer to Home’ will be developed and reflected in our community provider contract specifications, agreed by September 2024 to support a greater proportion of frail, older population to receive urgent and emergency care in the community.

A proactive approach to managing chronic disease and complex care through integrated neighbourhood team (INT) working will be embedded at scale. Using population health management INTs identify and prioritise specific cohorts, those prioritising complex and frail cohorts at risk, or rising risk, of deterioration and future unplanned care will be supported to design and target delivery of proactive and anticipatory care models, to predict deterioration earlier, prevent escalation of need and deliver timely urgent response closer to home before patients reach crisis point.

The ‘Care Closer to Home’ model will support integration of our Urgent Community Response (UCR) and Hospital at Home services with other community specialist services, primary care, hospital-based services and social care for seamless care and escalation purposes. We will boost our capacity for, and maximise referrals to, Urgent Community Response (UCR) to respond rapidly to urgent needs such as falls, decompensation of frailty, reduced mobility, or palliative care. Our hospital at home services will continue to provide safe and effective treatment to people living with frailty in their own home when acutely unwell.

Care Coordination Centres (CCCs) will closely align to the unscheduled care hub to ensure swift MDT coordinated response to safely navigate patients to the right care. CCCs effectively coordinate delivery of Care Closer to Home, preventing admission and facilitating rapid, safe, and appropriate discharge to avoid harms of hospital stays in those who are frail or older. A clear understanding of the demand for intermediate care and alignment to Discharge to Assess to ensure appropriate capacity and maximise timely access to support in the most suitable community setting for patient needs.

2025-26

Implement new ‘Care Closer to Home’ model reflected in community provider contracts from April 2025.

Continuous improvement and evaluation of the impact of our INT proactive care. Further support anticipatory care using remote monitoring and health technology data to identify patients at high risk of acute deterioration, and predict future hospitalisation, and target earlier community care, enhanced monitoring and oversight, to prevent deterioration and avoid unplanned hospital admission.

Scope expansion of our hospital at home to include other conditions and capabilities, driven by data in relation to population need in planned care and for children and young people.

Develop our Care Coordination Centres (CCCs) to be digitally enabled to manage daily flow and care coordination of patients.

Use data to map our population’s short and long-term care needs to ensure both intermediate care and long-term care services are fit for future ageing population and supports flow through the UEC pathway.

Continuous quality improvement approach to evaluate the impact of our ‘Care Closer to Home’ model, monitoring success of alignment of Discharge to Assess/Intermediate Care and the impact on personalisation and reduced ‘unrecoverable’ failed starts.

Progress indicators

• INTs delivering a collaborative service and continue to refine and develop new models of care with system partners.
• Reduce rate of unplanned hospitalisation for chronic ambulatory care sensitive conditions.
• Reduce emergency readmissions within 30 days of discharge from hospital.
• Reduce readmission rates from reablement.
• Increase the proportion of older people (65+) who were still at home 91 days after discharge from hospital into reablement/ rehabilitation services.
• Increase rate of patients discharged to usual place of residence following an acute admission.

2024-25

We will undertake a system wide review of alternative crisis services with the voluntary, community, faith and social enterprise (VCFSE) sector and clinical services. We will also enhance crisis cafes and sanctuaries and develop collaborative partnership working to ensure mobilisation of mental health ambulance response vehicles. We will also develop and monitor the impact of the system wide Mental Health Urgent Care Centre (18+) at Lister Hospital and explore options for increasing the offer to other acute trusts.

Develop a joint response car supporting community-based mental health crisis and need. Integration of mental health expertise in unscheduled care hubs and review support to those substance misuse and mental health, including expansion of the alcohol care support team service. Continue to map coverage of mental health crisis care to understand the gaps, including emergent neurodiversity. We plan to continue to develop our community services to improve the prevention of mental health crisis.

2025-26

To provide comprehensive coverage across the system of an integrated urgent care response to support people experiencing mental health crisis, including those simultaneously suffering substance misuse. To build on the improvements in 2024-25 and continue to develop our community services to support the prevention of mental health crisis.  

Progress indicators

• Increase the number of crisis beds available.
• Increase ‘see and treat’ for patients in mental health crisis.
• Reduced ambulance conveyances for mental health crisis.
• Improved patient experience.
• Reduce emergency department (ED) presentations for those with a mental health condition.
• Improved pathways for those with a mental health condition presenting at ED.

2024-25

Continue to monitor (as appropriate) the mobilisation of capital developments and evaluate the benefits of them to enhance accessibility to adult crisis services, improving quality of the environment as well as people’s experience. We will work with all partners to implement the Right Care, Right Person Programme (RCRP) which is a partnership approach aimed to ensure that the people in mental health crisis are seen by the right professional. Work with partners to reduce out of area bed placements, monitor the impact and outcomes of the RCRP approach and explore system options/proposals to support inpatient needs. 

2025-26

Increase access for children and young people (CYP) and improve outcomes, listening to their feedback, addressing waiting times and tackling health inequalities. Continue to increase access to Herts CYP mental health services in line with NHSE targets, improved navigation, and awareness. Ensuring offers are informed by data, effective, and can support preventative actions. Understand Herts CYP/F user experience and professional confidence in services to support any system improvement. Monitor and understand demand and capacity of CYP mental health services.

In west Essex, alongside expanding access, the focus will be on developing and improving core services, particularly in the areas of early intervention, prevention, community health, reducing inequalities, improving quality. With more of an emphasis on improving outcomes and experience of service for our CYP, families, and carers. 2026-2029: Work towards 100% of children and young people achieving access to specialist mental health care. Build on THRIVE methodology (i-THRIVE | Implementing the THRIVE Framework (implementingthrive.org) and principles, ensure Herts CYP are involved in shared decision making and feel empowered to have an active role around their own mental health and wellbeing.

Progress indicators

• Reduction in out of area bed placements and length of inpatient stay.
• Reduction in police handover time for S136 detentions.

2024-25

Continue to increase mental health support teams working with schools to embed effective whole school approach to the emotional wellbeing of students.

Hertfordshire focus: Continue to develop our Equity Equality Diversity and Inclusion (EEDI) practice and policy, to tackle health inequality enabling open and accessible services regardless of additional vulnerabilities (Core24Plus5). Increase access through improved system awareness and navigation, with clear accessible clinical pathways. Evaluate service delivery and activity to ensure it remains outcome focused, seek to develop a systematic approach with stakeholders to grow, retain and align the workforce to meet the Herts children and young people population needs.

Develop crisis support, ensuring continuation of 24/6 access and develop approaches to prevent crisis triggers using evidence informed data. Develop, grow, and embed co-production with children, young people, and families to ensure they are involved in shared decision making and feel empowered to have an active role in their own mental health and wellbeing. West Essex focus: Continue to ensure that children and young people (CYP) aged 0-25 have access to mental health services via adult mental health pathways and school/college based mental health support teams. Maintain 24/7 access to community crisis response and intensive home treatment as an alternative to acute inpatient admissions; sustain the target of 95% of CYP with eating disorders accessing treatment within 1 week for urgent cases and 4 weeks for routine cases. Ensure CYP mental health plans align with those for CYP with learning disability, autism, (Transforming Care cohort) special educational needs and disability (SEND), CYP’s services, health, and justice.

2025-26

Increase access for children and young people (CYP) and improve outcomes, listening to their feedback, addressing waiting times and tackling health inequalities. Continue to increase access to Herts CYP mental health services in line with NHSE targets, improved navigation, and awareness. Ensuring offers are informed by data, effective, and can support preventative actions. Understand Herts CYP/F user experience and professional confidence in services to support any system improvement. Monitor and understand demand and capacity of CYP mental health services.

In west Essex, alongside expanding access, the focus will be on developing and improving core services, particularly in the areas of early intervention, prevention, community health, reducing inequalities, improving quality. With more of an emphasis on improving outcomes and experience of service for our CYP, families, and carers. Work towards 100% of children and young people achieving access to specialist mental health care. Build on THRIVE methodology and principles, ensure Herts CYP/F are involved in shared decision making and feel empowered to have an active role around their own mental health and wellbeing.

Progress indicators

Improve service user experience of CYP mental health services.

2024-25

Continue to maintain early help and support by providing innovative digital therapies as well as efficient digital platform gateway for all mental health services; with focus on empowerment/self-care for Herts CYP/families/Carers, providing guidance, information, self-help and tailored support. In west Essex, continue to develop digital support offer for CYP Mental Health (MH); balancing digital offer with face-to-face provision, responding to feedback from CYP. Ensure there are digital leads across all North East London Foundation Trust (NELFT) Southend Essex Thurrock (SET) Child and Adolescent Mental Health Services (CAMHS). Development of comprehensive offer (web, social media, treatment options).

Progress indicators

• Increase the use of digital support, advice, and guidance in CYP mental health services.
• Improve service user experience of CYP mental health services digital support.

2024-25

Continue to review and monitor the ‘all age digital intervention offers’ including impact, outcomes data and experience feedback. To support those who are digitally engaged and motivated to use online mental health self-help tools and ‘AI’ based therapeutic interventions to gain quicker access to support.

Develop and embed the CYP mental health ‘front door’ triage team and the digital gateway portal and support improved navigation, increasing access, automated referrals, brief and single session interventions, advice, guidance to improve both the experience and journey of CYP. Enhance mental health data available on the Shared Care Record to provide greater information sharing across the system to enable greater visibility of patient needs at other care settings i.e. Emergency Department/Primary care.

2025-26

Increase deployment of the online library of self-care apps that can support community mental health models. Enable electronic access to appointments, letter, care plans to help primary care networks and community working. Use automation for common tasks to increase capacity and provide more time to care. Implement systems to make it easier to book, track and manage rooms, equipment and resources to support new models of care in community and primary care networks. Herts CYP mental health services ‘front door’ triage team functioning; with outcomes and benefits realisation expected in the summer of 2025. Undertake a review of the Herts CYP mental health triage team to understand the impact and consider growth.

Progress indicators

• Increased Mental Health data on Shared Cared record use.
• Reduce missed appointments.
• Increase access to electronic services i.e. appointments, letters.
• Improve patient satisfaction.

2024-25

In west Essex the focus will be on prevention and early intervention, acute and crisis, supporting recovery. Key priorities will include the expansion of the CYP mental health primary care roles to increase access. Expand Mental Health Support Teams in educational settings; expand access to First Episode Rapid Early Intervention for Eating Disorders (FREED) and Avoidant/ Restrictive Food Intake Disorder (ARFID), CYP Eating Disorder (CYPEDs) Pathways. Maintenance of CYPEDs community intensive support services; improving access to infant mental health service and increasing access to health and justice mental health provision.

Ensure continuity of early intervention and prevention (non-clinical services) designed to complement the core CAMH service offer. Extend the Mental Health Liaison Nurse roles in acute settings to assist paediatric teams to respond to mental health needs of CYP. Roll out of self-harm management toolkit in education settings, expanding the community mental health and children and young people learning disability neurodevelopment team. Mobilising at risk mental health (ARMS) teams; maintain pathways to support the Young Adults transition (18-25) and embed the principles of THRIVE to ensure services are needs led. In Hertfordshire evaluating the paediatric mental health liaison model for children and young people with mental health needs who present in acute paediatric settings as part of the wider crisis model. Design a new clinical model and pathways for ASD/ADHD services and explore potential shared learning from west Essex regarding ASD support hub pilots. Continue to reduce Out of Area placements and explore alternative options to maximise our local bed base. Continue with the Quality Transformation Programme for Mental Health, Learning Disability and Autism Inpatient Services under the Commissioning Framework for Mental Health Inpatient Services.

2025-26

Consider the implementation of new combined clinical model for ASD/ADHD across NHS providers in Hertfordshire.

Progress indicators

• 70% Service users reporting satisfaction with services received.
• 92% Referral to Treatment (RTT), incomplete pathways, CYP waiting to start treatment <18 weeks.
• 95% RTT (completed pathways) – CYP seen <18 weeks. Reduce the number of missed appointments to the target rate,10%.