2.1 Give every child the best start in life
Also supporting our Integrated Care Strategy Priority “Give every child the best start in life”.
Our ambition
All children will have the best start and be supported to live as healthily as possible.
Our challenges
Health concerns linked to social disadvantage, increasing social and emotional difficulties in young children, mapping through to school exclusions (including primary), youth justice entrants and increasing numbers of children with social and communication difficulties.
Children aged four to five years old in Essex (22.3%) and in Hertfordshire (20.1%) are classified as being overweight or obese. This increases for 10–11-year-olds in Essex to 33.1% and in Hertfordshire to 30% (2019/20 data).
Emergency hospital admissions for children aged under 18 years are significantly higher in East and North Hertfordshire and rates of Emergency Department (ED) attendances are higher in west Essex for children aged under five years than the national average. There are increasing numbers of children needing crisis intervention, with numbers of children in the care of their local authority and those needing mental health specialist hospital provision increasing.
What our residents say
We established a youth council in September 2023 with 10 youth ambassadors representing the voices of children and young people from across Hertfordshire and west Essex. We have been meeting with the youth ambassadors, to learn what young people want from services, and how best we engage them. This results in a co-production project to produce a number of videos and The Patient Association and the Youth Ambassadors gave their opinions and views on what is it like to access a GP surgery and the top health concerns for children and young people today.
A summary of the key findings are outlined below:
- Young individuals expressed a preference for engaging with health services through online platforms, such as apps.
- When seeking medical assistance, they indicated a desire to communicate with healthcare professionals who are more relatable in age, fostering a greater sense of understanding.
- To enhance outreach, it was suggested that health services should utilise social media platforms that resonate with the younger demographic, like Instagram and Snapchat.
- Young people with Special Educational Needs and Disabilities (SEND) require additional time for communication to ensure their voices are adequately heard.
- Some participants were unaware of the services provided by pharmacies, particularly for advice and contraceptives. They emphasised the need for increased promotion of these services in schools and on social media. Concerns were raised about the perceived lack of privacy in pharmacies.
- There is a demand for more education on overcoming mental health challenges among young individuals, as they feel current educational efforts are insufficient.
- To make informed decisions about their health, young people expressed a need for more information on the long-term effects of vaping and drug consumption.
Our plans
How will we know we made a difference?
We will have:
- reduced the numbers of stillbirths and deaths in the first week of life
- reduced waiting lists for neurodiversity services
- decreased waiting times across all community paediatric services
- reduced emergency admissions for all children under 18
- increased utilisation of hospital at home and other approaches to support children to have hospital level care in their own home.
2.2 Increasing healthy life expectancy and reducing inequality
Also supporting our Integrated Care Strategy Priorities “Improve support to people living with life-long conditions, long term health conditions, physical disabilities and their families” and “Support our residents to maintain healthy lifestyles”.
Our ambition
Reduce under 75 mortality from long-term conditions.
Our challenges
Whilst the Hertfordshire and west Essex population is (in general) less deprived than the national average, there are communities within each of our three place areas with much more significant deprivation, where health and other outcomes are not at the same level as other parts of the system.
Our populations life expectancy is reducing through conditions including heart disease and obesity with wide variation between our place areas.
Around 1 in 5 adults across our geography are physically inactive, which means around 20% of the adult population are at increased risk of a range of health conditions and diseases which are preventable through increased physical activity.
In 2022, the median age of death for people with learning disabilities in Hertfordshire was 61 years old (males and females). The national LeDeR Learning from Lives and Deaths Annual Report (2022) indicates that the median age of death of autistic adults is 55. This is considerably lower than the median age for the general population at 82.3 for males and 85.8 years for females (2018/20). 4.9% of our population take 10 or more medicines often for more than one long term condition. All medicines cause adverse effects and sometimes the cause is not recognised. By effectively regularly reviewing medicines with patients and carers these effects and some of their harmful outcomes can be reduced.
What our residents say
Our ICS commissioned online focus group sessions in early November 2022, to hear from stakeholders who work with or represent seldom heard communities. Each group brought together representatives who work closely with specific groups including BAME; Children and Young People; People Living in Poverty; and a General Inclusion Group.
This qualitative work brought these issues to light:
“Those people from deprived backgrounds on low-income jobs who are not able to afford appointments [as they are] working very long hours, very scared to take time of work, in terms of not getting time off work or would lose money to get appointments by GPs.”
“We need to be aware of the physical barriers like public transport and the cost of getting to these locations for these appointments”.
“The built environment has a huge influence on people’s health in the long term, can we get a better built environment? Can we do better in terms of our housing stock? Can we do better in terms of, I mean, with the financial crisis coming along? How are we helping our residents in terms of economic support, jobs and so forth?”
“We do a lot of work with families with children who are under five in one of, if not, the most deprived neighbourhoods in Hertfordshire and you know what we’re seeing there is, we’re trying to kind of marry together, health and well-being education and learning and development of skills and your kind of trying to work against a centralised kind of mechanisms and it does make it quite challenging. So one thing is whilst looking at priorities, it’s also about looking at the place’s priorities alongside those overarching ones and being able to be a little bit more flexible.” “The doctors don’t live in the communities where the people live and they don’t understand that you’re having a choice between paying for the bus to go to the food bank or pay for the bus to go to see the doctor, and then you get a snotty note saying why didn’t you turn up your appointment?”
In 2023, as part of the JFP Healthwatch report we found that 16% (84) of respondents said they would like more information about the side effects of medication, particularly the long-term effects, and 7% (37) want more information about any contra-indications or interactions between medications. 11% (55) of respondents said they would like more direct and precise information about what their medication is for, and how best to take it.
Our plans
How will we know we made a difference?
We will have:
- an increase in life expectancy across our system
- a lower rate of mortality from all cardiovascular disease
- an increase in the number of GP recorded hypertension patients with a blood pressure reading within the target range
- a fall in the rate of suicide across Hertfordshire and West Essex
- targeted work to identify patients with hypertension in our most deprived communities
- a reduction in high dose inhaled corticosteroid inhaler prescribing
- a reduction in high carbon inhaler use
- a reduction in overprescribing in people with learning disabilities.
2.3 Improving access to health and care services
Also supporting our Integrated Care Strategy Priorities “Support our communities and places to be healthy and sustainable” and “to improve our residents’ mental health and outcomes for those with learning disabilities and autism”.
Reduction in the numbers waiting for elective activity and diagnostics
Our challenges
- Post the pandemic patient health needs have increased and require more complex diagnosis and treatment.
- The current size of the waiting list is greater than the current capacity will allow.
- The numbers of patients waiting for elective treatment has fallen over the last six months but remains high.
- Outpatient and theatre productivity is currently below national standards and is inconsistent across the system, currently 80%, below the required 85% (Theatre productivity).
- We are finalising our elective strategy to increase capacity and improve productivity to ensure that patients are seen more quickly and waiting lists continue to fall. There are inconsistent pathways for the same conditions across our system providers leading to unwanted variation.
What our residents say
A survey into Joint Forward Plan priorities, carried out in 2023 by the ICB and thematically analysed by Healthwatch Hertfordshire heard from 1,124 respondents, predominantly aged 50+.
- When asked whether they would be prepared to travel to have non-urgent treatment more quickly, 70% said that they would be prepared to travel to another location in Hertfordshire or west Essex, and 59% said that they would be prepared to travel to a neighbouring area.
- 77% of respondents agreed that they would be happy to receive initial healthcare advice from a telephone appointment.
- 15% (60) of respondents suggested that the NHS could do more to support people by improving access to services. For example, a large proportion felt that the NHS needs to shorten waiting times, particularly in relation to GP services, secondary care and mental health services.
- 90% of people surveyed said that they would be happy to see other professionals, such as a physiotherapist, social prescriber or practice nurse if this person had the skills required to help them, rather than wait to see a GP.
Everyone is able to easily and rapidly access the right urgent and emergency care
Our challenges
Many people are accessing services that are not best suited to their urgent care needs. One third of emergency department (ED) attendances in HWE resulted in no investigation or treatment suggesting these needs could have been addressed by alternative same day access in primary care or integrated urgent care, to free up capacity to deal with true emergencies within ED.
Currently, there are delays in responding to ambulance calls across HWE, but many of these calls could be appropriately responded to by another service in primary or community care and would protect ambulance capacity to respond faster to the more serious emergencies.
What our residents say
A local survey to understand the views and experiences from people who had used our urgent and emergency care services in the past 12 month found the most cited suggestions for improvements related to primary care access, many citing difficulties in obtaining a same day GP appointment which often related to the 8am rush for appointments or about obtaining a face-to-face appointment. Almost one third of respondents reported they didn’t know where to seek help for urgent or same day care, and 1 in 10 respondents felt services were confusing or hard to understand.
Increase in the provision of early help to prevent mental illness and support the health and wellbeing of those with a Severe Mental Illness (SMI), learning disabilities or autism
Our challenges
In Hertfordshire, the excess mortality rate for adults with a severe mental illness is above the regional average and in Essex, the rate of premature mortality is similar for cancer, cardiovascular disease, and respiratory illnesses (Source: Health Needs Analysis Overview 2022). Mental health is a contributor to the gap in life expectancy between the most and least deprived areas, 6.9% for males in Hertfordshire and 2.9% in west Essex and 10.3% for females 7.6% in west Essex, (Source: Hertfordshire Public Health Evidence and Intelligence, 2022 and Essex Joint Strategic Needs Assessment 2021-22).
There has been a yearly increase over the last 3 years of adults reporting a long-term mental health condition. In 2022, the median age of death for people with learning disabilities in Hertfordshire was 61 years old compared to the national Learning from Lives and Deaths Annual Report (LeDeR) (2022) which indicates the median age of death of autistic adults is 55 years old. This is considerably lower than the median age for the general population at 82 years old for men and 85 years for women (2018/20).
Autistic people are up to three times more likely to experience mental ill health and for many ill health can be more difficult to recognise, this can cause delays in diagnosis and led to delays in accessing appropriate support or treatment. The relationship between drug use and mental health problems among young people is of particular concern. Research shows that mental health problems are experienced by 70% of drug users in community substance misuse treatment. Deaths by suicide are also common among those with a history of drug misuse, between 2008 and 2019 34% of deaths from suicide were amongst people known to be experiencing mental health problems.
What our residents say
A survey into Joint Forward Plan priorities by the ICB was, carried out in 2023 and thematically analysed by Healthwatch Hertfordshire heard from 1,124 respondents, predominantly aged 50+. 30% (136) of respondents said easier, quicker access to GP services would support them in getting the help they need for their mental health. Of these respondents, some also suggested that GP services should be more proactive in asking patients about their mental health and should be more aware of mental health issues.
24% (108) of respondents suggested waiting lists are too long, with many noting they have had to wait months before they were offered an appointment or treatment. Some respondents would like interim support while waiting for treatment. 10% (41) of respondents suggested that NHS staff need more training, particularly around how to support and interact with people with autism, people with learning disabilities, and people with sensory needs.
Our plans to improve access to health and care services
How will we know we made a difference?
We will have:
- faster access and delivery of cancer services in line with the cancer standards
- quicker access to diagnostic tests
- shorter waits for planned care
- easy and rapid access to same day or urgent care as needed
- fewer emergency hospital admissions for intentional self-harm across the system
- an enhanced response to urgent referrals to community crisis services
- a reduced use of inappropriate out of areas placements for mental health patients
- reduced emergency hospital admissions for intentional self-harm across the system.
2.4 Increasing the number of residents taking steps to improve their wellbeing
Also supporting our Integrated Care Strategy Priorities “Support our communities and places to be healthy and sustainable” and “Support our residents to maintain healthy lifestyles”.
Our challenges
Falling life expectancy through conditions including heart disease and obesity and the number of adults who are overweight was similar to that of England in 2020/21, and still notably high at 62%, with wide variation between districts.
Around 1 in 5 adults across our geography are physically inactive, which means around 20% of the adult population are at increased risk of a range of health conditions and diseases which are preventable through increased physical activity.
Smoking in adults is similar or better than the England average for all our districts; however, there is some variation between the areas with the lowest rates (St Albans at 5.4%) and the highest (Harlow at 18.9%).
What our residents say
A survey into Joint Forward Plan priorities, carried out in 2023 by the integrated care board and analysed by Healthwatch Hertfordshire heard from 1,124 respondents, predominantly aged 50+. Showed that 10% of respondents suggested that the NHS could focus more on prevention to help improve the health of the population, particularly those in the most need. Of this 10%, some felt that the NHS could work more closely with other services, including councils, Public Health and the voluntary sector to improve health outcomes. Respondents also suggested that prevention could focus on providing more education and practical support about how to live a how to live a healthy lifestyle with considerable support for more preventative interventions and early diagnosis through health checks.
They recommended; GPs awareness, education and training to signpost people to support services, particularly for gambling addiction, also addiction awareness in schools, colleges, universities and for parents to educate about soft socialisation to gambling including related harm and alcohol within families as well as for drug and alcohol addiction.
Our plans
How will we know we made a difference?
We will have:
- a reduction in the smoking prevalence in Hertfordshire and West Essex
- an increase in those who are on low incomes receiving targeted support
- an increase in our residents accessing information that will help them stay healthy and improve their wellbeing.
2.5 Ensuring financial sustainability
Also supporting our Integrated Care Strategy Priority “Enable our residents to age well and support people living with dementia”.
Our ambition
- Achieve a balanced financial position annually and efficiency and productivity targets achieved.
- Frail older people will receive urgent and emergency care as close to home as possible to avoid harm of hospital stays and minimise disruption to their lives.
Our challenges
Demographic changes in Hertfordshire and West Essex mean that our older population will be growing rapidly, with an expected increase in the next 10 years of those aged 65 in Hertfordshire by 23% and 28% in Essex. We also expect the number of over 85-year-olds to grow by 55% during this period. We expect demand for our services to increase in line with these demographic changes.
The older members of our population are typically the most intensive users of health and care services. For instance, 50% of people aged 65 years and over with a hospital admission are estimated to be living with frailty. The median average cost of admission for those aged 65 years and over is currently £3,309. Unless action is taken to reduce the anticipated demand and also to provide more efficient healthcare our costs will increase and it will become increasingly challenging to achieve financial balance.
Medicines spend is also increasing year on year, as we have people living for longer, identify more people who have conditions that need treatment and identify more treatments for different conditions, getting best value from our spend on medicines is essential and this can be achieved by using the best value medicine first, having an agreed outcome and criteria for discontinuation. Measuring the health outcomes of the medicines prescribed is a challenge and we are trying to do this taking a system population health approach.
Our plans to support our changing demographics and financial challenges
Financial recovery:
A range of high-impact schemes have been identified to help address our financial challenges in 2024-25, these broadly fall into five workstream areas:
- Initiatives that will improve productivity
- Initiatives that will manage workforce growth and reduce agency spend
- A whole system transformative approach to managing frailty and EOL care
- A whole system transformative approach to managing growth in mental health, learning disabilities and autism in the system
- Initiatives that will secure better value from contracts and increase efficiency
These are currently being developed into detailed projects with phasing of savings, including potential impact in 2024-25 being quantified.
How will we know we made a difference?
We will have:
- more care taking place at home or in the community
- developed a local workforce pipeline in line with workforce clinical expansion targets, support better retention of our workforce and reduce agency spend
- decreased our spend on urgent and emergency care.