Place Place Programme Place Lead Cheshire East Cheshire East Partnership Mark Palethorpe

Cheshire West Cheshire West Place Plan Delyth Curtis

Halton One Halton David Parr

Knowsley Knowsley Better Together Dianne Johnson

Liverpool One Liverpool Jan Ledward

Sefton Sefton Health and Care Partnership Fiona Taylor

St Helen’s St Helen’s People Board Sarah O’Brien

Warrington Warrington Together Andrew Davies

Wirral Healthy Wirral Simon Banks

/

(https://www.cheshireandmerseysidepartnership.co.uk)

CHESHIRE EAST

As with all areas of the country,

NHS and social care services in

Cheshire East are under

increasing pressure. While

standards of care locally are high

and the area’s three main NHS

trusts are rated ‘Good’ by the

Care Quality Commission, there

is an urgent need to transform

local care services.

The area has an ageing

population, life expectancy is

better than the England average

but there are large variations

between and within towns. As the

population of approximately 373,000 people gets older, more and more people are suffering from

long term conditions such as high blood pressure, liver failure, diabetes, cancer, dementia and other

mental health problems.

The place partnership board in Cheshire East is looking at whole system improvements and is

progressing a number of community solutions, to improve assessment and care for patients arriving

at hospital that avoids the need for admission; and move how we care closer to people’s homes to

improve their independence and wellbeing. Our agreed local priorities include:

Support the transformation of general practice as a core foundation of our progress to

implementing new models of integrated health and care communities

Agreeing a model of sustainable hospital services that link to other components of integrated

health & care services for local people and their communities

For specialist mental health services, deliver the NHS Five Year Forward View and provide

more care closer to home

Operate as a system within the total available financial resources

This significant transformation programme includes the development of eight care communities, five

in Eastern Cheshire and three in South Cheshire which are a key first step towards developing a

local integrated care system by 2020.

/

The ultimate aim is for “joined up local care” for the population of the Cheshire East Place through

integrated health and social care services provided to people where they live clustered around the

eight local communities of:

1. Crewe

2. Sandbach, Middlewich, Alsager, Scholar Green and Haslington

3. Nantwich

4. Bollington, Disley and Poynton

5. Chelford, Handforth, Alderley Edge and Wilmslow

6. Congleton and Holmes Chapel

7. Knutsford

8. Macclesfield

Mark Palethorpe, Executive Director of People for Cheshire East Council, is Senior Responsible Officer.

View the latest plans for Cheshire East here (https://www.easterncheshireccg.nhs.uk/Your-

Views/five-year-plan.htm).

/

Children are overweight or

obese by year 6

Adults suffer from depression

have a MH disorder

2 diabetes

Is the average age that men

e to over 75

/

(https://www.cheshireandmerseysidepartnership.co.uk)

CHESHIRE WEST

The overall quality of life is good for many residents in Cheshire West. However, there are places

where some communities experience multiple disadvantage and this affects their health and

wellbeing.

The population has an ageing profile, with the number of residents aged over 65 expected to

increase by more than 50% by 2029. The number of people over 85 will more than double and many

of these will have long term conditions.

The key lifestyle issues facing the area are

smoking, unhealthy weight, lack of physical

activity and substance misuse. The number

of smokers has fallen in recent decades,

but the smoking rate is still higher than the

national average and there needs to be

programmes aimed at reducing this.

Almost half of the areas' adults do not

exercise enough and the number of

overweight and obese adults and children is

increasing.

Heart disease and cancer are the key diseases that contribute to life inequalities for men; in women,

it’s cancer – particularly lung cancer.

A partnership approach for improving health and wellbeing will include addressing excess weight in

children of primary school age, improving mental health services and increased support for older

people.

The lead for Cheshire West is Delyth Curtis, Deputy Chief Executive – People, Cheshire West and

Chester Council. Further information can be found here:

https://www.cheshirewestandchester.gov.uk/your-council/policies-and-performance/council-plans-and-

strategies/place-plan/cheshire-west-place-plan.aspx

/

Children are overweight or

obese by yea r 6

Adults suffer from depression

have a MH disorder

die from cancer

Adults are over- weight or obese

Adults under

2 diabetes

die from hea

Is the average age that women

e to

People ta ke less than 30 mins

exercise a week

over 75

/

/

(https://www.cheshireandmerseysidepartnership.co.uk)

HALTON

Health has been steadily improving in Halton.

People are living an average of two years

longer than a decade ago.

Fewer adults smoke and, thanks to

improvements in diagnosis and treatment,

fewer people are dying of heart disease and

cancers.

More children and older people are getting

their vaccinations and immunisations, and

Halton is above the national average for

children participating in at least three hours

of sport or physical activity each week.

However, life expectancy in Halton remains below the national average.

The One Halton (http://www.haltonccg.nhs.uk/get-involved/one-halton) Partnership

The One Halton Partnership brings together local NHS services, the council and other partners to

improve health and care for local people. Its goals are to:

design and deliver services that enable people to take more responsibility for their own health and

wellbeing

ensure people stay well in their own homes and communities as far as possible

provide complex care that is timely and appropriate

The partnership works with local communities to ensure it delivers services that are organised and

delivered to get the best possible health and wellbeing outcomes for our population of all ages and

communities.

Covering two towns our neighbourhood “Hub model” allows multiple organisations and teams to work

together seamlessly to support our population. We have created four hubs that exist both virtually

and physically wrapped around the GP practices within Runcorn and Widnes supporting an

approximate 30,000-50,000 population.

/

/

Each hub is made up of health and care professionals, health improvement officers, wellbeing

practitioners and the voluntary sector to promote self-care and independence, helping people to get

the right care, in the right place, at the right time, from the right person that helps the individual to

help themselves stay well and when necessary seek support where necessary and to access as

quickly as possible. The hubs do not replace any existing GP practice but they are an opportunity for

practices and other health and care professionals to work better together.

Connecting Care for Children (CC4C)

We are creating opportunities for greater partnership working between organisations for children and

young people, plus creating an environment for community teams to work within the Neighbourhood

“Hub model” providing an opportunity to involve colleagues from social care, mental health, third

sector and education, with General Practice to address and manage children’s and adolescent health

issues. The Connecting Care 4 Children encourages shared learning, provides a whole person

approach including families & carers, increases parent and professional confidence in how child

health services fit into our neighbourhood Hub model, creating better outcomes through coordinated

care, enhanced paediatric skills, confidence and competence in the professionals and helps manage

unplanned hospital attendance and admissions.

Beat the Scrum

One initiative to promote healthy living is the Beat the Scrum project in partnership with Widnes

Vikings Rugby League Club. Widnes Vikings stars lead campaigns to help local people learn how to

make the right NHS choices when sick or injured, so they can be treated more quickly and help take

pressure off local health services.

Housing and health

As new homes are built and new places take shape, the One Halton Partnership is working to ensure

that new developments take into account the health and wellbeing of the population. This will mean

improved housing choices, better access to more green space and community facilities, and

providing an environment where individuals and families can flourish and thrive.

The partnership has also created a team with housing and health partners to better target health

campaigns to residents, to identify people who might need support to stay well, to train housing staff

to spot the early signs of Dementia and raise awareness of scams that target older vulnerable

people.

The Lead for Halton is David Parr (/about-us/meet-the-partnership), Chief Executive of Halton

Borough Council. Further information can be found here: http://www.haltonccg.nhs.uk/get-

involved/one-halton

/

Children are overweight or

obese by year 6

Adults are over- weight or obese

Adults under

2 diabetes

die

from cancer

people are living with a long term condition

have a MH disorder

Adults suffer

from depression

die from

Is the average age that wome n

e to

than 30 mins exercise a week

Is the average age that men

e to over 75

/

/

(https://www.cheshireandmerseysidepartnership.co.uk)

KNOWSLEY

In 2017 the borough’s Health & Social Care Transformation Plan was agreed and since then partners

have been working towards integrated locality teams. In July 2017 ‘Knowsley Better Together

(http://www.knowsley.gov.uk/business/what-is-knowsley-better-together)’ was launched as the

blueprint for the way in which public service partners, local businesses and local residents will work

together to deliver a new deal for communities and improved outcomes for residents across the

borough.

The aim of the Health & Social Care Transformation plan is to develop and implement new models of

care that cross organisational and service boundaries and are firmly centred on the needs of

individuals, families, carers and the local community. As a result we aim to:

• Increase in the number of people supported to

manage their own conditions

• Reduce avoidable admissions to hospital

• Increasingly integrated community-based

management of long-term conditions

• Improve the effectiveness of reablement

services to support people to remain at home

• Increase social prescribing

• Increase resilience and sustainability of the Knowsley Health and Social Care system

• Reduce delayed transfers of care

Services will be co-ordinated through four locality hubs across the borough and over the past two

years the partners across the borough have been working towards the delivery of integrated care

through the locality hubs.

Case Study: Kirkby locality hub

Kirkby is the most deprived area of the borough. Morbidity rates for the majority of diseases in

Kirkby are higher than the England average with the highest prevalence of disease being for

respiratory disease, hypertension, obesity and depression.

/

/

Multi-disciplinary team working for patients at high risk of admission to hospital is already established

within Kirkby. Close working between clinicians, social care professionals, patients and their carers is

already leading to some improvement in health and care outcomes, increased efficiency and

reduction in duplication.

The lead for Knowsley is Dianne Johnson (/about-us/meet-the-partnership), Accountable Officer for

NHS Knowsley CCG.

More information on Knowsley can be found here: https://www.knowsley.gov.uk/business/what-is-knowsley-better-together

/

Children are overweight or

obese by year 6

40 have Type

Is the average Age that women

Is the average age that men

e to

/

/

(https://www.cheshireandmerseysidepartnership.co.uk)

LIVERPOOL

Liverpool is once again a vibrant place,

yet high levels of deprivation and

health inequalities endure in parts of

the city, and deprivation is strongly

associated with poor health outcomes,

from childhood through to old age.

The city’s health and social care

system faces a number of key

challenges, including an ageing

population and increases predicted in

long-term conditions, including cancer,

dementia, cardio vascular and

respiratory disease.

One Liverpool

One Liverpool is a place-based, whole-system plan, setting out how the NHS, Liverpool City Council

and other key partners across the city’s health and social care system will come together to

establish integrated services.

Our aim is to better meet people’s needs, improve health outcomes, and to ensure that our local

health and care system is financially fit for the future.

The One Liverpool Plan sets out three main aims:

a radical upgrade in population health and prevention;

integrated community services;

standardised and sustainable acute and specialist services.

We need to take action now across all settings of care; embedding prevention, self-care and early

intervention; transforming community services to enable people to get the care they need, when

they need it with a broader offer that takes into account their social and economic needs and

ensuring that our hospital services offer consistently high quality services that are fit for the future.

/

/

Our ambitions for better health are for all-ages and incorporate parity of esteem for mental health. We

also need to tackle the long term health inequalities that leave the vulnerable and disadvantaged in

our city with a poorer experience of care, fewer years of healthy life and earlier death. This has to

change.

Partners will adopt a ‘One Team’ ethos, uniting primary care, social care, community physical and

mental health services and the voluntary sector; utilising our collective resources and pulling in the

same direction to ensure that people become healthier and get the best care.

The lead for Liverpool is Jan Ledward, Chief Officer of NHS Liverpool Clinical Commissioning

Group (CCG).

Find out more about One Liverpool and read operational plans

(https://www.liverpoolccg.nhs.uk/about-us/publications/one-liverpool-2018-2021/)

/

Children are overweight or

obese by year 6

40 have Type

Is the average age women will

live to

Is the average age men will live to

/

(https://www.cheshireandmerseysidepartnership.co.uk)

SEFTON

Sefton is a vibrant and diverse borough, with a rich cultural heritage and a wealth of stunning natural

resources that make it a great place to be. Whilst overall health in Sefton is improving, signi6cant gaps in health and life expectancy remain

between those living in the most deprived and least deprived areas of the borough, due to some

distinct local challenges and needs. Sefton's ageing population is growing much faster than the national average, increasing future

demand for health and care services. The number of people with long term conditions, sensory impairment, dementia, cancer and other

health problems is growing, as is the number of children with complex health and care needs.

Shaping Sefton for a healthier future Sefton Health and Care Transformation Partnership brings a range of organisations from across the

local NHS together with the council and other agencies to improve the lives of their residents. The work of the partnership builds on the Shaping Sefton (https://www.southseftonccg.nhs.uk/what-

we-do/shaping-sefton/) programme and its vision of ‘community centred health and care’. Collectively,

partners want to create health and care services that are better ‘integrated’ or joined up, so they work

seamlessly together. This approach will not only improve patients’ experience of their care and treatment but also help

ensure services remain sustainable into the future. Focused and continuous collaboration across the

partnership and a clear programme approach backed by strong leadership is required to achieve this

vision. It will see hospital, community, mental health, social care and primary care services (including

general practice) being even more focused around the needs of the local population. Sefton’s ‘place based model of care’ must be built up from community level using local clinician

expertise and knowledge and taking into account the special requirements of each of the differing

areas of the borough, known as ‘localities’. One of the areas the partnership is looking at is how best to ensure local hospitals continue to

deliver high quality care, whilst at the same time reducing the need for people to visit them in the

rst place by providing more services within the community.

/

/

This would build on the vast majority of health care that is locally delivered, improving not only the

experience of care for patients but keeping local health services both high quality and affordable. As this work takes shape, the partnership in Sefton will want to hear the opinions of people across

the borough and beyond about how local hospitals and the health and care services that support

them, provide seamless, sustainable and the best possible care for local people into the future. For more information go to https://www.seftonIveyearplan.co.uk/

(https://www.seftonIveyearplan.co.uk/).

Case Study: Integrated Frailty Pathway

Southport and Formby has a higher concentration of people over 65 than national average and

neighbouring localities. There is a signiLcantly high number of Care Homes (79) and a large demand

for step up / step down Intermediate Care Beds to enable hospital ow. The partnership has secured funding to bring together a team of professionals, starting work from

September, to manage the cases of patients with complex needs. Working across the localities, the team will be better able to assess, treat, evaluate and plan a

patient's care needs closer to home, with a focus on avoidance of admission to hospital, as well as

facilitating discharge. The lead for Sefton is Fiona Taylor, Chief Officer of NHS South Sefton CCG & NHS Southport &

Formby CCG.

Further information can be found here: https://www.southportandformbyccg.nhs.uk/what-we-

do/sefton-health-and-care-partnership/

/

/

/

/

(https://www.cheshireandmerseysidepartnership.co.uk)

ST HELENS

St. Helens is one of the most deprived council areas in England and life expectancy for both men

and women is lower than the England average.

The borough faces significant challenges in

improving outcomes for its residents and

reducing the unsustainable levels of

demand experienced by health care and

community services.

St Helens Cares

The St Helens People’s Board (a multi-

agency partnership established to tackle

these issues) has developed a new way of

delivering health and care called St Helens

Cares. Bringing together the council, local NHS organisations and other services such as the police and Dre

service, residents will:

bene t from a transformed, integrated care system, in which they receive care and support

which is joined up, of high quality, and affordable be supported and encouraged to do what they can to remain healthy, well and resilient live in a borough which encourages raising ambition, achieving aspirations, connectedness

and supports people to make the right choices This will be achieved by transforming how health, care and community services are organised and

delivered, and shaping a model of care which:

helps to achieve better outcomes for resident promotes independence and champions prevention works with local communities is clinically and financially sustainable

Adult Community Healthcare Services

/

/

In 2017, following a review of Intermediate Care and Out

of Hospital Nursing Services, a new way of providing

these services was introduced as the first step in the

redesign of out of hospital care for St Helens.

Experienced and multi-skilled teams working in the

community are responsive and proactive in their care of

patients; helping them to stay well and out of hospital for

longer. The Lead for St Helens is Sarah O'Brien (/about-us/meet-

the-partnership), Chief Officer of NHS St Helen's CCG.

Further information can be found here:

https://www.local.gov.uk/st-helens-peoples-board

Extra Care

Working with local housing trust, Torus, the St Helens

team have been able to reduce the number of patients staying in hospital beds over the winter

period who might be able to go home, but require adjustments to be made to their home first. Instead of the patient waiting in the hospital for these changes to be made to their home, they

were transferred to the extra care units within the Torus group. These units provide patients with

the comforts of home and mean their friends and family can visit any time they want to, but also

have healthcare professionals on hand when needed. This not only means that the hospital beds can be used for those who desperately need them, but

also gives patients a sense of independence and transition from hospital to home with the medical

support on hand for security.

/

/

/

(https://www.cheshireandmerseysidepartnership.co.uk)

WARRINGTON

Warrington is a large town in Cheshire, located on the banks of the River Mersey, with a resident

population of 208,800. Last year Warrington was hailed the ‘second best place to live in the UK’ (UK’s Best Place to Live,

Channel 4) and was placed fourth nationally in the uSwitch ‘Better Family Life Index’ in 2016. Warrington means business – it’s the only urban economy in the north of England to feature in the

Centre for Cities’ annual ‘Healthcheck’ (2018). Yet despite its apparent affluence, parts of our borough remain entrenched among the 10% most

deprived areas nationally. Stark health inequalities mean that there is a huge life expectancy gap (11

years for males and 10 years for females) between those living in the most and least deprived areas,

with smoking-related cancers, alcohol-related illnesses and heart disease among the greatest

challenges. Demands on services – emergency, hospital inpatient, primary care and social care – will be

exacerbated by a forecast 17% population increase by 2035 and the long term needs of an ageing

population, with Warrington’s over 65s population expected to grow by 27% by 2021. The health and social care system is under enormous strain as agencies try to cope simultaneously

with rising demand, staff shortages and unprecedented financial pressures. Those agencies are

meeting the challenge through the Warrington Together programme. Warrington Together is the borough’s main health and social care bodies, including third sector,

working together to explore ways of delivering improved, integrated services to the people of

Warrington. All have come together under an independently-chaired Warrington Together board. Health and social care services will work with the residents of Warrington to create a healthier,

happier Borough. Warrington Together will build a health and social care system to be proud of.

Local residents will tell us what they need, help shape change, play a part in their own wellbeing and

have a stake in the ownership of any new system. Services will be brought together at convenient locations borough-wide, where residents can access

the ongoing support they need to manage their own health and wellbeing. Partners will build on strong foundations to make better use of precious resources. Those who need

help the most can rely on the most support. /

Warrington Together will enable the people of Warrington to enjoy happier and healthier lives by

transforming the way we use our collective resources.

The lead for Warrington Together is Andrew Davies, Clinical Chief Officer, Warrington CCG.

More information: https://www.warrington.gov.uk/warringtontogether

/

/

/

(https://www.cheshireandmerseysidepartnership.co.uk)

WIRRAL Wirral is a borough of contrasts,

both in its physical characteristics

and demographics. Rural and

urban industrialised areas sit side

by side in a compact peninsula of

just 60 square miles of coastline.

The most recent population figures for Wirral suggest it is

about 321,000 making it one of

the largest metropolitan boroughs

in England. Demographically Wirral differs

slightly to England as it has a

lower proportion of younger adults

in their 20s and 30s and a higher

proportion of older people. The

area has many strengths but there

are also significant inequalities,

especially in relation to deprivation

which is most prevalent in the

eastern part of the borough.

In the most deprived areas of Wirral, life expectancy is 11.7 years lower for men and 9.7 years lower

for women than in the most affluent parts of the borough. The health of people in Wirral is varied

compared with the England average. Wirral is one of the 20% most deprived boroughs in England and about a quarter of children live in

low income families. Life expectancy for both men and women is lower than the England average.

This drives poorer health outcomes in these areas with people more likely to smoke, have lower

levels of physical activity and poor diets. Wirral also has an older population when compared to the national average especially those over 65 – with one in three living alone. Local priorities in Wirral include a healthy older age, a positive start

in life and keeping people well by reducing alcohol and tobacco use and lowering blood pressure. /

/

Unless there are big changes it is predicted that the biggest burdens of ill health for the people of Wirral will be:

Respiratory disease

Alcohol and alcohol related disease

Cancer

Diabetes

Heart disease

Stroke NHS Wirral Clinical Commissioning Group (CCG) is striving to reduce the significant inequalities in

the borough and aspires to eliminate them entirely in the future. Achievement of this ambitious aim

will need a partnership approach due to the complex nature of the issues. Several strategies are in place:

Joint Strategic Needs Assessment to inform of service development and joint commissioning Health and Wellbeing Board Strategy Enhanced services in Primary Care aimed at the early identification and treatment of disease Collaborative working with Wirral Council in several areas relating to reducing health

inequalities, including the ongoing development of the Better Care Fund and regular strategic

joint commissioning meetings Impact assessment of all CCG commissioning to ensure equitable service provision to prevent

further widening of the inequality gap The adoption by NHS Wirral CCG of a ‘vision’ which states ‘People will have the opportunity

to live longer and healthier lives regardless of where they live in Wirral’ The further development of a ‘Healthy Wirral’ plan that is built on the three principles of

Better Health, Better Care and Better Value

Healthy Wirral

The Healthy Wirral partnership is to enable all people in Wirral to live longer and healthier lives and

access the very best health and social care services when they really need them, as close to home

as possible.

Teams led by GPs and made up of health and care professionals and voluntary and third sector

organisations will work in nine neighbourhoods across Wirral. The teams will know and have affinity

with the local population and their needs, will identify people who would bene t from proactive care

support and have a detailed knowledge of available people, services and community assets and

where people are empowered to make the best choices, plans and actions for health and wellbeing.

Case Study – Wirral Neighbourhood Teams

Wirral has been successful in securing funding to enhance its ‘Neighbourhood’ teams with staff who

will be working out ways of improving how services can be delivered. Their initial focus will be

reducing unplanned hospital admissions amongst people over the age of 50 by 12% during 2018/19,

creating significant savings for the NHS. The lead for Wirral is Simon Banks, Chief Officer of NHS Wirral CCG. Further information can be

found here: https://www.wirralccg.nhs.uk/healthy-wirral/

/

/

/