Suffolk & North East Essex Integrated Care System

A healthy life for everyone

Achieving this Higher Ambition will mean that:
Everyone in Suffolk and North East Essex has a healthy life with good physical, mental and social wellbeing and ill health is prevented. 
As an Integrated Care System we will ensure that;
  • Children, adults and older people are supported to make health food and drink choices.
  • Children, adults and older people feel safe in their home and community
  • Children, adults and older people are support to be physically active
  • Children, adults and older people are socially connected and avoid loneliness
  • Children, adults and older people are supported to get the sleep that they need
  • Children, adults and older people have opportunities to volunteer to help them connected with and support others
  • Children, adults and older people have good sexual health
  • Children, adults and older people have opportunities to connect, learn and take notice
  • Children, adults and older people avoid the dangers of cigarette smoke
  • Children, adults and older people are able to live in a clean and sustainable environment
  • People with serious gambling problems receive high quality specialist support
  • People are able to avoid or reduce alcohol and drug related harm
What’s the current picture?
There are several dimensions to a healthy life:
  • Eating healthily, being physically active, sleeping well
  • Promoting good physical and mental health and well being
  • Healthy behaviours – avoiding smoking, alcohol and drugs and gambling
A healthy life benefits everyone living in Suffolk and North East Essex by:
  • Preventing ill health e.g. diabetes, cancer
  • Being socially connected and having purpose
  • Helping people to live well with long term conditions e.g. COPD, Diabetes, Obesity
  • Taking notice, connecting, learning
  • Slowing the progression of some conditions e.g. dementia, frailty
  • A clean and sustainable environment
  • Helping people to recover from ill health e.g. depression, cancer
Healthy life
The 2019 Green Paper ‘Advancing Our Health: Prevention in the 2020s’ describes a new approach:

‘We need to view health as an asset to invest in throughout our lives, and not just a problem to fix when it goes wrong. Everybody in this country should have a solid foundation on which to build their health... This means moving from dealing with the consequences of poor health to promoting the conditions for good health and designing services around user need, not just the way we’ve done things in the past.’

Deprivation affects our ability to life healthy lifestyles:

  • Activity levels decrease as deprivation increases, from 72% active in the least deprived areas, to 57% in the most deprived areas.
  • Food is the largest item of household expenditure for low income households, after housing, fuel and power costs.

Towards a Smoke Free Generation: A Tobacco Control Plan for England (2017) highlights:

  • Over 200 deaths every day are caused by smoking.
  • Smoking rates are almost three times higher amongst the lowest earners, compared to the highest earners.
  • Smoking accounts for approximately half the difference in life expectancy between the richest and poorest in society. The prevalence remains even higher in people with mental health conditions, where more than 40% of adults with a serious mental illness smoke.

Essex County Council’s weight management service had capacity for a tiny proportion of people who were overweight. Traditional services can foster dependence on professionally-led models, rather than building individual and community resilience. We needed to massively increase the number of people supported to lose weight, and ensure improvements lasted for the rest of their lives.

We discussed with our provider, Anglian Community Enterprise (ACE), how to maximise local opportunities for weight management support without over professionalising, and how to implement a more sensitive triage process which reflected the complexity of people’s excess weight on a continuum from relatively simple to relatively complex. We developed a new light touch delivery model involving 30 new local delivery partners including CsVS, libraries, district councils and others offering social support for weight management, rather than a professionally led service. We also developed an online offer. These services achieved an average weight loss of 3.7kg.

We recognised more of the same won’t work, and our team was given latitude to explore the new, over which we have less direct control. We are part way through the journey, and next steps involve working more directly with communities and citizens as delivery partners.

    Essex was chosen by Sport England as one of 12 areas in England to tackle physical inactivity in a groundbreaking way. Our Local Delivery Pilot (LDP) focuses on three localities across Essex, two of which are Colchester and Tendring.

    We aim to improve physical activity for everyone, but with a targeted focus on three populations: older people, families with dependent children and people with poor mental health.

    We are taking a whole system approach, increasing community engagement and cohesion through new social movements, networks and communications.

    We are developing community capacity and creating active environments. We are also learning from our experiences and creating sustainability.

    We are already developing new partnerships, and aligning our strategies and priorities to this work.

    We will continue to work closely with all our partners to ensure our whole system change work links closely with wider developments and to share our learning.

HOW we plan to make a difference

    1.1 People know how to make healthier food and drink choices.

  • Awareness programmes will enable children and adults to be aware of healthy nutritional choices. Awareness raising helps inform people about risks and to make both big and small positive changes.

    1.2 People have healthier food and drink choices available in the places where they live, work and study.

  • We will ensure public spaces, including health, care and leisure settings, provide healthier food and drink choices, and restrict unhealthy choices, for people who use the services and for staff. Every public sector setting, from leisure centres to hospitals, should have a food environment designed so the easy choices are also the healthy ones. Choices available should limit proportion, placement and promotion of foods high in fat, salt and sugar.
  • Children will have access to healthy food in school. All school environments will adhere to the School Foods Standards, which ensure children have access to healthy food at school.
  • We will support expansion of healthy breakfast clubs in schools. Breakfast clubs can contribute to improved attainment, attendance and overall health.
  • Children and families, adults and older people living in poverty will be helped to have access to healthy food. Access to healthy food is essential to a healthy weight. We will support schemes to access to healthy foods and how to cook them; and Healthy Start where families on low incomes can exchange vouchers for fresh or frozen fruit or vegetables and milk, and obtain free vitamins during pregnancy and early years.

    1.3 People have access to technology to help them make healthy nutritional choices.

  • We will explore opportunities for applications that enable people to use technology and data DRAFT to inform their eating decisions. Making best Five Year System Strategic Plan 2019 / 2024 | 37 use of technology widens access to information and advice to help people make healthy choices.

    2.1 All children are physically active at least an hour a day.

  • Early Years services will follow best practice guidance for physical activity including active play. Encouraging activity at an early life stage promotes healthy growth and development; and helps build positive habits as children grow into adulthood.
  • All school-age children and young people will have support and facilities to engage in moderate to vigorous intensity physical activity for at least 60 minutes every day. At least 30 minutes a day of activity should be delivered in school through active break times, PE, extracurricular clubs, active lessons, or other sport and physical activity events. The remaining 30 minutes should be supported by parents and carers outside of school time. Schemes such as Mile A Day are effective.
  • Physical activity is part of the Healthy Schools rating scheme. This scheme encourages obesity prevention measures and is taken into account during Ofsted inspections.
  • Families and children will be able to get active and play sport together. Measures will focus on helping children acquire a basic level of competence in sport and physical activity as well as supporting them to have fun, regardless of their level of ability.

    2.2 Adults are supported to be more active as part of their regular routine.

  • We will support activity programmes in workplaces. Enabling people to combine their work life and exercise will encourage people to increase their levels of activity. Support can include healthier ways to travel to work such as walking or cycling, or opportunities such as lunchtime exercise classes.
  • We will support access to activity programmes and leisure facilities. Social prescribing, low cost and no cost options, and publicity on the wide range of opportunities will help people access facilities.

    2.3 Older adults are supported to remain active for as long as possible into old age.

  • We will support community-based activity programmes specifically focused on older adults. These will help people keep their minds as well as their bodies active, help people connect with others, and maintain independence.
  • We will support activity programmes in care homes. Activities help maximise mobility and dexterity, prevent deterioration in health and wellbeing, and enable people to connect with staff and fellow residents.

    3.1 People understand the principles of good sleep hygiene. This includes regular sleep times, and avoiding screen time, alcohol and caffeine.

  • We will promote awareness of good sleep hygiene for everyone, so that people can help themselves to achieve a good night’s sleep.
  • We will help people with sleep disorders to access integrated physical and mental health support. Integrated services will enable a joined-up approach to both the symptoms and causes of poor sleep.

    3.2 Vulnerable children, adults and older people have a safe and healthy environment to sleep.

  • People with health conditions will be supported to have a safe bed in their own home, in hospital or in care settings. Safety involves not only avoiding injury, but also supporting comfort and good quality sleep.
  • Children and young people in families where there are safeguarding concerns will be supported to have a safe bedroom with the facilities they need for healthy sleep. Children are safe and healthy when they have privacy, a hygienic bed and comfortable sleeping environment and are free from abuse or neglect.

    4.1 People know how to maintain good sexual health

  • All young people, adults and older people will have accessible information on sexual health and safe sex practices, which is culturally sensitive and meets the needs of people at all ages and of all sexual orientations.
  • People will have access to a range of effective methods of contraception, planning for pregnancy, and personalised advice and care to enable the best option to meet their needs and minimise the risk of sexually transmitted infections.

    4.2 Young people have the support they need with unplanned pregnancy.

  • Young people will be given sexual health and contraceptive advice to prevent unplanned pregnancy.
  • Young people will have access to high quality care and support in the event of an unplanned pregnancy.

    4.3 People have support for sexually transmitted infections.

  • We will ensure that access to testing and treatment for sexually transmitted infections and blood borne viruses, together with contraceptive advice, is targeted to the needs of the most high risk groups.
  • We will promote awareness of HIV, and promote access to testing and treatment for HIV especially for high risk groups. This will help reduce the number of people who become aware of their HIV status at a late stage.

    4.4 People will have equal access to services and support.

  • We will work to address the stigmas associated with STIs, unplanned pregnancies and HIV with people, families, health and care staff, and the wider public.
  • We will train staff in health and care in good sexual health, how to discuss it with vulnerable people and those with limited understanding and communication, issues of consent for vulnerable young people and adults, and how to promote positive relationships.

    5.1 People live in a healthier smoke-free environment.

  • People of all ages will be helped to understand why they should not start smoking, and how to stop. Multi-media campaigns to prevent smoking and passive smoking, and promote smoking cessation. The system should explore local and regional approaches to stop smoking campaigns. Smoking cessation should draw on a range of theories. Public health messages on vaping will be incorporated.
  • People should be able to work in a smokefree workplace. We will support employers to encourage employees to stop smoking and adopt more healthy lifestyles. Employers will see the benefits of higher staff morale, improved production and lower rates of sickness absence.
  • Health and care settings will be smoke-free. Health and social care providers’ premises are all smoke-free. Health and care providers provide healthy environments for people who are accessing their services.

    5.2 People who smoke have advice and support they need to stop.

  • People accessing health and care services will have advice and support to stop smoking. All health and care organisations will encourage smokers to stop. Health and care organisations can make effective use of their contacts with people to encourage smoking cessation.
  • All hospital inpatients who smoke will be offered tobacco treatment services by March 2024. NICE guidance supports cessation in secondary care.
  • Pregnant women have support to stop smoking for their own health and their children and family’s health. Specialist support will be provided to pregnant women to stop smoking; following CO screening, those with elevated levels will be referred via an opt-out system for specialist support.
  • Introduction of local Smokefree Pregnancy Champions. The Champions will consider how prevalence can be reduced in their locality and lead action to achieve this.
  • People with mental health conditions will have support to stop smoking for their own health and the health of those close to them. Targeted and effective interventions will help people with mental health conditions to stop smoking, including smoke-free mental health units. Interventions are tailored to the needs of people with mental health problems, to improve their effectiveness.
  • People in areas which experience health inequalities will have targeted support that takes a personalised approach. Our system will identify the groups (such as people with mental health problems) and areas with the highest smoking prevalence. Commissioners and providers should understand the level of need to help target resources effectively. Action can be taken at organisational, locality, system and regional levels.
  • Our system will act to reduce health inequalities caused by smoking in their population. Local health and wellbeing partners can use ‘CLeaR’, an evidence-based improvement model that can assist in promoting local tobacco control activities.

    6.1 People know the risks of misusing drugs and alcohol and can keep themselves safe.

  • Awareness campaigns to help children and young people understand the risks of alcohol and drug misuse. Campaigns should be delivered in collaboration between health and care services, and include children educated at home as well as those in schools.
  • Local health improvement campaigns to promote less risky drinking and drug use, and to prevent harm. Campaigns should integrate health and care, and be based on, and target, local population needs. They should include societal attitudes to drugs and alcohol.
  • Identification and Brief Advice (IBA) to people who are most at risk of alcohol-related ill health. NICE recommends IBA in all adult health, social care and criminal justice settings. Support should incorporate the impact of social factors on alcohol use.
  • Tackle the misuse of prescribed medications. Eliminating the misuse of prescription medications reduces health complications and improves quality of life. People need better awareness of potential harms.

    6.2 People who have misused drugs or alcohol have high quality care and support.

  • Expansion of specialist 7-day Alcohol Care Teams (ACTs) in acute hospitals. ACTs significantly reduced accident and emergency (A&E) attendances, bed days, readmissions and ambulance call-outs. Services may be standalone teams or part wider teams including drugs and psychiatric liaison. Availability of medicines to treat overdose. Access to medications such as naxolone prevents avoidable deaths.
  • People who misuse drugs or alcohol have continuity of care in hospital and when going home, through pathways of care for drug or alcohol treatment in the hospital and in the community. People should not fall between gaps in care between emergency care, inpatient stays and home.
  • People will have access to a range of personalised community-based integrated drug and/or alcohol recovery and support services. Treatments include detoxification, psychosocial interventions, and safe supply/use of drugs. Safe havens also help people to access support. Agreements across all services will support sharing of information and effective care delivery, including risks to communities e.g. county lines or ‘bad’ batches of drugs in circulation.
  • Improving specialist support for people with co-occurring drug/alcohol and mental health problems. People with complex needs should have specialist support from professionals who can understand and manage the specific challenges they face.
  • Proactively identifying and advising armed forces veterans in need of drug or alcohol support. Proactive identification enables early interventions, reduces harm and helps recovery.
  • Support for the carers and families of people who misuse drugs or alcohol. Supporting carers helps improves their own health and wellbeing, prevents them becoming users themselves, and helps the cared-for person’s recovery.
  • People recovering from drug or alcohol misuse will have access to range of suitable housing provision, information and advice. The housing needs of people with alcohol and drug problems, and their families and carers where appropriate, will be assessed at the right time, to prevent homelessness or to help them move on to a suitable home.
  • People with drug and alcohol problems will have support from their peers. Peer support is particularly effective for people in marginalised groups and communities.
  • Children and young people with greater vulnerabilities will have access to integrated specialist drug and alcohol approaches. Support for vulnerable groups such as Looked After Children, care leavers, NEETs, and victims of sexual assault, abuse or exploitation, recognises and tackles the complexity of their needs.
  • Adults or older people with greater vulnerabilities or complex needs will have specialist integrated drugs and alcohol support. Specialist support recognises and tackles the complexity of vulnerable adults’ needs such as victims of domestic abuse or sexual assault, sex workers, homeless people, veterans and older people.
  • People who misuse drugs or alcohol have support to remain in work. Training and awareness among employers will ensure they treat drug and alcohol problems as a health concern, which in turn helps people to be identified and supported effectively.
  • Health and care providers and employers jointly help people back into work. Part of this approach involves addressing misconceptions about people who previously misused alcohol or drugs.
  • Parents have rapid access, appropriate assessment and integrated support for drug and alcohol misuse. Treatment and care should be delivered in partnership with children and family services.
  • People affected by domestic abuse should also have support for any drug or alcohol problems, as well as mental health problems, in an integrated way. Professionals recognise that domestic abuse is closely linked to drug and/or alcohol misuse and mental health, and should tackle these issues jointly.
  • We will develop effective pathways to integrated services for domestic abuse victims and perpetrators. Agencies will collaborate to help everyone in the family affected by domestic abuse.
  • We will support children and young people affected by parental drug or alcohol misuse in an integrated way.

    7.1 People will get the specialist help they need.

  • We will expand NHS specialist clinics, and integrated working to help more people with serious gambling problems. Over 400,000 people in England are problem gamblers and two million people are at risk. Expansion of services for people with serious gambling problems will help prevent and treat these issues.

    8.1 People will live in a safe environment.

  • People will have support in their neighbourhoods to tackle anti-social behaviour. A joined up approach is taken by housing, police, health and social care.
  • Victims of crime, including hate crimes will have health and wellbeing support. Integrated therapeutic mental health support for survivors of sexual assault. The service will be offered both immediately after an incident and to provide continuity of care where needed.

    9.1 People are supported to be socially included and less lonely.

  • We will improve public awareness of loneliness and social isolation. Awareness campaigns help tackle the stigma of loneliness and social isolation, helps people identify those close to them who might be experiencing difficulties, and encourages people to seek support.
  • People’s risk of, or experience of loneliness or social isolation will be recognised and supported. Training staff who work with vulnerable groups e.g. older people, vulnerable younger people, and isolated parents, enables people at risk of, or experiencing loneliness or social isolation to be recognised earlier and supported appropriately.
  • People will have social wellbeing support in work. Employers will be encouraged to commit to the Campaign to End Loneliness pledge to supporting their employees’ social wellbeing.
  • People will have support for loneliness and social isolation, by including loneliness and social isolation holistically more consistently in personalised care planning, and involving people in shaping their care in an individualised and culturally sensitive way. This will help achieve positive outcomes for the person.
  • Bereaved people will have social support to avoid loneliness. People are at risk of loneliness and social isolation following bereavement.
  • We will promote ways people can be connected to others digitally in a positive way, including social media and enabling people to be online at home. Connecting people digitally helps them to build and maintain relationships with friends, family, and people with similar interests and Case Study: Tackling physical inactivity in Essex head on Essex was chosen by Sport England as one of 12 areas in England to tackle physical inactivity in a groundbreaking way. Our Local Delivery Pilot (LDP) focuses on three localities across Essex, two of which are Colchester and Tendring. We aim to improve physical activity for everyone, but with a targeted focus on three populations: older people, families with dependent children and people with poor mental health. We are taking a whole system approach, increasing community engagement and cohesion through new social movements, networks and communications. We are developing community capacity and creating active environments. We are also learning from our experiences and creating sustainability. We are already developing new partnerships, and aligning our strategies and priorities to this work. We will continue to work closely with all our partners to ensure our whole system change work links closely with wider developments and to share our learning. Digital contacts should not replace face to face social contacts, people benefit from a range of methods to maintain relationships.
  • We will extend befriender, volunteer and peer support schemes, and use settings such as children’s centres to connect people. Support from people who are part of the local community and who understand the challenges can help people make social contacts. Social prescribing provides a valuable way to promote social contact.
  • We will improve access to community and public transport. Accessible transport, particularly in rural areas, helps people to see friends and family, and access community facilities.
  • We will extend services that reach into communities such as mobile libraries, TEFL and adult learning. Improving access to community facilities also provides opportunities for social contact.
  • People in groups and communities will support each other to understand and tackle loneliness and social isolation, using approaches that involve whole settings e.g. schools, residential homes, groups, and neighbourhoods, in a culturally sensitive way. Targeting group settings and communities helps ensure inclusivity, respects diversity, creates safe spaces for people to obtain the right support for them, and helps everyone to help each other. Inter-generational and multi-cultural approaches also help break down barriers between people.
  • We will Involve people who are lonely or socially isolated in developing health and social care policies and services to ensure services are culturally sensitive and will meet the specific needs of local people and communities.

    9.2 People are encouraged to volunteer to help them connect with and support others.

  • People will know the options available for volunteering, by co-ordinating information on local volunteering opportunities. Improved collating and disseminating of information on volunteering opportunities will help people to know the breadth of options and encourage them to try it.
  • People will be able to volunteer flexibly, by increasing opportunities for micro-volunteering. Micro-volunteering is a flexible system where people offer their time when they can, it is particularly suitable for people who cannot make a regular weekly commitment.
  • We will support increasing opportunities to try out volunteering for a day. Allowing people to try volunteering before making a commitment helps overcome their fears about whether they will like volunteering or be able to commit to it.

    10.1 People understand the importance of connecting, learning and taking notice.

  • We will promote awareness of opportunities for people to connect with events and schemes in their local communities where they can connect with others, learn and share.

    10.2 People can connect with friends, family and their communities.

  • We will enable people who are socially isolated to have the opportunities to maintain contact with family and friends. We will promote contact both face to face through schemes such as community transport, and virtually by supporting people to have access to, and training in digital technology and using the internet.
  • We will help people connect with green spaces to improve their mental health and wellbeing. The natural environment is valuable in both prevention and therapy, and measures such as social prescribing and personalised care planning can support people to benefit from this resource.
  • We will encourage good neighbour schemes where people can meet and support each other. This builds community assets and helps prevent social isolation.

    10.3 People engage in lifelong learning.

  • We will encourage people to continue lifelong learning through further education, evening classes, learning new skills. Lifelong learning supports positive mental health, keeps people mentally active, and provides opportunities for people to connect with others with similar interests.
  • We will reduce waste across the public sector wherever possible, including minimising availability of single-use plastics such as plastic cups and cutlery.
  • We will promote reuse and recycling, for example in paper and plastics.
  • We will use eco-friendly products wherever possible, such as low/zero plastic cleaning products.
  • We will encourage people to grow their own fruit and vegetables to cut down on air miles, and to minimise packaging by using their own containers to bulk buy dry foods
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Suffolk & North East Essex Integrated Care System
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