Improving health and care in Greater Manchester

Contents

Foreword

Executive Summary

• Our vision
• How we will work
• The current situation
• Embedding the Greater Manchester Model for Health
• Acting on our missions
• Strengthening our communities
• Helping people get into, and stay in, good work
• Recovering core NHS and care services
• Helping people stay well and detecting illness earlier
• Supporting our workforce and our carers
• Achieving financial sustainability
• Monitoring Our Progress

Introduction

Context

• About Greater Manchester
• The Greater Manchester Strategy

The Greater Manchester Integrated Care Partnership

• Our shared vision, outcomes and commitments
• How we work

Influences on this strategy

• Data and health needs
• Evidence and evaluation
• Pressures on current services and the health and care workforce
• What residents are telling us
• The challenges

Responding to the challenges

Embedding the Greater Manchester Model for Health

• The Greater Manchester Model for Health
• Creating the conditions for good lives
• Providing proactive and preventative integrated care through our neighbourhood model
• Integrating care through our providers

Meeting today’s challenges – our missions

• Strengthening our communities
• Helping people get into, and stay in, good work
• Helping people stay well and detecting illness earlier
• The recovery of core NHS and care services
• Supporting our workforce and our carers
• Achieving financial sustainability

Monitoring Our Progress

• Utilising data to address inequality

Appendix 1 – Locality plans

Appendix 2 – Engagement on the strategy

Footnotes

Greater Manchester Integrated Care Partnership Strategy

Improving health and care in Greater Manchester 2023-2028

Foreword

This is Greater Manchester Integrated Care Partnership’s strategy for the next five years.  It follows our first strategy ‘Taking Charge’ Together published in 2015.

Our first strategy helped us develop our model of integrated neighbourhood and place based working. We established strong provider collaborations across secondary, primary, mental health and social care. We established an expansive strategic partnership with the Voluntary, Community and Social Enterprise (VCSE) sector, pioneering new approaches to community led care and support. We progressed a system wide Population Health Plan alongside scaled improvements and innovation in mental health access and provision, extended access in primary care and significant improvements in social care quality.

Finally we established a nationally leading model to connect the health and care system with academic and industry partners in the pursuit, discovery and spread of innovation.

This work generated an increase in life expectancy for our residents prior to the COVID-19 pandemic, which bucked the trend nationally when compared with other areas of the country. Highlighting the success of health devolution in Greater Manchester and establishing a positive foundation of which to move forward, especially given the ongoing challenges of national austerity.

In spite of the progress we made, too many people living in Greater Manchester still spend far too much of their lives in poor health and severe inequalities remain.

The pandemic, which affected Greater Manchester more deeply than other areas in the country, set back our progress in tackling these challenges. Its impact means that the backlog of people waiting for care and support in Greater Manchester has reached levels that we would never have wished to see. This has a profound effect on people’s ability to get on with their lives, exacerbating poverty and inequalities across our city-region.

Looking ahead, the impact of the current cost of living crisis is likely to last well into this decade and is anticipated to impact Greater Manchester harder and for longer. Resources for public services, in terms of both money and people, will be constrained for some time into the future.

Realising our ambition for the next five years also means taking on the more immediate challenges we face including the significant care backlog, workforce shortages, our health and care estate, the ongoing impact of inflation and the lack of a long-term national strategy for social care.

We won’t be overcome by these challenges, Greater Manchester will come together with common purpose. Our task is nothing less than to mobilise all the resources at our disposal and point them to improving the health and well-being of our population. This means health and care services, local government, the Greater Manchester Combined Authority (GMCA), the VCSE, academia, businesses, the arts and culture – the whole of civic society.

We must accelerate our work to bring the NHS, public services, and the wider community together to deliver a neighbourhood based, integrated, preventative, person-centred model of care and support that enables people to live a good life. We must work as equal partners with communities across Greater Manchester and empower people to be much more active participants in their own health and well-being.

We must capitalise on our history of joint working with our ten councils, and our unique position as an Integrated Care Partnership co-terminus with a Mayoral Combined Authority, to tackle the social determinants of health and put health and wellbeing at the heart of every policy. These activities hold the key to preventing poor health and reducing demand for services in primary care, formal social care and our hospitals.

We must ensure that we utilise the potential of the integrated care system to organise care to generate maximum impact on health according to standards informed by our quality ambitions, addressing unwarranted variation in access, experience and outcomes for every resident receiving care.

We must harness the power of innovation and technology in the cause of population health improvement. Greater Manchester will be an integrated care system which is alert to discovery, open to innovative change and equipped to ensure it is spread effectively across our city region.

This strategy describes the improved outcomes we want to achieve for all people in Greater Manchester and how we will work together to achieve these. It will be supported by a more detailed delivery plan that we will complete by June 2023.

Sir Richard Leese

Chair, NHS Greater Manchester Integrated Care

Paul Dennett

Chair, Greater Manchester Integrated Care Partnership

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Executive Summary

This is Greater Manchester’s Integrated Care Strategy. It sets out how we intend to work together to improve the health of the people of our city-region through the Greater Manchester Integrated Care Partnership.

It follows on from our first strategy ‘Taking Charge’ published in 2015, through which we established our model of integrated neighbourhood and place-based working, supported by strong provider collaborations and strategic partnerships. While good progress was made, including an increase in life expectancy compared to other similar areas nationally, too many people living in Greater Manchester still spend more of their lives in poor health than people in other parts of the country – serious and longstanding inequalities remain.

Greater Manchester is home to more than 2.8 million people and is growing. The ten councils – Bolton, Bury, Manchester, Oldham, Rochdale, Salford, Stockport, Tameside, Trafford and Wigan – and the Mayor of Greater Manchester work together as the Greater Manchester Combined Authority (GMCA) and with businesses, communities and other partners including the NHS, Greater Manchester Police and Transport for Greater Manchester, as described in the Greater Manchester Strategy (GMS)[1].

Our Integrated Care Strategy sets out how we, as an Integrated Care Partnership, comprising the NHS, local authorities, and partners across the VCSE, Healthwatch and the trade unions, will improve health and care for the people of Greater Manchester, playing a key role in delivering the GMS.

Our Vision

As partners in Greater Manchester, we share the GMS vision of wanting Greater Manchester to be a place where everyone can live a good life, growing up, getting on and growing old in a greener, fairer more prosperous city-region.

Specifically we as an Integrated Care System want to see a Greater Manchester where:

• Everyone has an opportunity to live a good life
• Everyone has improved health and wellbeing
• Everyone experiences high quality care and support where and when they need it
• Health and care services are integrated and sustainable

What we will do to achieve these:

• Ensure our children and young people have a good start in life
• Support good work and employment and ensure we have a sustainable workforce
• Play a full part in tackling poverty and long-standing Inequalities
• Help to secure a greener Greater Manchester with places that support healthy and active lives
• Help individuals, families and communities feel more confident in managing their own health
• Make continuous improvements in access, quality, and experience – and reduce unwarranted variation
• Use technology and innovation to improve care for all
• Ensure all our people and services recover from the effects of the COVID-19 pandemic as effectively and fairly as possible
• Manage public money well to achieve our objectives
• Build trust and collaboration between partners to work in a more integrated way

How we will work

Our strategy sets out how we will work together as a system to:

• Understand and tackle inequalities
• Share risk and resources
• Involve communities and share power
• Spread, adopt, adapt
• Be open, invite challenge, take action
• Focus on names not numbers

The current situation

Greater Manchester has some of the lowest life expectancy in England, with differences between the most and least deprived areas of 9.5 years for men and 7.7 years for women[2].  Further differences exist between communities according to race and ethnicity, gender, disabilities, poverty and social exclusion, sexuality and age, as shown through a range of external analyses.

This, coupled with increasing demand and a workforce crisis, is putting strain on our services.  Residents have told us they have real concerns about funding and staffing levels, difficulties in accessing appointments, and waiting times for hospital care. We are responding to these challenges by:

Embedding the Greater Manchester Model for Health

Our Model for Health sets out how we will work together, with our communities, to enable the conditions for good lives, prevent poor health and ensure support is available before crises occur and to provide consistent and high-quality care wherever it is accessed. This is a social model for health, rather than a predominantly medical one, so focuses on the role of people and communities as well as health and care services.

Acting on our missions

Our strategy sets out the following missions, which are our priority actions in response to the current challenges.

Strengthening our communities

We will help people, families and communities feel more confident in managing their own health. We will act on this with a range of programmes, including working across Greater Manchester to support communities through social prescribing, closer working with the VCSE and co-ordinated approaches for those experiencing multiple disadvantage.

Helping people get into, and stay in, good work

One of the purposes of Integrated Care Systems is to support wider social and economic benefits from NHS investment. We will act on this by expanding our Work and Health programmes, working with employers on employee wellbeing, through the Greater Manchester Good Employment Charter [3] and developing social value through a network of anchor institutions[4].

Recovering core NHS and care services

We will work to improve ambulance response and A&E waiting times, reduce elective long waits and cancer backlogs, improve access to primary care services and core mental health services, improve quality and reduce unwarranted variation

Helping people stay well and detecting illness earlier

We will collaborate to reduce smoking rates, increase physical activity, tackle obesity and alcohol dependency. We also want to do more to identify and treat high blood pressure, high cholesterol, diabetes, and other conditions which are risk factors for poor health and early We will embed a comprehensive approach to reducing health inequalities.

Supporting our workforce and our carers

We will promote integration, better partnership working and good employment practices, as well as supporting our workforce to be well and addressing inequalities faced in the workplace. We want more people choosing health and care as a career and feeling supported to develop and stay in the sector. We will consistently identify and support Greater Manchester’s unwaged carers.

Achieving financial sustainability

Financial sustainability – ‘living within our means’ – requires an initial focus on financial recovery to achieve a balanced position. We will confirm, quantify and tackle the main reasons for financial challenges in Greater Manchester, implementing a system wide programme of cost improvement, productivity, demand reduction and service transformation.

Monitoring Our Progress

We are clear about the progress we intend to make and are committed to demonstrating it.  Our strategy sets out progress measures against our outcomes and missions, which focus on helping people to live good lives, improved health and wellbeing, better standards of care and support and greater integration of services.

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Introduction

The way in which health and care services are organised in every part of England changed on 1 July 2022, when the Health and Care Act 2022 came into force. Greater Manchester is now an Integrated Care System (ICS) – a partnership of organisations that come together to plan and deliver joined up health and care services and improve the lives of people who live and work here. Our ICS is called Greater Manchester Integrated Care Partnership.

There is a requirement for all ICSs to develop a strategy. NHS organisations and local authorities must then have regard to this strategy when making decisions about the use of health and care resources.

This document is Greater Manchester Integrated Care Partnership’s strategy. It sets out how we intend to work to improve the health of the 2.8m residents here. It focuses on the contribution of health and care to enabling everyone to live a good life through improved wellbeing.

In Greater Manchester we had a strategy for health and care, called “Taking Charge”[5], which was developed in 2015 following the devolution of funding for health and social care from the Government to the city-region and covered 2016-2021.

This new strategy builds on the work undertaken across Greater Manchester through Taking Charge, sustaining and extending examples of progress whilst acknowledging and addressing evident challenges.

It recognises and responds to today’s context of an extended period of austerity affecting public services, the aftermath of a global pandemic and the pressures associated with the cost-of-living crisis on families, businesses, charities and public services. Those stresses have shown the impact of deprivation on health outcomes for our citizens, compounded by a multitude of wider inequalities. This is a challenge for the whole of Greater Manchester and reinforces the ongoing need for a broad public service reform agenda, linked to a demanding environmental agenda and the building of a more inclusive economy. In all of these integrated health and care has a significant role to play.

We will develop and publish a Joint Forward Plan (JFP) by the end of June 2023 as a delivery plan for the ambitions in this strategy and this plan will be updated annually.

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Context

About Greater Manchester

Greater Manchester is home to more than 2.8 million people and has an economy bigger than that of Wales or Northern Ireland. Greater Manchester’s population in the 2021 Census was estimated to be 2,867,800. This is an increase of 185,272 on the 2011 Census and represents a growth of 6.9% in ten years, higher than the growth across England and Wales (6.3%) over the same period.  All Greater Manchester local authorities have seen population growth since 2011, with the highest rate of growth being in Salford (15.4%).  This was also the highest actual percentage growth of any metropolitan district in the country. The City of Manchester’s population has grown by the most within Greater Manchester with an increase of 48,873 in the ten years.  Amongst the 36 metropolitan districts in England, only Birmingham (71,855), had a larger actual growth than Manchester.

There are ten councils in Greater Manchester: Bolton, Bury, Manchester, Oldham, Rochdale, Salford, Stockport, Tameside, Trafford and Wigan. All are unitary authorities, eight are metropolitan borough councils and two, Salford and Manchester, are city councils.

The Greater Manchester Combined Authority (GMCA) is made up of the ten Greater Manchester councils and the Mayor, who work with other local services, businesses, communities and other partners to improve the city-region.

The ten councils have worked together for many years on issues that affect everyone in the region, like transport, regeneration and attracting investment.

The Greater Manchester Strategy

The Greater Manchester Strategy (GMS) is developed by GMCA on behalf of multiple partners across the city-region. It is our collective blueprint for a decade from 2021-2031, setting out how, working collectively across Greater Manchester, with our communities, we can deliver the shared vision:

“We want Greater Manchester to be a place where everyone can live a good life, growing up, getting on and growing old in a greener, fairer more prosperous city-region”

The GMS focuses on improved wellbeing for the people here, with better homes, jobs and transport. The strategy describes how we will work to continue to make Greater Manchester a great place to visit, invest and study, with thriving businesses which are both UK and world leading, in sectors including low carbon and digital.  The GMS is designed to ensure that activity supports the achievement of a greener, fairer and more prosperous Greater Manchester, in a way which is inclusive, innovative and forward thinking. It builds on the pioneering and progressive culture which underpins Greater Manchester. It also shows how Greater Manchester can be held to account, with a delivery plan showing the collective actions being taken, and a performance framework to demonstrate progress.

As an Integrated Care Partnership, we have an integral role in delivering the GMS.  The GMS focuses on the following shared outcomes:

The wellbeing of our people

• A Greater Manchester where our people have good lives, with better health; better homes; culture and leisure opportunities and better transport
• A Greater Manchester of vibrant and creative communities; a great place to grow up get on and grow old, with inequalities reduced in all aspects of life

Vibrant and successful enterprise

• A Greater Manchester where diverse businesses can thrive, and people from all our communities are supported to realise their potential
• A Greater Manchester where business growth and development are driven by an understanding that looking after people and planet is good for productivity and profitability

Greater Manchester as a leading city-region in the UK and globally

• Greater Manchester as a world-leading low carbon city-region
• Greater Manchester as a world-leading digital city-region

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Greater Manchester Integrated Care Partnership

In July 2022, Greater Manchester’s health and care arrangements changed, as they did everywhere in the country, under the Health and Care Act 2022. The following bodies and organisations were established:

• Greater Manchester Integrated Care Partnership (this is the name of our integrated care system) connects NHS Greater Manchester Integrated Care, the Greater Manchester NHS Trusts and NHS providers across the whole of primary care with the GMCA, councils and partners across the VCSE, Healthwatch and the trades unions. It is one of 42 integrated care systems across England. It is one of the largest and one of only two which covers the same geographical area as a Mayoral Combined Authority.
• Greater Manchester Integrated Care Partnership Board is a statutory joint committee made up of NHS Greater Manchester Integrated Care and councils within Greater Manchester. It brings together a broad set of system partners to support partnership working and it is the responsibility of this Board to develop this Integrated Care Strategy – a plan to address the wider health, and care needs of the population.
• NHS Greater Manchester Integrated Care, or NHS Greater Manchester (our integrated care board) is a statutory NHS organisation leading integration across the NHS, managing the NHS budget and arranging for the provision of health services in a geographical area. It supports ten place-based integrated care partnerships in Greater Manchester as part of a well-established way of working to meet the diverse needs of our citizens and communities.

Our shared vision, outcomes and commitments

As partners in, and participants of, the Greater Manchester Strategy, we share the vision of wanting Greater Manchester to be a place where everyone can live a good life, growing up, getting on and growing old in a greener, fairer more prosperous city-region.

For the Greater Manchester Integrated Care Partnership this means we want to see a city region where:

• Everyone has an opportunity to live a good life
• Everyone has improved health and wellbeing
• Everyone experiences high quality care and support where and when they need it
• Health and care services are integrated and sustainable

Our shared commitments to ensure we achieve those outcomes are to:

• Ensure our children and young people have a good start in life
• Support good work and employment and ensure we have a sustainable workforce
• Play a full part in tackling poverty and long-standing Inequalities
• Help to secure a greener Greater Manchester with places that support healthy and active lives
• Help individuals, families and communities feel more confident in managing their own health
• Make continuous improvements in access, quality, and experience – and reduce unwarranted variation
• Use technology and innovation to improve care for all
• Ensure all our people and services recover from the effects of the COVID-19 pandemic as effectively and fairly as possible
• Manage public money well to achieve our objectives
• Build trust and collaboration between partners to work in a more integrated way

How we work

The creation of NHS Greater Manchester, and our new Integrated Care Partnership, gives health and care partners the opportunity to work together to face the challenges the current economic climate presents to our communities and to public services.

Transforming public services, integrating care to provide solutions which are more than medicine, and working with communities; not simply ‘doing to’, will fundamentally challenge our approaches to delivery and working together. The way that members of the Integrated Care Partnership work together, with each other and with our communities, will play an important part in achieving our vision.

Our Way of Working

Behaviours:

• Understand and tackle inequalities.  We will take action at individual, team, organisation, and system levels, informed by data, to understand and tackle inequalities.
• Share risk and resources.  We will set out our expectations of each other, share data ­­­­effectively, support joint working with shared resource and create a culture of collaboration. This must happen at every level and in every place.
• Involve communities and share power.  We will consistently take a strengths-based approach with co-design, co-production and lived experience as fundamental ingredients.
• Spread, adopt, adapt.  We will Share best practice effectively, test, learn and celebrate success, with supportive governance and resources. Adapt and implement best practice locally, in organisations and across systems.
• Be open, invite challenge, take action.  We will be open, honest, consistent and respectful in working with each other. Work on the boundaries and differences that we have in a constructive way, to support effective change.
• Names not numbers.  Ensure we all listen to people, putting them at the centre, and personalising their care.

This will involve rapidly increasing the level of integrated neighbourhood and locality working that connects all partners and communities who can contribute to improving health and tackling inequalities.  This will move us to a stronger model of collaboration at a Greater Manchester level, ensuring more consistent and standardised responses to systemic challenges.

To ensure we play our part in delivering our shared vision across Greater Manchester, we will capitalise on both:

• The connection with neighbourhoods and communities that locality working offers – to integrate health and care with wider public services and tackle the root causes of poor health; and
• The scale that a single Greater Manchester organisation offers – to drive consistent improvement, reduce unwarranted variation and make the best use of our collective resources.

Within Greater Manchester we have arrangements for providers to work together effectively at scale, including:

• The Greater Manchester Provider Federation Board (PFB): a membership organisation made up of the eleven NHS trusts and foundation trusts who provide NHS funded services across Greater Manchester and East Cheshire. It includes the NHS providers of 111, 999, patient transport services (PTS), community mental health and physical health services and hospital mental health and physical health services.
• The Greater Manchester Primary Care Board (PCB) has been supporting collaboration and integration since 2015 and will continue to support the delivery of outcomes at all levels of, and across, the system, through its various programmes and its work with all 67 Primary Care Networks[6] (PCNs) in Greater Manchester.
• Greater Manchester Directors of Adults’ and Children’s Social Care collaborating to support transformation of social care at scale. For adult social care this also includes joint working with the Greater Manchester Independent Care Sector Network.

Voluntary, Community and Social Enterprise (VCSE) sector providers are part of a three-way agreement (the VCSE Accord) between the GMCA, NHS Greater Manchester and the VCSE sector represented by the Greater Manchester VCSE Leadership Group, based on a relationship of mutual trust, working together and sharing responsibility, and providing a framework for collaboration. The VCSE has also established an Alternative Provider Federation as a partnership of social enterprise and charitable organisations operating at scale across Greater Manchester. It provides an infrastructure for alternative providers to engage with NHS Greater Manchester on a Greater Manchester footprint.

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Influences on this strategy

We have drawn on a variety of sources in order to identify our vision, shared outcomes and commitments:  

• What the data and research is telling us about health needs
• What the evidence and evaluation is telling us
• The pressures on current services and the health and care workforce
• What residents are telling us

These influences together identify a series of challenges for Greater Manchester Integrated Care Partnership, to which this strategy responds.

Data and health needs

Among its population of 2.8m people, Greater Manchester has some of the lowest life expectancy in England, with differences between the most and least deprived areas of 9.5 years for men and 7.7 years for women[7].

Significant disparities exist between and within Greater Manchester’s ten localities. In some those living in the neighbourhood with the shortest life expectancy can, on average, expect to die a whole decade before those in neighbourhoods which fare best. In some places the disparity is as big as 17 years.

Further disparities exist between communities according to race, ethnicity, gender, disabilities, poverty, social exclusion, sexuality and age. For example:

• The poorest children are four times as likely to have a mental health difficulty as the wealthiest[8]
• Black people are almost five times as likely to be detained under the Mental Health Act[9]
• The rate of mental health problems in adults with a learning disability is 40% at any one time, and 36% for children and young people[10]. Almost eight in ten autistic adults experience a mental health problem[11], compared with one adult in six in the general population[12]
• LGBT people are less satisfied with their life nowadays than the general population, scoring it 6.5 out of 10, compared with 7.7 for the general UK population[13]
• More than eight in ten women in Britain have felt as though they have not been listened to by healthcare professionals[14]
• Black women are 3.7 times more likely to die during pregnancy or childbirth compared to white women with women from Asian backgrounds facing 1.8 times the risk of maternal mortality[15]

In each case there are direct implications for the design and delivery of health and care services to achieve equity in terms of timely access, experience of care and the outcomes of that care.

The 2021 Census confirmed the broad trends of continuing population growth that we see for Greater Manchester, and especially the cities of Manchester and Salford,[16]. The scale of growth in recent decades across Greater Manchester outstrips the population losses of the 1970s and 1980s.

The scale and characteristics of the growth in Greater Manchester’s population will have implications for services such as health and social care for the elderly, school places and public transport but will also mean that Greater Manchester public services’ funding from central government should be expected to change in accordance with these population changes.

In 2020, the Institute of Health Equity (IHE), led by Professor Sir Michael Marmot, published an update on the 2010 Marmot Review of health inequalities in England, which included a parallel report dedicated to Greater Manchester[17].The IHE followed this with a detailed analysis of how Greater Manchester could become a Marmot city-region by tackling inequalities across the life course, published as Build Back Fairer in Greater Manchester: Health Equity and Dignified Lives[18].

The principle of ‘proportionate universalism’[19] emphasised as part of that work, recognises that, in order to reduce inequality, greater help will be needed by those with greater challenges to overcome.

The Independent Inequalities Commission (IIC)[20], showed the main socioeconomic inequalities in Greater Manchester to be centred on housing and the lived environment; education and skills; power, voice and participation; income, wealth and employment; connectivity and access to care and support. In a bid to address these inequalities, the IIC recommended that Greater Manchester focus its energy and resources on attaining two main goals: equality and wellbeing.

The IIC identified that in terms of income, wealth, and employment:

• Nearly a quarter of Greater Manchester adults of working age (24%) are economically inactive, well above levels for England as a whole (21%)
• For people from minority ethnic groups in Greater Manchester, employment rates are over 10% below the overall working-age employment rate
• Only half of Greater Manchester working-age residents with a disability are in employment
• 37% of the city-region’s working-age population have higher level (Level 4+) skills, compared to the England average of 40%; and Greater Manchester has a disproportionately high proportion of working-age people with no qualifications (9%)
• The skills deficit reinforces the predominance of lower value, low pay employment in the city-region compared to the south of England and Greater Manchester’s international comparators. Low income levels underpin high levels of child poverty (26%) in Greater Manchester, which are well above the national rate of 18%
• There is compelling evidence of ageism in recruitment and retention of older workers, leading to low incomes and lack of social roles in mid-life and later life

Greater Manchester commissioned an Independent Prosperity Review in 2019 which was updated in 2022[21] in the light of the COVID-19 pandemic, the UK’s exit from the European Union and the inflation and energy price shock.

It showed that:

• Greater Manchester’s productivity has been about 10% below the national average in recent years
• Among the causes – explaining about 30% of the productivity gap – is lower labour market participation caused by health problems.
• There are very strong correlations between employment levels and health conditions. Research found that as much as 75% of the variance in employment rates across the neighbourhoods of Greater Manchester is accounted for by health (correlations for mental and physical ill-health were similar)

Greater Manchester is relatively deprived compared to other ICSs in England – with the third highest percentage of the most deprived areas in England, compared with the 42 ICSs. Deprivation varies across localities within Greater Manchester, as our analysis of needs and plans from each locality demonstrates (Appendix 1)

Evidence and evaluation

The years following health and care devolution in 2016 have been times of change for the whole population and a range of improvements in health have been achieved:

• Reductions in smoking prevalence
• Supporting more children to be school-ready
• Reductions in people who are physically inactive
• Positive employment outcomes for people with health-related barriers to work
• All of these show sustained performance compared to the rest of England

Taken together, these changes contributed to an improvement in life expectancy against comparable areas. A study by University of Manchester researchers published in Lancet Public Health[22] shows life expectancy in Greater Manchester was higher than comparable areas between 2016 and 2019, In the short-term, life expectancy remained constant in Greater Manchester but declined in comparable areas in England. In the longer-term, life expectancy increased at a faster rate in Greater Manchester than in comparable areas. The study showed the benefits, linked to devolution on life expectancy, were felt in the most deprived localities where there was poorer health, suggesting a narrowing of inequality.

There is much about our Model for Health, connecting social, medical and behavioural factors, which has been demonstrated to work and will remain the focus of our work with communities in neighbourhoods throughout the life of this strategy.

Pressures on current services and the health and care workforce

Like all health and care systems, Greater Manchester is facing a range of challenges, some of which can be addressed within Greater Manchester while others also require changes at a national level. The impact of the COVID-19 pandemic has been huge, and exacerbated many of the challenges which were already having an effect on the wellbeing of staff and the sustainability of services:

Demand for NHS services

• Over 535,000 people were waiting for treatment as of February 2023 compared to 220,000 before the COVID-19 pandemic
• Prior to the pandemic, Greater Manchester was not meeting national standards for cancer, and the equivalent of five additional theatres are required now, five days a week, to address the cancer surgical backlog
• Mental health demand and acuity is high as a direct consequence of the pandemic, with national predictions that mental health needs will remain at elevated levels for some time to come
• Two thirds of GP practices in Greater Manchester were reporting increased levels of demand, with a further one fifth reporting significant or very significant increased demand in February 2023. Over one quarter of pharmacies and two fifths of dental practices and optometrists are reporting challenges – sometimes significant – to the delivery of their service

 NHS resources

The Greater Manchester system has both an efficiency and a productivity challenge. NHS Greater Manchester inherited a system structural budget deficit (commitments over revenue) of over £500 million (out of a total budget of £6.5 billion) on its establishment on 1st July 2022.  This reflects the ongoing cost of additional resources (mainly workforce) put in place during the COVID-19 pandemic. One of the national requirements of an ICB is to bring the system into balance.

Demand for social care

• There is growing demand on local authorities for social care support, and expenditure on social care continues to rise[23]: 600 people a day join a waiting list nationally[24]
• 64% of local authorities reported local provider closures, contract hand backs,
  or ceased trading[25]
• There are disproportionately high numbers of children and young people across Greater Manchester who are at risk, vulnerable or have complex needs. At the end of 2021/22, there were 92.1 looked after children per 10,000 under 18 years olds in the care of the local authorities of Greater Manchester, compared to 69.8 per 10,000 in care of authorities across England overall[26]
• The financial challenges in children’s services are being driven largely by a combination of increased demand for and cost of placements for looked-after children, alongside unprecedented workforce challenges also common to adult social care, particularly around recruitment and retention of social workers and other professionals, with increased use and rising cost of agency staff

Pressures on the health and care workforce[27]

• Recruitment and retention – with particular pressures in nursing and midwifery, dental nursing, care workers and within the VCSE sector. We also know that we have an ageing workforce and a high turnover of people within adult social care
• Health and wellbeing – the COVID-19 pandemic and subsequent recovery has been really challenging for our workforce. As a result, sickness absence levels remain extremely high, putting further strain on our workforce and our finances
• Lack of diversity amongst our workforce must be addressed, to ensure decisions are being made and care is being provided that meets the needs of everyone
• Lack of parity between the NHS and social care – payment of the living wage, access to occupational sick pay and wellbeing support needs to span the totality of the workforce including social care, primary care and the VCSE.
• Cost of living crisis – our staff, in common with our communities, face increasing fuel and food costs. In areas of primary care and social care we know that turnover is impacted by people finding better pay in the retail sector
• Financial challenges – the workforce crisis is contributing to our financial strain with high sickness absence rates, agency and locum spend and reduced workforce productivity. Resolution to the workforce crisis must focus on retention, as well as thinking about working in a different way, embracing digital advancements and reducing costly agency and locum spend

What residents are telling us

Phase Two of the Big Conversation[28] took place in October 2022 and involved a range of methods for engaging people across the length and breadth of Greater Manchester. More than 2,000 individuals were involved, including men and women, older and younger people, carers, LGBTQ+, people with disabilities, members of different BAME communities, asylum seekers, refugees and other excluded groups including sex workers and the street homeless.

Across Greater Manchester residents told us there is:

• Widespread concern with funding and staffing levels for the NHS, as well as social care and the local VCSE
• Widespread concern about the difficulties experienced in accessing GP appointments, as well as other access problems such as waiting times for hospital care
• Demand for more personalised and person-centre care, which takes account of the different needs of different individuals and communities, and recognises that one size does not fit all
• Demand for more and better partnership working with the VCSE sector which is seen as ideally placed to help statutory services negotiate some of the above
• An expressed need for more action on prevention and the wider determinants of health, including help with the cost of living

Throughout the engagement the first two themes overshadowed all others. Further details of the engagement process with residents, staff and the Greater Manchester Integrated Care Partnership are given in Appendix 2.

The latest Greater Manchester Residents’ Survey (Jan 2023)[29] highlights relevant challenges relating to the cost-of-living crisis:

• As a result of the cost-of-living crisis, employed respondents in Greater Manchester are more likely than those across Great Britain to be working more hours than usual (33% v 18%); looking for a job that pays more money (23% v 18%) or working more than one job (13% v 3%)
• 71% of respondents are worried about the rising cost of living, with more being ‘very worried’ in Greater Manchester than nationally. 85% of people who are disabled or not in work due to ill health or disability are worried
• 40% of respondents had a food security level classified as ‘low’ or ‘very low’– and have experienced food insecurity in last twelve months. Food security is where people are confident that they can access a sufficient amount of affordable, nutritious food
• 36% of respondents noted that their household experienced some form of digital exclusion (not being able to get online). Disabled people and older residents are more likely to be digitally excluded

Young people in Greater Manchester, participating in #BeeWell (a programme that annually measures the wellbeing of young people across Greater Manchester) have indicated[30]:

• In 2021, the average life satisfaction and mental wellbeing scores of young people across Greater Manchester were lower than those of young people in England (in studies using the same measures as in #BeeWell)
• 16% of young people responding to the ‘Me and My Feelings’ measure reported a high level of emotional difficulties and are likely to need significant additional support.
• The life satisfaction average score is 6.2 out of 10 for girls but 7.2 for boys. There are sizeable inequalities for young people who identify as LGBTQ+
• Across Greater Manchester, just over one in three young people (34%) are reaching the recommended levels of physical activity set by the Government’s Chief Medical Officer of at least one hour per day. This falls to 27% of girls, 27% of Asian pupils, and 18% of Chinese pupils
• Pupils from a range of ethnic groups (for example, over a third of Black and Chinese pupils) report experiencing discrimination because of race, skin colour, or where they were born (occasionally, some of the time, often or always)
• Over a third of young people who identify as gay or lesbian report at least occasionally experiencing discrimination because of their gender, and this rises to around 40% for young people who identify as bisexual or pansexual, or transgender

The challenges

This information demonstrates that there are challenges which demand a response through this strategy:

• How to continue the improvements already made
• The wider influences on health and good lives
• Health and work
• Access to services and increasing demand
• Health outcomes and heath inequalities
• Workforce recruitment and retention
• Financial resources
• Ensuring equitable opportunity and service provision across the whole of Greater Manchester

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Responding to the challenges

There are three core elements of this strategy which describe how we will respond to the challenges highlighted through data, evidence and engagement:

1. Embedding the Greater Manchester Model for Health. This shows how we work with communities to prevent poor health, and ensure support is available before crises occur, to reduce demands on formal NHS and social care services. It shows how we work together to provide consistent and high-quality care so Greater Manchester residents can be assured that care is just as good wherever it is accessed. It is a social model for health (rather than predominantly a medical one), has people and communities at its heart, and is based on innovating and spreading what works.
2. Identifying and acting on our missions to address today’s challenges. This strategy outlines our shared commitments – everything we will do together across the next five years – and focuses on the missions which connect the whole system to our most significant and deep-rooted challenges. Each mission responds directly to what the residents of Greater Manchester have told us, the pressures facing public services and our workforce and the evidence and research into what drives our health needs and what works to respond to them.
3. Monitoring our progress. We will ensure that we are clear about the progress we intend to make, and that we can demonstrate how we are meeting it.

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Embedding the Greater Manchester Model for Health

In 2015 we described the key elements to transforming our health and care model in our plan ‘Taking Charge’[31].

That approach, responding to NHS England’s Five Year Forward View[32] committed us to:

• A radical upgrade in population health and prevention
• Transforming community-based care and support
• Standardising acute and specialist care
• Standardising clinical support services
• Enabling better care

This was ambitious, comprehensive, and relevant to the long-term transformation of health and care. There are significant areas of progress since 2015, as well as important areas for further development. The model for health has evolved and developed over the last seven years and it must now frame how we work.

The Greater Manchester Model for Health

We have the opportunity to realise a ‘social’ (rather than a predominantly medical) model for health, including population health and prevention, given the depth of relationships between the NHS, councils, wider public service partners and the VCSE in Greater Manchester. This is a model which offers more than medicine and positively addresses the full range of determinants of health.

The Greater Manchester Model for Health is based on core principles of co-production, working with people and communities rather than ‘doing to’. We have exceptional examples of integrated neighbourhood working, mature provider collaboration, public service reform and evidence of impact since 2015.

We have a unique opportunity to drive our research, innovation and discovery efforts and support deployment at scale through Health Innovation Manchester[33].

Our challenge is that this Model is not universally realised across Greater Manchester. Our aim through this strategy therefore is to confirm the actions and approaches necessary to achieve this and maximise the effectiveness of how we work together to improve our outcomes.

The following section describes the core characteristics of the Model and the focus of its further development.

Creating the conditions for good lives

We pursue a ‘health in all policies’[34] approach to maximise our influences on the social determinants of health. These include:

Strong communities and families – as part of the response to the COVID-19 pandemic, we saw that improved levels of volunteering assisted the wellbeing and health of both those volunteering and those receiving support. The appetite for rapid innovation saw services blended with the VCSE sector due to their direct reach into communities, services run from local community buildings and befriending services bridging the gap for people. The willingness to care and volunteer offers real potential to secure a lasting legacy from the pandemic.

An inclusive economy – an approach to economic development where everyone can participate in local economic life; where local resources and wealth are redirected into the local economy and where local people have more control. Where the contribution of public services is maximised through the Greater Manchester social value framework[35], including our contribution to the local economy in relation to employment, procurement, building and land use, and our environmental impact.

An age friendly Greater Manchester – responding to the opportunities and challenges of an ageing population in our city-region, focusing on reducing inequalities and ageing well. This requires a change in approach to health and social care to ensure more proactive care, healthy and active ageing and ensuring people get the right care when they need it.

Skills, education and good work – supporting early years development to enable more children to be school ready; ensuring successful educational experiences in schools and colleges which support positive mental health and securing more control of the post-19 skills system to lead to better employment opportunities across the city-region. Focussing also on good work through the spread of the Greater Manchester Good Employment Charter, improving pay and supporting wellbeing in work.

Good Homes – connecting with the GMCA, councils and Greater Manchester’s housing providers to improve the availability and quality of housing, including supported housing. Tackling and preventing homelessness and developing homeless healthcare as part of an approach to health that includes people who are socially excluded (inclusion health[36]).

Healthy places – developing neighbourhoods with cleaner air and access to green spaces where communities can come together, connect and support each other, enjoying their local environment and benefitting their physical and emotional health; where active travel through walking and cycling is made easy and supported by our collective work through GM Moving, our city-region wide movement to get people moving.

Diet and food security – improving diets and tackling food insecurity (where people are not confident that they can access enough affordable, nutritious food) to improve physical and mental health, educational and economic outcomes. In children, food security positively affects happiness and life satisfaction, social skills, and quality of life scores.

Health and justice – addressing the health, social care and criminal justice factors that can lead to life-long poor physical and emotional health, and reduced life-expectancy, for people in the criminal justice system, as offenders or victims. Working with Greater Manchester Police, the National Probation Service, education professionals, youth justice and local authorities to address the underlying causes of violent crime and work together with communities to prevent it. This forms part of Greater Manchester’s approach to tackling serious violent crime, ensuring victims of violent crime get the right support, and improving the criminal justice response to all forms of serious violence.

Providing proactive and preventative integrated care through our neighbourhood model

Utilising people and community centred approaches alongside proactive primary care as part of a comprehensive neighbourhood model spanning public services, local business and community-led groups. This aims to maintain good health and independence and reduce demand on acute and crisis services. This ambition is underpinned by our blueprint for primary care which is being developed.

Integrated neighbourhood teams – typically organised for 30-50,000 residents and coterminous with primary care networks, which are groups of GP practices working together in local areas.

Our integrated neighbourhood teams work to connect all primary care services including GPs, dentists, pharmacists and optometrists with community, social and local acute care, local VCSE and wider public services (such as housing providers, schools, employment support and the local police and fire and rescue service). We will not miss the opportunity to maximise the enormous potential of community pharmacy within those integrated teams to reduce pressure on GPs and hospitals.

Utilising population health management tools to anticipate care needs and provide support and preventative care before crises occur. Integrating local urgent care to provide an urgent community response and reduce the need for people to need ambulance or hospital support.

Our digital transformation plans are key to connecting and improving this aspect of the Model through improved data availability, particularly for community services, ensuring those at highest risk are identified and supported appropriately, and the expansion of remote monitoring and virtual wards.  We are continuing to enhance the Greater Manchester Care Record and its use for direct care, secondary uses and research. For the integrated care workforce, we are promoting the development of neighbourhood based integrated health and social care roles, including the expansion of the blended roles programme.

The neighbourhood model is the key to making our model for health a reality, ensuring that people are supported to live well and continue doing the things they love, with the support they need, whether they’re diagnosed with a long term condition, cancer, dementia, or they’re at the end of their life and receiving palliative care.

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Screening and immunisation – identifying those at greatest risk and supporting early detection and therefore earlier treatment and support. Reducing health inequalities and addressing differences in uptake among different groups.

Reducing harms from tobacco, alcohol and drugs – reducing smoking prevalence as part of our Make Smoking History programme; reducing alcohol and tobacco harms especially during pregnancy and changing lives with those experiencing multiple disadvantage and struggling with the complexities of drug, alcohol, mental health and associated problems. This has been a key element of our public service reform journey for a number of years now and ensures we work across sectors to tackle the root causes of demand on services, while improving population health on a more sustainable basis.

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Living well at home – social care in Greater Manchester is fundamentally about better lives, not the provision of services. It is rooted in the power of co-production with people, carers and families to deliver better outcomes for all. It is much more than how we meet the challenge of supporting the flow of people in to and out of our hospitals, although that remains critical. It includes all the changes needed to ensure people have greater independence and enhanced wellbeing within stronger, more resilient communities. Our adult social care ambitions support people to ‘live well at home’, as independently as possible, making sure that the care and support they receive responds to their strengths and what matters most to them; valuing and respecting carers through recognition and support; supporting people with complex needs with enhanced care at home to prevent them going into hospital and to return home as quickly as possible; and working with social care providers to improve quality and ensure a resilient and diverse market for care.

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Supporting children and young people – providing early help to families with a focus on improving educational attainment, speech and language and healthy weight.  Ensuring good emotional wellbeing with earlier targeted intervention and expansion of community based mental health services. Co-produced support for children and young people with special educational needs. Support through transitions as part of a 0-25 model and boosting outcomes for young people leaving the care system through support in education, employment and training, health and finances.

Integrating care through our providers

Urgent and emergency care – using a clinically guided Greater Manchester approach to develop the pathways between local urgent care services such as GP out of hours, 111 and Accident and Emergency and more specialist emergency care such as for major trauma, hyper-acute stroke and heart failure. Empowering the Greater Manchester provider collaboratives to organise and deliver a consistent approach to triage, treatment and transfer across urgent and emergency care sites.

Planned care – using the provider collaboratives to direct planned care recovery and address the backlog through a single shared patient list targeting health inequalities, offering virtual outpatient services and managing staff wellbeing. Managing the flow of new patients needing diagnosis and treatment enabling access to specialist opinion and developing models for community diagnostic hubs.

End of life and palliative care – The Greater Manchester commitments to palliative and end of life care[37] provide the foundation for working collaboratively to ensure people can live well as they approach the end of their life, and die as comfortably as possible in the place of their choice. Equitable access to high quality, holistic, personalised palliative and end of life care, at home and through our hospices and other providers, not only ensures a more positive experience of death and dying for Greater Manchester individuals and their families, but also protects other health care services

Cancer care – comprehensive preventative approaches to reduce people’s risk of developing cancer. Orientating the whole system towards early detection, diagnosis and treatment to improve survival outcomes and experiences. Considering the full range of people’s needs to enable them to live well with and beyond cancer. Bringing together world class researchers and clinicians with our research bodies to constantly improve the lives of people affected by cancer.

Mental health – multi-disciplinary, strengths based team connecting to neighbourhood and community-based care. Increases access to evidence based clinical interventions, psychological therapies and social support. Using “Thrive” principles[38] to meet the dynamically changing needs of children, young people, adults and older people with common mental health problems, severe mental illness, and those with very complex needs who may not currently meet the thresholds for secondary care services. People receiving support can move between different types of help as their needs change.

Sustainable services – responding to the need for a proactive approach to acute service sustainability, to identify services that are vulnerable without intervention and taking earlier action. The initial priorities are in dermatology and ophthalmology.

Health innovation and spread – reducing the time from discovery to spread by connecting the healthcare system with academia and industry to respond to health and care challenges and be at the forefront of the national and global agenda in discovery science, innovation into practice and population health. Developing our approaches to unlock the full potential of our digital and data assets to support redesign and transform care to benefit Greater Manchester residents.

Transforming how people engage with health and care services digitally by bringing in new technologies and using data to provide more accurate and effective care and treatment. Harnessing the power of data and technology to move beyond the basic ability to share information, to digitally reimagine services to fully support the integration of care, empower people to take greater control of their health and wellbeing and accelerate innovation into practice.

Using technology appropriately so people will be able to receive care and treatment based on the most accurate information, where and when they need it, allowing people to better monitor their own health and plan their care, alongside professionals.

Analysing de-identified personal data to better review and plan services based on accurate information. Supporting ground-breaking research into new cures and treatments that could save lives here and around the world.

Significantly growing our activity in community-based research. Through Health Innovation Manchester, using our available resource for research and innovation to tackle local problems, developing and deploying proven innovation at scale through leveraging industry and national resource and investment; maximising our contribution to economic development in Greater Manchester.

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Meeting today’s challenges – our missions

Section 5  sets out the challenges this strategy responds to, and it is through our missions that the current challenges will be addressed.

Everyday life for many is precarious and repeated shocks affecting people’s sense of security and wellbeing are now widespread; for example, the effects of the cost-of-living crisis and what that means for food and fuel security, digital exclusion, housing, and employment security. These directly impact people’s health.

Poor health remains the single most important factor driving long term exclusion from employment and participation in the economy. That exclusion affects a quarter of our working age population.

Participants in our Big Conversation emphasised their concern about the problems accessing core health and care services. Reducing long waits as core services are restored is essential to maintain the confidence of those residents requiring our care, in the context of increasing demand.

The failure to prevent illness and its late detection means that our health and care system remains locked in a cycle of responding to crisis. Greater Manchester’s population experiences higher mortality than it should and people spend a greater proportion of their lives in poor health, especially those with disabilities, those from racially minoritised communities and those facing multiple disadvantage. An upstream model of care and earlier intervention remains a consistent ambition to improve health outcomes and reduce health inequalities.

Addressing our workforce challenges gives us our biggest opportunity to improve the way we provide health and care for our communities. The Greater Manchester public has expressed its own concerns about the pressure on our health and care workforce, in terms both of numbers and staff wellbeing. We must also recognise the additional pressure and challenge faced by unpaid carers supporting their loved ones every day; the more that stresses emerge in public services the greater the consequent demands move to families and carers.

The pressure on public finances over an extended period means resources don’t match the demand on health and care services; long term financial sustainability is a huge challenge.

It is these challenges which have led us to identify six missions requiring action in each neighbourhood, in all ten localities and across the whole of Greater Manchester:

• Strengthening our communities
• Helping people get into, and stay in, good work
• Helping people stay well and detecting illness earlier
• The recovery of core NHS and care services
• Supporting out workforce and our carers
• Achieving financial sustainability

All of these missions are underpinned by the need to ensure equity, which means providing greater help for those with greater challenges to overcome in order to reduce inequality.

Strengthening our communities

This strategy recognises the stresses on daily life for many of our residents, which have been significantly increased through the cost-of-living crisis. This will lead to a crisis in health. This strategy needs to enable individuals, families and communities feel more confident in managing their own health. This is about helping communities support each other.

NHS Greater Manchester works closely with leaders from Greater Manchester’s VCSE sector, and we have put in place an accord agreement[39] which contains eight commitments shared across the sector, NHS Greater Manchester the GMCA and its constituent councils. We want to further develop how we work together to improve outcomes for Greater Manchester’s residents, enabling good lives for all and strengthening our communities.

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Our focussed actions here include:

• Continue to develop social prescribing in Primary Care Networks to enable people to  be able to get opportunity, advice and support in their community to lead a healthy happy life.
• Coordinate our response to poverty – food, fuel, and transport.
• Address historic under-investment in mental health, learning disability and autism and expand our community-based provision through the Living Well model
• Embed the VCSE Accord to grow the role of the VCSE sector as an integral part of a resilient and inclusive economy
• Progress our Net Zero climate change contribution to achieve a net zero carbon footprint by 2038
• Deliver a Greater Manchester-wide consolidated programme to deliver better outcomes for those experiencing multiple disadvantage and co-occurring conditions building on learning and effective approaches from the Supporting Families (Troubled Families) programme, Rough Sleeper Initiative, Housing First, Changing Futures and Working Well.
• Equip people with the skills, connectivity and technology to get online, partnering with the Digital Inclusion Action Network[40], and focusing on all under-25s, over-75s and disabled people.

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Helping people get into, and stay in, good work

One of the purposes of integrated care systems is to support wider social and economic benefits from NHS investment.  This is important everywhere, but for Greater Manchester it has the potential to be nationally significant in raising overall productivity and supporting a necessary rebalancing of the national economy. 

Current Government economic policy is centred on creating the conditions for accelerated economic growth.  The public sector in the North makes a greater contribution to Gross Domestic Product (GDP), employment and economic activity than elsewhere in the country. We believe that approaching this mission with focus and energy is essential to helping to address the widening inequalities that we see across our communities.  We also believe that supporting people to have full lives and to be healthy and well is the best way to reduce public service demand pressures over the medium and long term. 

All ICSs are developing the role of the NHS in local economies and Greater Manchester is developing a network of anchor institutions[41] to further develop our contribution to the local economy in relation to employment, procurement, building and land use, and our environmental impact. We must consider what needs to be done to drive prosperity across Greater Manchester and the role of the Integrated Care Partnership in achieving this.  In considering this we need to understand why children fall behind, why long term worklessness persists, and how Greater Manchester’s health and skills inequalities can be addressed in order to reverse longstanding and structural inequality.

Our focussed actions here include:

• Expansion of our Work and Health Models[42] to prevent people falling out of work, getting people back into work, and supporting people with learning disability, Autism and severe mental illness to be placed and trained in work.
• Working with employers on employee wellbeing, through the Greater Manchester Good Employment Charter, to ensure new and existing jobs right across Greater Manchester are ’good work’[43].
• Implementing the Greater Manchester Social Value Framework[44] and community wealth building approaches through a Greater Manchester network of anchor institutions.

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Helping people stay well and detecting illness earlier

We have described the features of a Greater Manchester Model for Health focused on putting health at the heart of all our city-region policies and integrating public services to address the wider determinants of health, alongside NHS Greater Manchester’s ambitions for how health and care services are provided.

Many conditions which contribute to shorter healthy life expectancy are preventable. We will collaborate with focus and purpose to deliver comprehensive, scaled approaches to the main modifiable risk factors – tobacco, physical activity, obesity/food and alcohol – which can lead to death. At the same time we will also prioritise secondary prevention[45] – treating high blood pressure, high cholesterol, diabetes and other conditions which are risk factors for poor health and early death from cancer, cardiovascular, diabetes and respiratory diseases. We will move away from siloed approaches by partnering with our residents and communities, spreading evidence-based approaches, involving all providers and utilising innovative data architecture and capability  to develop interventions and models of care that engage those from higher risk populations. 

We recognise that specific communities face greater challenges concerned with prevention, early detection and early treatment. These include people with severe mental illness, people with disabilities, communities facing disadvantage or discrimination as a result of ageism, racially minoritised communities and communities in poverty. We will, therefore, embed a comprehensive approach to reducing health inequalities to deliver improved equity, equality and sustainability across health and care.

Our focussed actions here include:

• Application of CORE20PLUS5[46] to reduce health inequalities across Greater Manchester, drive early cancer diagnosis, hypertension case finding, reduce hospitalisation for COP­­­­D, increase health checks for people with severe mental illness or learning disability, and improve maternity outcomes.
• Drive prevention through increased physical activity, reductions in smoking and obesity.
• Expansion of culturally appropriate services that better reach into disadvantaged communities.
• Apply evidence-based falls prevention approaches consistently across Greater Manchester.
• Monitor and target unwarranted variation for populations affected by inequalities.
• Expand the use of tools for finding people at risk of poor health and providing anticipatory care, partnering with our residents.

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The recovery of core NHS and care services

Improving access to high quality, core services and reducing long waits is the main issue raised by Greater Manchester residents participating in the Big Conversation and this will be delivered through our approach to the recovery of services. This covers the full range of core NHS and care services where reliable and timely access has been set back.

Our focussed actions here include:

• Improving ambulance response and A&E waiting times
• Reducing elective long waits and cancer backlogs, and improving performance against the core diagnostic standard
• Making it easier for people to access primary care services, particularly general practice
• Ensuring universal and equitable coverage of core mental health services and continuing to value parity between mental and physical health
• Pursuing best practice to improve quality and reduce unwarranted variation

There are activities underway already to ensure these improvements occur, but we are also signalling where further action needs to be undertaken through this strategy. Recognising that NHS Greater Manchester must have regard to this strategy in developing its own plans with NHS partners, additional detail is provided here in relation to those areas where NHS Greater Manchester has the most direct influence.

Primary care – We recognise the role of primary care as part of the wider Greater Manchester urgent and emergency care system and its aim to deliver responsive same day services. In organising primary care, we always seek to balance convenience and continuity of care in relation to who sees a patient, between online or face to face appointments according to the patient’s wishes and needs. NHS Greater Manchester will seek to secure additional capacity when periods of surge demand occur, which we assess through our framework for reporting pressures. Primary care providers will enable the spread of access to online advice on symptoms and self-care, going to a community pharmacy, a GP appointment, an urgent treatment centre, or the 111 out-of-hours clinical assessment service. NHS Greater Manchester and primary care providers will also engage on options to address the current issues surrounding access to NHS dental services and develop a dental access plan.

Urgent and emergency care – Our collective improvement activities will support people to be seen more quickly in emergency departments through better ambulance handover and initial decision making. Improved flow across the system will be supported through embedding approaches such as ‘Discharge to Assess’[47]; and to reduce need for hospital attendance and admission through a two-hour urgent community response in all ten localities in Greater Manchester, improved NHS 111 call handling, and enhanced support to care homes.

Planned care –we will increase the number of surgical hubs – focused only on planned surgical procedures to protect capacity for elective (planned) activity.  We will reduce unwarranted clinical variation through approaches including ‘Getting It Right First Time’[48] and maximise bed and workforce capacity, including expanding the availability of virtual wards. We will increase system theatre utilisation, reducing length of stay for elective patients and overall day case rate. Improved support for patients waiting for treatment will be provided through better care navigation, consistent patient initiated follow up and more ‘While You Wait’[49] and ‘My Recovery’ resources. A focus on health inequalities will run through each of the elements of the elective recovery plan.

For children and young people, we will reduce waiting times to within national standards through a Greater Manchester-wide approach to paediatric elective recovery with common clinical prioritisation, establishment of dedicated paediatric surgery hubs, sharing of best practice to maximise activity and transforming pathways.

Cancer Care – We will strengthen Greater Manchester compliance with best practice pathways defined nationally, initially in breast, skin, head and neck, breast and gynaecology and then on to tumour sites where national guidance does not yet exist. We will improve diagnostics through enhanced mutual aid (organisations supporting each other) and increased diagnostic capacity and reporting dedicated to cancer. We will roll out the ‘Single Queue’ diagnostics approach[50] and increase sustainable diagnostic capacity through community diagnostic centres[51]. We will implement the Greater Manchester lung model of care and accelerate roll out of targeted lung health checks.

Mental Health and Learning Disability – We will continue to support high levels of mental health needs and the ongoing provision of crisis services including increases in liaison and system working with Greater Manchester Police (GMP) and the North West Ambulance Service (NWAS). We will also work in partnership to support people with a serious mental illness to access housing and employment and. to reduce long waits, additional support to tackle waiting lists will be sought alongside reducing waits for physical health checks, as it will for  with a learning disability.

We will adopt a proactive approach to supporting children and young people to reduce the impact of mental health problems, and specifically to improve the pathway for eating disorders, and improve the interfaces of inpatient services with the whole system including alternatives to admission and discharge.

We intend to increase our longer-term baseline investment in mental health services, recognising that demand now is substantially above pre- pandemic levels and that Greater Manchester has historically under-invested in mental health, learning disability and autism compared to other areas. This has resulted in significant variation in the availability of services across Greater Manchester, which must be properly resourced going forward through an agreed investment plan. This is consistent with seeking parity of esteem for mental health services with physical health services and will be challenging for the Greater Manchester system in terms of allocating limited resources.  Recognising the starting position, our ambition would be to move Greater Manchester to the middle quartile of expenditure per capita with consequent improvements in access and outcomes across the life of this strategy.

Supporting our workforce and our carers

These are extremely challenging times for our health and care services as we face significant financial pressures and a workforce crisis. We have high sickness absence rates, recruitment and retention challenges. At the same time, we recognise the enormous pressures faced by carers, making life harder for the people they are trying to support. As an Integrated Care Partnership, we need to take action to create the conditions to allow our people to provide the best possible care – including our paid and unwaged workforce.

We have a People and Culture Strategy[52] to promote integration, better partnership working and good employment practices. The strategy also seeks to address the causes of sickness to keep our workforce well and addressing the inequalities we know people face in the workplace.

Our intention is to ensure we have more people choosing health and care as a career of choice, and that they feel supported to develop and stay in the sector. We want a cultural shift to create a more compassionate and inclusive leadership culture, bolstering a culture of collaboration and a culture where wellbeing matters.

Our actions will demonstrate the value we place on those providing care across health and care and our commitment to support, retain, develop and enable wellbeing in our workforce, as well as at home for unwaged carers.

Our focussed actions here include:

• Increase in membership of the Greater Manchester Good Employment Charter[53] and payment of the Real Living Wage, which will improve employment standards including security, flexible working, employee engagement, recruitment, people management, wellbeing provision and inclusion.
• Improve workforce wellbeing: we will increase access to wellbeing and absence management resources, with the aim of improving wellbeing and reducing sickness to support better workforce planning and ensure safe staffing.
• Address inequalities: we will improve diversity at senior manager and executive level and improve the experience for our workforce with protected characteristics
• Grow and develop our workforce: we will increase recruitment to the sector from within our own communities, including key areas such as nursing, midwifery, social care and mental health. We will support more people to develop and stay and improve our workforce planning system infrastructure.
• Workforce Integration: we will increase the opportunities for sharing and partnership working across our system and organisational boundaries and increase the number of people working in integrated roles.
• Provide more consistent and reliable identification and support for Greater Manchester’s unwaged carers, building on the Greater Manchester Carers’ Charter and the Greater Manchester Working Carers’ Toolkit.

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Achieving financial sustainability

Achieving financial sustainability for the health and care system can be described as ‘living within our means’ and ensuring that expenditure does not exceed income. As previously highlighted, our system has a deficit because spending has been higher than income. Action is urgently required to address the drivers of both cost and demand in the system.

In the initial phases of delivering this strategy a necessary focus on financial recovery, to achieve a balanced position, will drive our activities.

The first step is to address each of the principal reasons for the financial, efficiency and productivity challenges in the Greater Manchester integrated care system, in order that the Greater Manchester system leadership collectively owns the outputs from this process and agrees to the actions necessary to address the challenges.

Our focussed actions here include:

• Develop and implement a comprehensive system wide programme spanning cost improvement, productivity, demand reduction and service transformation.
• Identify factors from successful system working to implement the programme, including the behaviours and incentives for system working.

This programme will be specific and well-defined, requiring close monitoring and tracking of each of the system financial improvement interventions, and comprises the following:

• Identifying and addressing the most significant demand drivers across the Greater Manchester integrated care system
• Developing a comprehensive system wide programme spanning cost improvement, productivity, demand reduction and service transformation.

Specifically, to:

• Confirm the assessment of in-year cost improvement opportunities
• Maximise patient flow and theatre productivity approaches
• Incentivise Provider Collaboratives to optimise their collective sites and workforce and reduce structural costs
• Balance incentives and funding to support the management of new demand in primary and social care and reduce demand elsewhere in the system
• Scale social support and prevention to reduce demand for formal health and social care.

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Monitoring Our Progress

We are committed to reporting on how successful we are in achieving the ambitions set out in this strategy and have identified progress measures against our outcomes and missions. These are high-level measures, on which we expect to see change in the longer term.

We want to see a Greater Manchester where ….

Everyone has an opportunity to live a good life.

This is prioritised in our missions for…

• Strengthening our communities

We will measure

1. Reduced anxiety
2. Improved life satisfaction
3. Feelings of safety

These measures are already monitored through the GMS and progress can be seen here: GMS improved health and reduced inequalities measures

• Helping people get into, and stay in, good work

We will measure

1. Number of people starting work
2. Number of people staying in work

GMS safe and vibrant communities measures

These are from the Work and Health programmes regular monitoring.

Everyone has improved health and wellbeing

This is prioritised in our missions for…

Helping people stay well and detecting illness earlier

We will measure:

• Life Expectancy and Healthy Life Expectancy. Healthy life expectancy already monitored through the GMS and progress can be seen here

GMS shared outcome:
Healthy Life Expectancy

• Avoidable mortality rates. Aiming to be in line with England average by 2030.

• Reductions in health inequality in the onset of multiple morbidities. Aiming to narrow the 15-year gap in the onset of multiple morbidities (such as mental health, hypertension, diabetes) between the poorest and wealthiest sections of the population.

• Physical activity. These measures are already monitored through the GMS and progress can be seen here: Active lives

• Smoking prevalence.  Smoking

• Obesity. Obesity

Strengthening our communities

We will measure…

• See above.

Everyone experiences high quality care and support where and when they need it

This is prioritised in our missions for…

The recovery of core NHS and care services

We will measure…

• Year-on-year improvement in meeting national targets for core services.  Taking the number of measures in the NHS operating framework (as defined each year) as a base and measuring the number where Greater Manchester has met the target compared to other ICSs.  We are aiming for an increase in the % of targets being met year on year.
• Equitable service provision across all areas in Greater Manchester. Specific initiatives will be identified each year, from priority programmes for spread, and equitable provision monitored until it is achieved.

Supporting our workforce and carers

We will measure…

• Increase in Good Employment Charter membership from the health and care sector.
• Number of health and care organisations paying the RLW.

This will be monitored through the People and Culture strategy.

Health and care services are integrated and sustainable

This is prioritised in our missions for…

Achieving financial sustainability

We will measure…

• Deliver balanced recurrent ICB and system financial position by 2024/25. This will be monitored through routine ICB reporting.

The recovery of core NHS and care services

We will measure…

• See above.

Utilising data to address inequality

We are committed to utilising the intelligence generated to give us a better understanding of inequality across the city-region, in terms of both spatial and demographic variation. We also want to understand how outcomes vary for our diverse communities, including variance by age, sex, ethnicity, disability, sexual orientation and trans status, and religious affiliation. The development of our Greater Manchester Health and Care Intelligence Hub is key to this, building on the Greater Manchester Digital Platform[54]. The hub is a web-based portal that is being co-designed to bring together data, community insight, web-based tools, guidance, shared learning and workforce development resources to support people working in health and care to better understand health inequalities and variation in care in their areas and implement models of care.

We will develop and publish a Joint Forward Plan (JFP) by the end of June 2023 as a delivery plan for the ambitions in our Integrated Care Partnership Strategy and this plan will be updated annually.  It will include progress measures for the elements of the plan which support the overall ambitions in this strategy.

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Appendix 1 – Locality plans

Our ten localities in Greater Manchester – Bolton, Bury, Manchester, Oldham, Rochdale, Salford, Stockport, Tameside, Trafford and Wigan – all have local authority plans
(or strategies), locality plans for health and care and Health and Wellbeing plans.
The Joint Strategic Needs Assessments (JSNAs) in each locality have specifically informed the Health and Wellbeing plans, as well as the other plans.

It is a statutory responsibility for the ICP strategy to have regard to these plans[55], which have informed the whole of the strategy.

Links to each of these plans for each of the localities, where information is available at time of writing, are given in the table below, along with a link to the Health and Wellbeing Board in each locality. This information will be updated as plans in localities are updated and confirmed.

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Appendix 2 – Engagement on the strategy

This strategy has been developed through engagement with the public, staff and stakeholders in the Greater Manchester system, in addition to the analysis of a wide range of documents and reports (see Appendix 1).  This process has been iterative with comments from initial engagement used to inform versions of the strategy considered later in the process.

Public engagement

Phase one of the Big Conversation took place in Spring 2022, with organisations, staff and citizens giving their views on the vision and priorities at that time, through an on-line survey. 1,334 people responded (including staff and citizens).

Respondents were somewhat representative of the population but less representative of sex (males) and age (younger and older people). In general, there was overwhelming support for the vision and principles, however, it was suggested that the language used to describe priorities was not accessible to some groups of people and did not give a clear indicator of what was being done.

Findings from phase one were considered at a collaborative event attended by over 100 VCSE organisations and NHS engagement leads.  This led to a further deep dive to reach underserved communities and understand what matters most and we named this Big Conversation phase two.

Phase two took place in October 2022 and was led by the voluntary and community sector including GM=EqAl[56], Healthwatch and local infrastructure organisations.  This enabled us to reach deep into communities and involve those who are less likely to take part in surveys or provide their views in traditional ways. Phase two was more detailed and focused on priorities and actions.

Individuals and groups considered the following questions, which were developed in partnership with the public and a range of VCSE organisations:

For community groups: What would make the biggest difference for communities you serve in relation to being healthier, happier, and better?

For individuals: What would make the biggest difference to your life in relation to being healthier, happier, and better?

• What’s stopping this?
• What would help this?
• What’s the most important thing health and care services need to improve?

Engagement from phase two reached over 2,000 people representing communities of identity/interest and elicited over 10,000 views.  Responses are summarised in the strategy section ‘what residents are telling us’.

Staff engagement

Although staff, as members of the public, may have taken part in the Big Conversation, we carried out a separate engagement process with staff from across Greater Manchester in February 2023, using an online survey with telephone support if needed. This engagement focused on the missions and the ways of working.

Responses from 156 staff indicated broad support for the missions, although with feedback on the language and terminology used, and strong support for the missions for prevention and early detection, and for our workforce and carers. The ways of working were also supported, with many describing how they could promote them in their own role.  Communication of the ways of working across the whole system was regarded as important. 

System engagement

We have taken an iterative and inclusive approach to engagement across the Greater Manchester system since the initial development of the outline for the strategy.

March-Sep 2022

We established a strategy working group comprising a range of stakeholders from across the system, including localities, which met monthly from March 2022, to support this strategy development work. The group developed a set of draft outcomes and shared commitments during the first part of 2022, taking into account the four national objectives for ICSs and the original principles from devolution which were reaffirmed in the review of partnership working undertaken during the pandemic. These were tested through the Big Conversation phase one.

Sep-Dec 2022

A revised version of the strategy was therefore developed, discussed, and agreed by the strategy development group in September, prior to approval by the Integrated Care Partnership (ICP) Board at its first (shadow) meeting on 20^th September 2022, with further development and the engagement process considered at the first formal (public) meeting of the ICP Board on 28th October 2022[57].

The ICP Board held a workshop focused specifically on the ICP strategy on 2^nd Dec 2022, where the Board was supportive of the proposed missions which had been developed from the analysis of data and evidence undertaken to date.

Jan-Feb 2023

During this period, a written ‘Engagement Draft’ and accompanying slide set was considered by stakeholders across the system, including at the ICP Board on 20^th Feb 2023[58] where the importance of the Joint Forward Plan, now under development, being the delivery plan for the strategy was emphasised[59].

Much of the feedback during this time came from a range of meetings including locality boards and Health & Wellbeing Boards, Trust boards, Greater Manchester networks spanning primary, secondary, social care and VCSE sectors, trade unions, professional networks including public health leadership, finance and estates, and clinical networks including medical and nursing directors and Allied Health Professionals. Over 30 meetings

were attended with feedback gathered through those discussions, and written feedback also received from localities, VCSE leadership and interest groups.

This enabled the missions and the Model for Health to be refined, ensuring that they align with other plans and strategies, with emphasis on the response to the key challenges facing the system.

We would like to thank all those who have been involved in any way in this development process and look forward to ongoing engagement as the delivery plans are developed and agreed across Greater Manchester.

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Footnotes

1 https://aboutgreatermanchester.com

2 https://www.instituteofhealthequity.org/resources-reports/greater-manchester-evaluation-2020/greater-manchester-evaluation-2020.pdf

3 https://www.gmgoodemploymentcharter.co.uk

4 https://www.health.org.uk/publications/reports/building-healthier-communities-role-of-nhs-as-anchor-institution

5 https://www.greatermanchester-ca.gov.uk/media/1120/taking-charge-of-our-health-and-social-care-plan.pdf

6 Primary Care Networks involve GP practices working together with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas in groups of practices known as primary care networks (PCNs).

7 Codling, K. & Allen, J., Health Equity in Greater Manchester: The Marmot Raeview 2020. London: IHE, 2020 https://www.instituteofhealthequity.org/resources-reports/greater-manchester-evaluation-2020/greater-manchester-evaluation-2020.pdf

8 https://www.centreformentalhealth.org.uk/sites/default/files/2018-09/newcentury.pdf

9 https://www.ethnicity-facts-figures.service.gov.uk/health/mental-health/detentions-under-the-mental-health-act/latest#:~:text=The%20data%20shows%20that%3A,228%20detentions%20per%20100%2C000%20people

10 https://www.nice.org.uk/guidance/ng54/chapter/Context

11 Lever and Geurts (2016) https://doi.org/10.1007/s10803-016-2722-8

12 https://webarchive.nationalarchives.gov.uk/ukgwa/20180328140249/http:/digital.nhs.uk/catalogue/PUB21748

13 https://www.gov.uk/government/publications/national-lgbt-survey-summary-report

14 https://www.gov.uk/government/publications/womens-health-strategy-for-england

15 Saving Lives, Improving Mothers’ Care 2018-20

https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2022/MBRRACE-UK_Maternal_MAIN_Report_2022_UPDATE.pdf

16

https://greatermanchester-ca.gov.uk/what-we-do/research/census-2021-greater-manchester-topic-briefings/

17 Codling, K. & Allen, J., Health Equity in Greater Manchester: The Marmot Review 2020. London:

IHE, 2020. https://www.instituteofhealthequity.org/resources-reports/greater-manchester-evaluation-2020

18 Marmot, M., Allen, J., Boyce, T., Goldblatt, P. & Morrison, J., Build Back Fairer in Greater Manchester:

Health Equity and Dignified Lives. London: IHE, 2021. https://www.instituteofhealthequity.org/resources-reports/build-back-fairer-in-greater-manchester-health-equity-and-dignified-lives-briefing-note

19 Proportionate universalism is the resourcing and delivering of universal services at a scale and intensity proportionate to the degree of need. Services are therefore universally available, not only for the most disadvantaged, and are able to respond to the level of presenting need.

20 The Next Level: Good Lives for All in Greater Manchester https://www.greatermanchester-ca.gov.uk/media/4605/the-next-level-good-lives-for-all-in-greater-manchester.pdf

21 https://www.greatermanchester-ca.gov.uk/what-we-do/economy/greater-manchester-independent-prosperity-review/ipr-2022-evidence-update/

22 Britteon P et al, published October 2022, https://doi.org/10.1016/S2468-2667(22)00198-0

23 https://digital.nhs.uk/news/2021/new-overview-of-adult-social-care-statistics-is-published-by-nhs-digital

24 https://www.adass.org.uk/surveys/waiting-for-care-july-22

25 https://www.adass.org.uk/autumn-survey-report-2022

26 https://democracy.greatermanchester-ca.gov.uk/documents/s24692/Item%206%202023%2002%2010%20ICPB%20-%20An%20Integrated%20Approach%20to%20delivering%20our%20Ambition%20for%20Children.pdf

27 GM People and Culture Strategy https://gmintegratedcare.org.uk/workforce

28 https://gmintegratedcare.org.uk/big-conversation

29 https://greatermanchester-ca.gov.uk/what-we-do/research/resident-surveys

30 https://gmbeewell.org/research/publications/beewell-reports-briefings

31 https://www.greatermanchester-ca.gov.uk/media/1120/taking-charge-of-our-health-and-social-care-plan.pdf

32 https://www.england.nhs.uk/five-year-forward-view

33 https://healthinnovationmanchester.com

34 https://www.gov.uk/government/publications/local-wellbeing-local-growth-adopting-health-in-all-policies

35 https://www.greatermanchester-ca.gov.uk/what-we-do/economy/social-value-can-make-greater-manchester-a-better-place

36 https://www.gov.uk/government/publications/inclusion-health-applying-all-our-health

37 https://peolc.net/about-us

38 http://implementingthrive.org/wp-content/uploads/2019/03/THRIVE-Framework-for-system-change-2019.pdf

39 https://www.vcseleadershipgm.org.uk/about-the-vcse-Accord

40 https://www.greatermanchester-ca.gov.uk/what-we-do/digital/digital-inclusion-agenda

41 https://www.health.org.uk/news-and-comment/charts-and-infographics/the-nhs-as-an-anchor-institution

42 https://www.greatermanchester-ca.gov.uk/what-we-do/work-and-skills/working-well

43 https://www.shawtrust.org.uk/what-is-good-work-and-why-is-beneficial

44 https://www.greatermanchester-ca.gov.uk/what-we-do/economy/ https://www.greatermanchester-ca.gov.uk/what-we-do/economy/social-value-can-make-greater-manchester-a-better-place

45 “catching the causes of ill health as early as possible to prevent or reduce the chances of them leading to more serious conditions” https://www.england.nhs.uk/our-work/prevention/about-prevention-programme

46 https://www.england.nhs.uk/about/equality/equality-hub/national-healthcare-inequalities-improvement-programme/core20plus5

47 https://www.local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/systems-resilience/overall-approach/discharge-to-assess

48 https://gettingitrightfirsttime.co.uk/

49 https://whileyouwait.org.uk

50 https://gmcancer.org.uk/single-queue-diagnostics

51 https://www.gov.uk/government/news/40-community-diagnostic-centres-launching-across-england

52 GM People and Culture Strategy https://gmintegratedcare.org.uk/workforce

53 https://www.gmgoodemploymentcharter.co.uk

54 https://greatermanchester-ca.gov.uk/what-we-do/digital/empowering-people/the-greater-manchester-digital-platform

55 https://www.gov.uk/government/publications/guidance-on-the-preparation-of-integrated-care-strategies

56 https://www.gmcvo.org.uk/GMEqualityAlliance

57 https://gmintegratedcare.org.uk/wp-content/uploads/2022/10/developing-the-gm-integrated-care-partnership-strategy.pdf

58 https://democracy.greatermanchester-ca.gov.uk/documents/s24691/Item%205%202023%2002%2010%20ICPB%20-%20Integrated%20Care%20Strategyv2.pdf/

59 https://gmintegratedcare.org.uk/wp-content/uploads/2023/03/2023-24-planning.pdf

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