Our Health, Our Lambeth Lambeth Together health and care plan 2023-28

Appendix 1.2 – Activities and impact measures  (Aspiration 2)

Physical and mental health conditions are detected early and people are supported and empowered to manage these conditions and avoid complications

People receive early diagnosis and support for physical health conditions

All people eligible for an annual health check have access and there is an increase in uptake; with a specific increases/focus in uptake for people with learning disabilities and those living with severe mental illness. Increase the number of cancer cases diagnosed at stage 1 or 2. People living with HIV know their status, the virus is undetectable, they live and age well and there are zero HIV related deaths.


Neighbourhood and Wellbeing Delivery Alliance – with contributions from: Living Well Network Alliance, Sexual Health, Staying Healthy, Learning Disabilities and Autism Programmes.


The NHS Health Check

  • Redesign the NHS Health Checks programme in Lambeth to ensure a focus on improving uptake for those at most risk, by focusing on outreach and delivery in community settings.
  • Target health inequalities by increasing invites and uptake of NHS Health Checks and improving referral/diagnosis rates for those with highest risk.
  • Embed population health management approaches making better use of data.
  • Align to the Vital 5 prevention work in community settings.
  • Evaluate and review new programme delivery.

Serious Mental Illness (SMI) Annual Health Checks/Health Action Plans

  • Primary care to implement a quality improvement plan with Living Well Network Alliance support to ensure delivery of SMI Healthcheck in line with national targets and quality metrics.
  • Undertake targeted promotion of SMI Healthchecks to patients and carers particularly those from black and minority ethnic communities.

Learning Disabilities and Autism Annual Health Checks (AHC)/Health Action Plans

  • Work with health and care partners to ensure access to and delivery of AHC’s in line with national line targets and quality metrics.
  • Personalised care – improve % of people with an agreed Health Action Plan following identified risk as result of AHC.
  • Promotion of AHC amongst target population especially those from Black communities i.e., Big Health Week.

Cancer Screening

  • Increase the uptake of all cancer screening across our diverse communities particularly for those whom English is not their first language including the local Portuguese and Spanish speaking community.
  • Deliver the Catch 22 Bowel Cancer Screening initiative, involving targeted work to increase the uptake of bowel cancer screening in Lambeth where 26 General Practices identified with the lowest uptake have been invited to take part in the bowel cancer screening calling initiative and non-responders will be contacted by Catch 22 multilingual facilitators.
  • Public educational and promotional event(s) to include raising awareness of the national cancer screening programmes (Breast, Bowel and Cervical) and Prostate Cancer.
  • Improvements in Severe Mental Illness (SMI) and Learning Disability (LD) yearly health checks to include discussions and encouragement to take up cancer screening opportunities.

HIV testing and pre-exposure prophylaxis (PrEP)

  • Development of data dashboard of HIV testing and diagnoses across the system.
  • A new HIV care and support and peer support network will be in place.
  • Educational and promotional stakeholder events will raise awareness of HIV programme ambitions.
  • A GP Champion for HIV is in place.
  • Sexual Health and HIV training commissioned for primary care staff.
  • Collect real time and demographic data on PrEP usage.
  • Increase access to PrEP for all service users.

Impact measures

The NHS Health Check is a health check-up for adults in England
aged 40 to 74. It is designed to spot early signs and lower the
risk of stroke, kidney disease, heart disease, type 2 diabetes or
dementia. Our aim is for increased uptake of the NHS Health Check
for all eligible adults, and increased uptake of health checks to more than 60% of adults with severe mental illness and more than 75% of adults with a learning disability or autism. Additionally, we want to see an increase in the percentage of patients who have severe mental illness, with health risks linked to smoking, alcohol use and their weight, given appropriate advice.

We will contribute to meeting the cancer faster diagnosis standard by March 2024 so that 75% of patients who have been urgently referred by their GP for suspected cancer are diagnosed or have cancer ruled out within 28 days and increase the percentage of cancers diagnosed at stages 1 and 2 by 2028.

We will improve rates of all cancer screening programmes thus improving early Bowel, Breast and Cervical cancer diagnosis for our Lambeth residents

Lambeth has an ambition to reach the Fast Track Cities goal of zero HIV stigma, transmissions and deaths. To achieve this, all those living with HIV need to know their status to be able to receive treatment and support. Testing all those who require bloods to be taken whilst in Emergency Departments helps to identify those who do not know their status and link them to HIV care and treatment, and to re-engage those in treatment who may have become disengaged. It can also help to normalise testing for HIV and contribute to reducing stigma. We will increase the percentage of eligible people receiving an HIV test whilst attending Emergency Departments and increase the number of Lambeth residents who are new and continuing PrEP users.


People who have developed long term health conditions have help to manage their condition and prevent complications

Diabetes is identified early and managed well. Those with chronic pain have consistent, high quality support, are not over medicalised, have community support and streamlined pathways. High blood pressure is prevented and identified through the use of blood pressure checks. Personalised care approaches and structured medicines reviews are utilised to ensure that people are prescribed the right medicines for them and know how to take them.


Neighbourhood and Wellbeing Delivery Alliance.



  • The Lambeth Community Diabetes Service will work very closely in partnership with General Practices, Primary Care Networks, Guy’s and St Thomas’ Hospital (GSTT), King’s College Hospital (KCH), The South London and Maudsley Hospital (SLaM), Community Pharmacies and other partners, to improve population health and reduce inequalities.
  • The Community Diabetes Service will do this through several approaches. This includes working with GP practices to deliver teaching and multi-professional identification and review of priority people.
  • We will also use local Quality Improvement methods to support GPs in delivering diabetes reviews including training, guidelines and other resources developed with colleagues across South East London.
  • Healthcare professional learning events.
  • Implement recommendations from patient feedback via Centric community researchers.
  • Supporting people with diabetes with holistic and personalised care will be part of the care planning approach from General Practice, social prescribers and community pharmacy.

Chronic Pain

  • Improve the information that the GP has to advise those with chronic pain to access treatment.
  • Work with a group of patients who have chronic pain to improve the provision and information to access pain services in the community and from their GP.

High blood pressure (hypertension)

  • Hypertension workstream to coordinate all Lambeth hypertension activity with a focus on reducing health inequalities.
  • We will support General Practice to meet national targets to reduce hypertension.
  • We will support a new community pharmacy hypertension check service to reduce demand in General Practice.
  • We will use a local Quality Improvement methods to support GPs in delivering training and support around hypertension care including access to training, guidelines and other resources developed with colleagues across South East London.
  • The local Community Hypertension Service will provide support to General Practice in managing more complex disease.
  • We have implemented a community diagnostics service for cardiovascular disease, which helps us identify hypertension.

Medicines Optimisation

  • We will work with our GPs and pharmacies to support more people to access medication reviews.
  • Priorities include supporting review of people taking multiple medicines who may be suffering from adverse effects or not benefitting from medication to ensure they receive appropriate
    medicines to support their goals through shared decision-making approaches.
  • We will develop our Medicines and Prescribing network for multi-professional clinical staff in General Practice to support training and sharing of best practice.
  • Reducing medicines waste through engaging with our public and net zero targets for medicines.

Impact measures

For diabetes to be well-managed a series of annual checks are available to monitor and improve the overall health of people with diabetes. These checks will help reduce the risk of complications associated with the condition. We will increase the proportion of people with Type 2 diabetes who receive these checks on an annual basis.

Local research shows that chronic pain, along with anxiety, is the most prevalent long term condition in Lambeth. A greater proportion of women, Black and Asian populations in our most deprived communities live with chronic pain. To improve outcomes for people with chronic pain, we know people need reviews to help them set and achieve their quality-of-life goals. GPs and their linked staff will ensure they have processes in place to ensure that people suffering from chronic pain are known to them. We will increase the level of support provided by offering education on living well with pain, reviews to set goals and improvements, and review of medication.

Increase the number of people with known hypertension whose target blood pressure is achieved.

Multiple medicines can cause multiple adverse effects without any additional benefit. We will increase the number of people over age of 65 who are taking 10 or more medicines, having a medication review. Evidence tells us that reducing the number of inappropriate medicines in older people reduces harm.

colourful hearts

When emotional and mental health issues are identified, the right help, support and diagnosis is offered early and in a timely way

Mental health support is available in the community and schools and is a timely and a positive experience. We reduce the number of people reaching a mental health crisis point and give prompt and appropriate support to people in crisis


Living Well Network Alliance and Children and Young People’s Alliance.


  • Monitor and review Living Well Network Alliance Single Point of Access capacity and performance to agree service model.
  • Implement NHSE Community Mental Health Framework, including recruitment of staff to provide enhanced capacity to deliver community based mental health treatment, care and
    crisis intervention.
  • Undertake regular outreach sessions at community events within Lambeth to promote the Lambeth Talking Therapies service, audit service user experience to feedback into service development and pilot model of culturally appropriate group therapy with Black Thrive.
  • Roll out Dialog tool during 2023 to 2024, including training and support to staff, to ensure a robust and consistent process to capture service user self-reported wellbeing.
  • Roll out mental health training offer to GPs to increase capacity and capability to identify, assess, and address mental health needs of patients, and refer onwards.
  • Expand community reablement support to help people with practical issues that can help prevent crisis that lead to loss of accommodation and/or admission to hospital and care settings.
  • Extend capacity of Home Treatment Team and further VCS community based out of hour crisis options such as the Evening Sanctuary to assist more people to improve service user experience and contribute toward unplanned admission avoidance, and monitor impact including number of users of these services who would say they would otherwise have attended A&E.
  • Recruitment of Mental Health Practitioners to ensure coverage across PCNs in Lambeth, to provide early identification, assessment and intervention to people with a range of emotional, phycological and mental health conditions in primary care i.e. anxiety, depression, sleep disorders, so that people can access or be signposted/referred to the right support in the community quickly, improving prospects for resolution or improvement and reducing risk of deterioration that may lead to crisis or negative impacts on relationship, work, housing and overall wellbeing.
  • Roll out Living Well Network Alliance’s Staying Well offer across Lambeth, which will involve mental health support staff working more closely with GPs, Social Prescribers and local communities as part of neighbourhood teams to ensure more convenient and better
    joined-up care between General Practice and community mental health services.
  • Develop specialist eating disorder and complex psychological and behavioural needs pathway to enable more people to be supported in the community and reduce unplanned admission due to crisis.
  • Improve the diversity in ethnicity of children and young people accessing Mental Health School Teams – agree baseline from 22/23 annual report, set target for 23/24 with regular monitoring and establish task and finish group to consider how this can be improved.
  • We will continue to develop and deliver our Mental Health School Teams in Lambeth schools and improve the diversity in ethnicity of children and young people accessing this support – we will roll out of MHSTs to another 14 schools in early 2023/24, enabling us to
    ensure we have widespread cover across 28 schools.
  • Working with a voluntary sector provider to consult with children and young people in schools, to better understand emotional health and wellbeing needs relating to our LGBTQ+ community.
  • Delivering a pilot with SLAM and community organisations (The Well Centre, Coram and Place 2 Be) to better understand how we can join up our response to CYP emotional health and wellbeing need, bringing services, data and statutory provision together.

Impact measures

Reduce average wait times for triage and initial assessment following a referral to the Living Well Network Alliance Single Point of Access to under 72 hours by 2024.

Increase access to and recovery rates for Lambeth Talking Therapies for Black African and Caribbean residents to ensure they are as least as good as those of White residents.

Monitor Living Well Network Alliance service user self-reported wellbeing.

Increase the percentage of patients in secondary care due to a mental health crisis, who are discharged and are not re-admitted within 30 days.

Improve access to mental health support for children and young people, ensuring that 95% of children and young people with eating disorders are seen by a clinician within 1 week for urgent appointments and 4 weeks for routine support and that no child or young person waits longer than 44 weeks for an assessment and commencing treatment with Child and Adolescent Mental Health Services. We will ensure we meet the national access target, which for Lambeth is ensuring
2,112 CYP have access to Child and Adolescent Mental Health Services across a 12-month period.