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

Appendix 1.3 – Activities and impact measures (Aspiration 3)

People have access to and positive experiences of health and care services that they trust and meet their needs  

People have access to joined-up and holistic health and care delivered in their neighbourhoods 

People are supported by integrated working by GPs, mental health services, community health, social care staff and others. Children and young people remain supported by health and care services when they transition to adulthood where appropriate. 


Neighbourhood and Wellbeing Delivery Alliance  – With contributions from: Living Well Network Alliance and Children and Young People’s Alliance 


  • Lambeth Together Delivery Alliances support the development of equitable provision of integrated care in the borough – the Neighbourhood and Wellbeing Delivery Alliance (NWDA) supports the creation of health and care community networks (called Thriving communities) to inform neighbourhood service development with a particular focus on providing an equitable offer of health and social care and development of localised health solutions for all our residents 
  • NWDA partner organisations (PCNs, secondary care, social care, community care, VCS etc) recognise that to develop integrated working across the borough and in neighbourhoods requires an iterative, partnership approach that acknowledge the complexity of the system and allows new approaches to be tested, developed and implemented at scale 
  • Primary Care Networks (PCN) and community-based partners will explore opportunities to evolve integrated neighbourhood provision and models using insight from residents and service users to inform localised provision such as neighbourhood teams for mental health and workforce development to support flexible multi-disciplinary teams 
  • Use our wide range of existing estates for the delivery of integrated services from a range of partners including community groups 
  • Each PCN to have a social prescribing team which is expanding and recruiting to specialist posts in recognition of local need, including dedicated children and young people posts and mental health  
  • Re-launch and monitoring of Consultant Connect as first line for advice and guidance for primary care clinicians and encouragement of uptake in use – working with SEL team to identify any actions which may lead to increase in successful answer rates – Consultant connect allows GPs real-time specialist advice and so allows the patient to receive their care in the community rather than in hospital 
  • Adults’ and children’s mental health teams will work more closely together to improve planning, communications, and the transition of young people to adult mental health services – upon transition to Adult Mental Health Services, we aim to have in place an improved transitions pathway between CAMJHS and Adult Mental Health 
  • Refine and develop the approach to Population Health Management around the Core20  
  • 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 
  • A programme of communication with Lambeth’s population to allow a greater understanding of the differing healthcare roles, services available, and how they can have direct access to the right service for their need  
  • Development of the London Care Record that supports the delivery of holistic care to patients and can be used from across health and care services 
  • Ensure there are tailored ways to support groups who often find it difficult to access healthcare, such as asylum seekers and traveller communities.  

Impact measures

Increase usage of consultant connect by primary care. 

All young people aged 17.5 years old, open to CAMHs will have a clear transition pathway to ensure they remain supported by health and care services when they transition to adulthood. 

Patients understand the services they can directly access and we see an increase in the numbers of self-referrals to those services, rather than referrals from GPs. 

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People know where to go to get the right help, and are treated at the right time, in the right place, for their needs

People can access the right support in the right place at the right time, utilising the most appropriate help including primary care, community pharmacy, 111, urgent treatment centres and emergency departments. More people attending hospital, are treated and go home on the ‘same day’ and people admitted to hospital are discharged in an appropriate timeframe with a reduction in preventable delays. People needing scheduled treatment are suitably prioritised and any unnecessary waits are reduced. People in need of support due to the harms caused by drug or alcohol misuse, are offered it at the persons point of need and support services can work together to counter these harms with the individual and wider communities. ‘Virtual wards’ allow patients to get the care they need at home safely and conveniently, rather than being in hospital.


Neighbourhood and Wellbeing Delivery Alliance – With contribution from: Substance Misuse programme.


Urgent and Emergency Care transformation and access 

  • Review of communication, engagement and behavioural activities including analysis of options to improve local public messaging on sites and in communities  
  • Demand management including review of access routes and alternative appointment slots in community/primary care and access to these and the potential benefits of digital access in emergency departments to support direct appointment bookings 
  • Review and implement best practice standards for Same Day Emergency Care including opening times, access routes and ring-fencing use of capacity 
  • Ensuring that the population receive access to a primary care professional that is appropriate to their clinical need  
  • Deliver a programme of communication with Lambeth’s population to allow a greater understanding of the differing healthcare roles, services available, and how they can have direct access to the right service for their need  
  • Increase the use of digital tools including the NHS app so that patients may more easily be equipped to take greater control over their health and care and to access care at the right time and place 
  • Continue to ensure that patients are not excluded from accessing health care through digital poverty by evaluating our pilot which involves members of our population teaching others to access technology practically and sharing lived experiences 
  • Use digital software (Apex) to support GP practices to understand their population needs and provide and redeploy workforce accordingly across Primary Care Networks  
  • People experience culturally appropriate translation services for our diverse population so consultations can be supported by in person translators or virtually as appropriate 
  • Development of the London Care Record that supports the delivery of holistic care to patients and can be used from across health and care services  
  • Evaluate the benefits of basing GPs and Social Prescribing Link workers in Emergency Departments in meeting the needs of patients whose needs can be better met elsewhere  
  • Increase referrals by primary care via consultant connect into Same-Day Emergency Care, increase communications and engagement with primary care to raise awareness of Same-Day Emergency Care and access criteria – monitor activity, demand and any unmet demands for Same-Day Emergency Care at both GSTT and Kings 
  • Enhance direct access for diagnostics using local Community Diagnostic Hubs 
  • Working with providers on High Intensity Use services to support demand management in Urgent and Emergency Care (UEC) 
  • Continue triage service for urgent and elective eye consultations, as well as direct referral pathways from community optometrists to Minor Eye Condition Service across Lambeth and SEL  
  • People with mental ill-health have the right support at the right time to avoid unnecessary periods in ED including by being discharged appropriately and in a timely way from ED and inpatient beds 
  • Engage in the development and deployment of a London Care Record that supports Advanced Care Planning. 

Substance Misuse 

  • Support collaboration, information sharing and joint working arrangements between drug and alcohol treatment and other key local agencies, to better understand and meet the needs of vulnerable/priority groups 
  • Complete a Joint Strategic Needs Assessment Health Profile of Substance Misuse in Lambeth using different data sources to better understand our population, collaboratively working with partners and local communities to investigate and identify the current and future health and service needs of our population 
  • Improve identification of those with high risk drinking through use of the Vital 5’ tool and implementing brief intervention and onward referral and increase the uptake of training amongst primary care staff on Information Brief Advice on alcohol.    

‘Virtual wards’  

  • Lambeth Together and Partnership Southwark develops the model for ‘Virtual Wards’, bringing benefits to multi-disciplinary working across the borough and building on the ‘At Home’ model in operation. 

Impact measures

Everyone who needs an appointment with their GP practice gets one within two weeks and this includes all populations. Those who contact their practice urgently are assessed the same or next day according to clinical need. 

Increase the volume of appointments provided by General Practice in line with our SEL system trajectory. 

Increase referrals into urgent community response (UCR) from all key routes, with a focus on maximising referrals from 111 and 999 and creating a single point of access where not already in place – consistently meet or exceed the 70% 2-hour urgent community response (UCR) standard.  

Improve access to healthcare professionals through increased use of community pharmacies; GPs and NHS 111 direct people to pharmacies to support people with minor ailments and advice around self-care. 

Increase the number of people using the community pharmacy consultation service for support and help with common ailments. 

An increase in the numbers of self-referrals to direct access services, rather than referrals from GPs. 

Reduce the number of drug and alcohol related A&E attendances. 

Our aim is to help keep people treated at home or within the community, by increasing the provision and utilisation of ‘virtual wards’. In doing so, it will ensure patients receive high-quality care that is tailored to their individual needs, while also helping to reduce the burden on hospital services, prevent unnecessary hospital admissions, and ensure that patients receive the right care, in the right place, at the right time. We will create capacity in Lambeth for 140-150 ‘virtual ward’ beds and work towards their utilisation.  


Older adults are provided with the right health and care support at the right time, live healthy and active later lives and are supported to age well 

Older adults, with a focus on maximising their independence, have access to good quality care services which range from support to remain at home to support to live in care homes. Lambeth is an age-friendly and dementia friendly borough and supports people in ageing well and continuing to tackle the challenges that lead to poorer outcomes in older age. Adults have personalised care and support by health and care services during the end of their lives. 


Neighbourhood and Wellbeing Delivery Alliance 


  • Review Joint Strategic Needs Assessment Health Profile of Older People in Lambeth using different data sources to better understand our population, collaboratively working with partners and local communities to investigate and identify the current and future health and service needs of our population, to inform our future service planning.
  • Make Lambeth an Age Friendly Borough where people can live healthy and active later lives. To achieve this, we will work with older people and charities like Age UK Lambeth to make Lambeth a better place to grow older – this will include a focus on supporting people in ageing well and continuing to tackle the challenges that lead to poor outcomes in older age.
  • Review delivery model of reablement across the partnership; integrating clinicians, ensuring access to the service is equitable in general and between the community pathway and the discharge pathway.
  • Review of pilot on Adult Social Care ‘front door’ with Age UK Lambeth and design future model of delivery, ensuring an inclusive and equitable service, with an interface with community health and primary care.
  • Work collaboratively within SEL ICS to implement and embed a ‘core offer’ for community Specialist Palliative Care providers. 
  • Prioritise integration of Palliative and End of Life Care into frailty pathways and ‘virtual wards’ models.
  • Work collaboratively with the Lambeth Carers Service to ensure carers are supported in their caring role, have access to the information and resources they need, and feel recognised locally for their contribution.
  • Review, launch and implement new Carer’s Strategy and review the support and information available for carers. 
  • Carers to receive health and wellbeing interventions, including vaccinations, from the right workforce in their general practice Primary Care Network.
  • Carers can access support through their practice Personalised Care team including Social Prescribing Link Workers.    
  • Enable primary care providers to develop Advanced Care Planning in their practices and around them – linking with local system providers to share ideas and collaborate. 
  • Falls are the largest cause of emergency hospital admissions for older people, and significantly impact on long term outcomes, e.g. being a major precipitant of people moving from their own home to long term nursing or residential care. To reduce emergency admissions due to falls in people aged 65and over we will carry out a falls prevention campaign which will include Lambeth based falls prevention leaflets, e-training to non-health care staff and increased provision of strength and balancing classes. 
  • We will make dementia friendly training available to help ensure that people with dementia feel understood, valued and able to contribute to their community.
  • Development of the London Care Record that supports the delivery of holistic care to patients and can be used from across health and care services.
  • We will work to ensure we use best practice procurement and commissioning models that deliver inclusive services, working with partners such as Age UK Lambeth and Opening Doors to provide care that is accessible across our diverse communities including Black and LGBTQ+ residents.
  • We will continue to work with providers to make sure services are person-centred, that are able to meet people’s needs and operate safely. 

Impact measures

Intermediate Care including Reablement helps people live independently, and/or recover from an episode of ill health. It is therapy-led and provided in the person’s own home with care arranged by an integrated team of mainly Health & Social Care professionals. We will monitor the number of people with an intermediate care offer.  The service is non-chargeable for up to six weeks and we will   monitor the number of  people who  have a reduced  need  for  care   at  the   end of this  service.  

We have commissioned Lambeth  Carers  Service to ensure carers are supported in their caring role, have access to the information and resources they need, and feel recognised locally for their contribution. We   will work collaboratively with the   Carers   Service    to   ensure   its effectiveness and Adult Social Care will ensure 90% of carers of the users of Adult Social Care Services are offered  a  carers  assessment.  

We will target improvements in end of life care linked to the National Palliative and End of Life Care 22-25 strategic priorities of accessibility, quality and sustainability. We will work towards an increased % of people identified as being in their last year of life on practice registers and increase number of people with Personalised Care and Support Plan (PCSP). 

Increase the percentage of Lambeth Residents’ Survey respondents aged 65 and over that describe their health as good.  

Increase in uptake of flu/pneumococcal and Covid-19 vaccinations in people known to be Carers. 

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Women have positive experiences of maternal healthcare and do not experience a disproportionate maternal mortality rate 

Maternal outcomes improve for all, and the disparity of maternal outcomes for Black women is eradicated. 


Children and Young People’s Alliance.


  • Work with colleagues across the system to pull together a comprehensive dataset for Lambeth women using maternity services to counter significant inequalities in experience. This includes partnership working through Local Maternity and Neonatal Systems (LMNS) consolidating maternity metrics across providers and utilisation of analytic resources produced by SEL BI team, such as, Core20PLUS5. This will allow us to create a localised action plan to meet the specific needs of Lambeth women.
  • Continue to deliver the actions from the final Ockenden report as set out in the April 2022 letter as well as those that will be set out in the single delivery plan for maternity and neonatal services.
  • Make progress towards the national safety ambition to reduce stillbirth, neonatal mortality, maternal mortality and serious intrapartum brain injury.
  • Ensure all women have personalised and safe care through every woman receiving a personalised care plan and being supported to make informed choices, including increased use of continuity of midwifery care.
  • Improve access to perinatal mental health services.
  • Women are asked by midwifery and health visiting services about domestic abuse and substance use throughout pregnancy, to be offered the right support, and supported around their contraception needs postnatally. 

Impact measures

Continuity of care in maternity refers to the provision of care throughout the pregnancy, birth, and postnatal period by the same healthcare provider or team. The benefits of continuity of care in maternity include improved maternal and foetal outcomes, increased satisfaction with care, reduced healthcare costs, and better communication and trust between the healthcare provider and the patient. Continuity of care also allows for the early detection and management of potential complications and can lead to a more personalized and individualized approach to care. Continuity of maternity care is delivered for at least 75% of women from Black, Asian and minority ethnic communities.  

We will monitor the rates of maternal mortality during labour, neonatal deaths and pre-term birth and expect to see them reducing. 


People with learning disabilities and/or autism achieve equal life chances, live as independently as possible and have the right support from health and care services 

People with learning disabilities and/or autism are discharged from inpatient settings and supported to live in the community with appropriate accommodation and care. Health and social wellbeing across the life course for all people of all ages, with learning disabilities and autism, improves.  


Learning Disabilities and Autism programme with contributions from: Children and Young People’s Alliance.


Specialist inpatient units discharge  

  • Review crisis intervention/admission prevention services to agree improved borough offer 
  • ALD Placement Transformation Strategy – Ensure accommodation-based placements maximise lifelong independence underpinned by clear systematic contractual framework to ensure best value 
  • Commission bespoke option for group of named individuals that are most complex and at highest risk. 


  • People with learning disabilities are less likely to be in employment than the overall population. We will monitor and report on how many people are with learning disabilities are in work and how many opportunities for supported employment we are able to create 
  • Developing new supported employment and internship opportunities through our health and care partners. 

CYP ASD Diagnosis  

  • Develop the Lambeth All-Age Autism Strategy with users, carers and partners 
  • Engagement piece working with Lambeth Council’s Communication Team 
  • Understand local population of people with autism and mapping exercise using local and national data, PH data - Pathway and diagnosis in Lambeth Council, Employment and Children, Young people and SEND  
  • Work with partner organisations in developing the LBL strategy. 


  • Working with SEL ICB and health partners to ensure accurate capture of information for patients with learning disability and autism to ensure they get the right access to health provision; support performance and quality monitoring, and underpin effective population health planning 
  • Contribute to the South East London Integrated Care Board Learning Disability and Autism Programme and support the development of integrated, workforce plans for the learning disability and autism workforce 
  • As part of the Suicide Prevention Action Plan and feeding into the Autism strategy work with mental health services to improve the experience of people with autism – relevant recommendations from the evidence review on autism and suicide are considered and adopted. 

Impact measures

It is vital we reduce reliance on inpatient care for patients with learning disabilities and/or autism (LDA), while improving the quality of inpatient care. We will increase the number of children and adults discharged from specialist inpatient units, with a particular focus on reducing the rates of Black patients placed in overly restrictive settings. 

People with learning disabilities are less likely to be in employment than the overall population. To achieve our outcome, we will increase the proportion of people with LDA in work or education, aiming for an increase to 5%, by increasing the number of supported employment and supported internships we create through our health and care partners. 

People with a learning disability often have poorer physical and mental health than other people. It is important that everyone over the age of 14 who is on their GP’s learning disability register has an annual health check; we will improve the rate of uptake for an Annual Health Check and Health Action Plan, for those with LDA, and ensure that there is no disparity in uptake between ethnic groups. 

We will reduce the waiting times for an Autism Spectrum Disorder (ASD) diagnosis for children and young people.   

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People using mental health support services can recover and stay well, with the right support, and can participate on equal terms in daily life   

People with mental health needs are able to recover, live independently, live in stable and appropriate accommodation, and in education, training, volunteering or employment.


Living Well Network Alliance 


  • Expand community reablement support to help people with practical issues that can help prevent crisis that leads to loss of accommodation and/or admission to hospital and care settings whilst helping people maintain or regain skills that promote independence and beneficial quality of life, reduce dependence on use of institutional care 
  • Extend capacity for Living Well Network Alliance Home Treatment Team to support more people experiencing mental health crisis in the community 
  • 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 
  • Work with statutory partners to ensure work opportunities for people with Severe Mental Illness (SMI) and other Long term conditions and ensure full mobilisation and monitoring of the L Living Well Network Alliance Individual Placement Support Service (IPS) to enable more people with SMI to achieve their goal of sustainable paid work with a fair wage whilst accessing support to help find and maintain employment and monitor the service against intended goals 
  • Work with Black Thrive and partners including Lambeth Council Employment and Skills as part of the ‘No Wrong Door’ initiative to enable people who are vulnerable including people with SMI or other conditions can access a range of specialist and mainstream information, education and vocational support to so that people have  meaningful, learning and occupation opportunities that provide structure and builds confidence and skills 
  • Deliver on the reprovision of the Lambeth Hospital together with SLaM, including the mobilisation of a redesigned inpatient care model to provide better quality and more culturally appropriate clinical service 
  • Roll out Dialog tool during 23-24, including training and support to staff, to ensure a robust and consistent process to capture service user self-reported wellbeing.  

Impact measures

Increased numbers of people with Severe Mental Illness (SMI) are supported to live in their own home and  200 people per year are supported by the Living Well Network Alliance into paid employment.  

We will monitor the number of referrals Living Well Network Alliance teams make for service users to additional support routes (such as  education, training and employment support, Community Support, Alcohol Advice, Smoking, Benefits advice, Dietician, Family Support) and the number of service users reporting a positive experience of using mental health services, feeling they have benefited from support and are more independent and in control of their lives, particularly those from Black and other minority ethnic communities. 

We will monitor repeated A&E attendance and acute mental health inpatient readmissions as part of performance and quality monitoring to assess effectiveness and as part of reflective learning to ensure recovery and/or other agreed goals are met. 


People who are homeless, or at risk of becoming homeless, (including rough sleepers and refugees) have improved health 

In supported housing, residents have access to a GP and holistic support with their mental health and substance use. Homeless vulnerable adults and rough sleepers receive tailored support to manage physical and mental health conditions to prevent serious illness and the overall number of entrenched rough sleepers is reduced. 


Homeless Health programme With contributions from: Living Well Network Alliance and Substance Misuse programme.



  • A specialist team will support single households in Temporary Accommodation to secure offers of long term settled accommodation  
  • Improve the quality of temporary accommodation through closer contract monitoring and improved technology 
  • The Lambeth Rough Sleeping Outreach Team will continue to target all rough sleepers found in Lambeth to ensure everyone is offered a route off the streets. Long term entrenched rough sleepers will continue being case worked by specialist roles within the team such as a Living On The Streets worker, and embedded roles such as a Public Protection Officer and an Approved Mental Health Professional.  
  • Through contract monitoring and audit visits we will identify the numbers of people in supported housing who are not yet registered with a GP. We will work with service providers and health colleagues to target those individuals and identify any potential barriers. 
  • Develop model to allow cross referencing GP registration for those in supported housing, with engagement with GP   
  • Develop intelligence to review how long rough sleepers brought into accommodation, have sustained tenancy.  
  • Enhanced outreach and engagement, (including outreach for people with disabilities and new parents) including targeted street outreach for: people experiencing rough sleeping and homelessness (aligned with and complementing rough sleeping grant initiatives where relevant), targeted vulnerable/priority groups including sex workers, crack, heroin users and alcohol users who are not in contact with treatment, young people not accessing services 
  • Expansion of treatment provision for substance misuse and alcohol dependence 
  • Improve identification of those with high risk drinking through use of the ‘Vital 5′ tool and implementing brief intervention and onward referral 
  • Increase referrals to substance misuse services from the police (custody), probation and criminal justice system 
  • Develop comprehensive prevention programme for substance misuse 
  • Increase number of people accessing and completing treatment for substance misuse. 

Impact measures

To improve the health outcomes of those who are homeless or at risk of becoming homeless, we first want to reduce homelessness overall. We will therefore work to increase the number of people resettled into longer term accommodation by preventing or relieving homelessness and increase the number of rough sleepers brought into accommodation. 

Increase the number of households that move on from temporary accommodation into settled housing.  

Increase the proportion of people living in our supported housing that are registered with a GP.   

Monitor our rate of residents in supported housing engaged with mental health support services.  

As substance use is a significant cause of poor health outcomes for our street homeless population in Lambeth, we will also monitor how effectively we refer people to drug treatment services upon their release from prison, and what proportion then complete their treatment.  

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