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Health and Care Strategy

2026/2031

Shaping NHS services to improve

the health of our communities

and residents in Devon

Content

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy1 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Contents

Contents ...............................................................................................................................................................................................2

Foreword ..............................................................................................................................................................................................3

Personas ..............................................................................................................................................................................................4

Executive Summary .............................................................................................................................................................................6

Introduction ..........................................................................................................................................................................................7

Our system ......................................................................................................................................................................................... 13

How the strategy was developed ....................................................................................................................................................... 20

Learning from local, national, international examples......................................................................................................................... 25

Design Phase: Co-creating the future ................................................................................................................................................ 31

Looking forward .................................................................................................................................................................................. 62

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy2 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Foreword

I am honoured to introduce our new,

ambitious Health and Care Strategy

for Devon. This strategy reflects our

shared vision to transform the way

health and care services are

delivered across the county,

ensuring that every individual

receives the right care, at the right

time, in the right place.

It is shaped by the priorities set out in

the NHS 10 Year Health Plan: Fit for

the Future, which sets a bold and clear

roadmap for the future of healthcare

across England over the next decade.

The NHS Plan challenges us to build a

sustainable, person-centred health and

care system that improves outcomes,

reduces inequalities, and supports

people to live healthier lives.

Our Devon-wide strategy aligns fully

with these national ambitions and goes

further by placing a strong emphasis

on collaboration across health, social

care, voluntary, and community

sectors.

We know that the challenges facing

Devon’s population are complex. From

an ageing population to rising demand

for mental health services, and the

ongoing need to tackle health

inequalities, we must work smarter and

more innovatively.

This strategy sets out clear priorities to

improve prevention and early

intervention, integrate services more

effectively, and support people to

manage their own health and

wellbeing.

By focusing on personalised care,

digital innovation, and workforce

development, we aim to create a

resilient and responsive system that

delivers high-quality care close to

home. As we set out our vision for the

future of health and care, we remain

firmly committed to delivering services

that are not only high-quality and

person-centred, but also financially

sustainable. This strategy reflects our

dedication to making responsible

choices that ensure long-term value,

resilience, and equity across our

system. By rooting our new model of

delivery, we aim to safeguard

resources while continuing to meet the

evolving needs of our communities.

Importantly, this strategy embodies our

commitment to ‘place-based’ care,

recognising the unique needs of

communities across Devon—from

urban centres to rural areas.

We are determined to break down

traditional barriers between health and

social care, working together in

partnership with local authorities,

voluntary organisations, and, crucially,

the people we serve.

This is a pivotal moment for health and

social care in Devon and together we

will build a healthier, more connected

Devon.

I look forward to working with all our

partners and communities as we

embark on this vital journey.

Libby Ryan-Davies

Chief Strategic

Commissioning

& Planning Officer

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy3 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Personas

The Devon personas have been

developed to bring to life the

experiences of people across our

communities, helping us to

understand the impact of health and

care services on real lives.

Personas are not statistical profiles,

but carefully constructed stories

that reflect the complex needs,

circumstances, and aspirations of

different groups in our population.

By grounding planning and

engagement in these lived

perspectives, we can design services

that respond to what matters most to

people, rather than to systems alone.

The use of AI has enabled these

personas to be expanded and

enriched, drawing on a wide range of

local and national data, strategic

priorities such as the NHS 10-Year

Plan, and insights from local

engagement.

This approach ensures that each

personas remain dynamic, evidence-

based, and sensitive to emerging

challenges and opportunities.

By using personas, decision-makers

can more clearly see how changes in

policy or service delivery might be

experienced by different people.

They provide a powerful way to test

ideas, explore unintended

consequences, and identify

opportunities for prevention,

integration, and innovation.

Most importantly, they help to ensure

that patient and public insights are not

only heard but actively shape the

design of future health and care

services in Devon. Some examples of

how we can apply the personas with

application of the model are described

on the next page.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy4 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Margaret Plum, 84, Mid Devon

Riley Rivers, 9, Exeter

Margaret’s healthcare can be fragmented, hospital-focused and

she has several conditions including mild dementia, hypertension,

osteoarthritis, mobility issues, and she is at risk of falls. She is

heavily reliant on carers and rural transport, and experiences

loneliness.

Riley lives with his mum. He has epilepsy and is waiting for an

attention deficit hyperactivity disorder (ADHD) assessment. At

present, most of his care is hospital-based. His epilepsy requires

multiple appointments, and he faces a lot of challenges with

behaviour and stigma at school.

Under the NHS Devon strategy her experience shifts significantly.

Care is delivered closer to home through neighbourhood health

hubs and regular frailty checks, reducing the need for hospital

travel.

Prevention becomes central: dementia-friendly programmes, falls-

prevention groups, and personalised exercise support improve

her independence.

Technology plays a supportive role, with a simple wearable fall

detector linked to her GP and carers, ensuring

quick

response

and reassurance.

Social prescribing connects her to befriending groups and

accessible transport, tackling loneliness and isolation. A shared

care record prevents repetition and coordinates her support

across services.

For Margaret, delivering the NHS Devon strategy means fewer

crises, stronger community connections, and a system designed

around prevention, independence, and dignity in later life.

Under the NHS Devon strategy, Riley’s experience becomes

more joined-up and community-centred. His epilepsy reviews take

place in his neighbourhood community hub, with results shared

across health and care providers.

The NHS and schools work closer together to help manage his

conditions, reducing stigma and improving his experiences at

school.

Early intervention is prioritised: school-based mental health

teams help Riley manage behaviour and anxiety before crises

escalate, and his ADHD assessment is completed more quickly.

Technology, such as a wearable seizure monitor, provides

reassurance and reduces unnecessary hospital visits.

Through social prescribing, Riley joins inclusive after-school

activities, while his mum accesses peer and financial support.

His care shifts from fragmented hospital journeys to integrated,

preventative, community-focused support, helping him thrive

as a child.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy5 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Executive Summary

NHS Devon’s Health and Care

Strategy sets out a bold and

necessary transformation to ensure

the long-term financial sustainability

of our health and care system. With

a projected financial gap of £781

million by 2030/31 if we do nothing,

the strategy recognises that

maintaining current models of care

is no longer viable.

Instead, we are committing to a

fundamental shift in how services

are commissioned, delivered, and

measured—anchored in value,

outcomes, and efficiency.

Central to this transformation is the

adoption of a new three-tier model of

delivery—Neighbourhoods, Place, and

Specialist Settings—designed to

integrate care around local populations

and reduce reliance on acute services.

Neighbourhoods will become the

default delivery point for non-specialist

activity, supported by multidisciplinary

teams and commissioned through lead

provider frameworks. This approach

enables proactive, personalised care

and supports the strategic shift from

treatment to prevention.

To deliver this model within a

constrained financial envelope, NHS

Devon is implementing a set of

strategic commissioning intentions

aligned with the Model ICB blueprint.

These include a rigorous focus on

productivity—both organisational and

system-wide—using tools such as the

Model Hospital and mutual aid

arrangements.

Providers will be expected to

harmonise quality and performance

standards at the lowest sustainable

cost and deliver a minimum 3% cost

improvement programme (CIP) beyond

baseline efficiencies.

Contracting protocols are also evolving

to reflect this strategic direction. NHS

Devon will move towards

commissioning for outcomes rather

than activity, with clear expectations

and key performance indicators (KPIs)

embedded in contract negotiation

meetings commencing October 2025.

These meetings will ensure alignment

between provider plans and the ICB’s

five-year commissioning roadmap,

enabling a more accountable and

transparent planning process.

To stimulate transformation, growth

funding will be directed into a

Neighbourhood Development Fund,

supporting schemes that reduce acute

activity and improve community-based

care. Specialties such as dermatology,

urology, orthopaedics, and cardiology

will be commissioned through lead

provider arrangements, with further

transformation planned in urgent care,

community hospitals, and midwifery-

led units.

This strategy is not only a financial

imperative—it is a commitment to

delivering equitable, but high-quality

care also that meets the needs of

Devon’s population now and into the

future.

Through disciplined commissioning,

innovative contracting, and system-

wide collaboration, NHS Devon will

build a health and care system that is

both resilient and sustainable.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy6 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Introduction

NHS Devon Integrated Care Board

(ICB), responsible for planning,

funding, and overseeing services

across the county, is leading a bold

and necessary transformation. Our

communities face rising demand, an

ageing population with increasingly

complex needs, entrenched health

inequalities, and persistent financial

pressures—all intensified by the

ongoing recovery from the Covid-19

pandemic.

Despite the dedication of staff across

NHS and care services, the system is

under sustained strain. People in

Devon continue to experience long

waits for elective treatment, there is

pressure on urgent and emergency

care, and delays in accessing

assessments, diagnosis, treatment and

community-based support across a

spectrum of services.

Services can feel fragmented and

difficult to navigate, with care often

arriving only at crisis point. Outcomes

and access vary significantly

depending on geography and

circumstance, and the financial

position across the system

remains fragile, limiting the ability to

invest in new models of care.

The current system is not designed to

meet the modern, diverse needs of

Devon’s communities—whether that’s

rural and coastal populations with

limited access, children and young

people needing earlier mental health

support, or older adults living with

multiple long-term conditions who

require more joined-up, personalised

care.

Strategic and financial

context

NHS Devon’s core funding

encompasses all commissioned

services, including acute, mental

health, and community care. Almost

80% of running costs are attributed to

staffing, with the remainder covering

estates and other non-pay expenses.

Despite receiving £163 million above

its needs-based population allocation,

the system remains financially fragile,

requiring £54 million in deficit support

to break even in 2025/26.

This financial imbalance limits the

capacity to invest in innovation,

respond to rising demand, and deliver

sustainable improvements. However,

the strategic redistribution of resources

across Devon’s four localities is

beginning to correct historical

inequities, bringing planned

expenditure closer to fair share

allocations and aligning with the

principles of the Model ICB Blueprint.

Our population of around 1.3 million is

ageing rapidly, with 24% aged 65 or

older, well above the national average,

and growth among those aged 75+

accelerating.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy7 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

This demographic shift, combined with

geographic and social inequalities,

creates stark contrasts in health

outcomes, with up to a 20-year

difference in healthy life expectancy

across the county.

Rising demand across all service

areas, especially the delays in

accessing assessments, diagnosis,

treatment and community-based

support is compounded by workforce

shortages, fragmented care pathways,

and infrastructure risks.

The system’s IT and estates vary

significantly in quality, with some

facilities in urgent need of repair,

posing risks to continuity and safety.

Nationally, policy frameworks such as

the NHS Long Term Plan and the

Fuller Stocktake have laid the

foundation for the expectations for the

NHS to deliver.

They call for a fundamental

reconfiguration of services dissolving

the long-standing divides between

primary, community, and secondary

care, and enabling more joined-up,

person-centred approaches.

At the heart of this transformation is

the emerging Neighbourhood model, a

nationally endorsed delivery vehicle for

integrated care.

This model envisions care being

designed and delivered at a local level,

tailored to the specific needs of

neighbourhood populations, typically

serving 30,000 to 50,000 people. It

brings together general practice,

community services, mental health,

social care, the voluntary sector, and

increasingly, public health and housing

working as a single team around the

individual.

The Neighbourhood model is not

simply a structural change, it

represents a paradigm shift in how

care is conceptualised and delivered. It

is the mechanism through which the

three strategic shifts outlined by

government are being operationalised.

This Strategy should be seen

alongside the NHS Devon Strategic

Commissioning Intentions and full

Medium Term Financial Plan

Our health and care

strategy describes our

future model and how we

align services to deliver

optimal outcomes for our

population.

Our strategic

commissioning

intentions will describe

how we will allocate

resource to deliver the

future service model

within allocation.

Our medium-term

financial plan will

describe the financial

model the strategy will

need to be delivered

within and impact of

commissioning intentions.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy8 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

From hospitals to

community and primary

care: shifting the centre of gravity

of the NHS closer to people’s

homes.

The three shifts

From analogue to digital:

embedding digital tools to support

access, coordination, and self-

management.

From treatment to

prevention: focusing on early

intervention, population health, and

reducing health inequalities.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy9 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

This national direction is underpinned

by growing evidence that locally

integrated, neighbourhood-based care

delivers better outcomes, improves

patient and staff experience, and

reduces unwarranted variation. It also

enables more effective use of

resources by aligning services around

population need rather than

organisational boundaries.

As Integrated Care Boards (ICBs), we

are expected to lead the

implementation of this model ensuring

that neighbourhood teams are

empowered, resourced, and supported

to deliver care that is proactive,

personalised, and equitable.

Our vision

“We imagine a Devon where everyone can live well—on their own terms, in

communities that value equity, sustainability, and belonging.

This means recognising the rich complexity of people’s lives, identities, and

experiences, and the many factors that shape health and wellbeing beyond

traditional services.

By nurturing a culture of curiosity, care, and shared responsibility, we will work

across boundaries to challenge injustice, reimagine support, and act boldly

together.

Rooted in trust, lived experience, and community strengths, we are committed to

lasting change—so that everyone, especially those historically underserved, can

thrive now and for generations to come.”

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy10 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

A targeted strategic

approach

In response, NHS Devon’s strategic

long-term approach will mark a seismic

shift toward place-based, outcome-led

delivery though a new model of care

that is based around Neighbourhood

Delivery.

This transformation is guided by the

principles of the NHS 10-Year Plan

and the NHS Medium Term Planning,

which emphasizes earned autonomy,

reduced duplication, and a relentless

focus on productivity and value. We

aim to fully embrace the greater

financial flexibility, with fewer national

priorities and more local discretion to

tailor services to community needs.

Devon’s strategy embraces this

opportunity, aligning its financial

planning, workforce development,

digital innovation, and care redesign

with the overarching goal of improving

population health, reducing

inequalities, and delivering consistently

high-quality care.

This strategy is not just about recovery,

it is about building a sustainable future

and builds on existing work across the

Integrated Care System, including the

Joint Forward Plan, the Integrated

Care Strategy, and local authority and

provider plans.

It draws on national guidance such as

the NHS 10-Year Plan and the Model

ICB Blueprint, which advocate for

earned autonomy, reduced duplication,

and a sharper focus on productivity

and value.

By aligning local priorities with national

expectations, Devon is embracing the

opportunity to tailor services to

community needs, supported by

greater financial flexibility and system-

wide collaboration.

Structured around new model of

delivery, the strategy sets out high-

level commissioning intentions that

reflect a shared ambition across all

services directly commissioned by the

ICB.

It aims to stabilise the system in the

short term, while enabling long-term

transformation through redesigned

care pathways, digital innovation, a

stronger focus on prevention and

population health, and better use of

workforce and estate resources.

Operating within a defined financial

envelope, the strategy supports a shift

from reactive and siloed approaches to

proactive, preventative, and integrated

models of care placing people at the

centre and ensuring that care follows

the individual, not the other way

around.

Achieving this vision will require a

phased, pathway-led, and coordinated

effort, underpinned by strong

leadership and alignment across the

system.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy11 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

The strategy is anchored by four core

principles:

• sustainability, through financial,

operational and environmental

resilience

• quality and value, by delivering

effective care that maximises impact

• person-centred care, designed

around what matters to individuals

and communities, and an

• accessibility, ensuring equitable

access regardless of location,

background, or circumstance.

By looking outward to national models

and inward to local insights, Devon’s

strategy sets a clear direction for

transformation—one that is grounded

in collaboration, shaped by evidence,

and focused on delivering better

outcomes for all.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy12 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Our system

Progress has been made to improve

services and outcomes, NHS Devon

faces a range of long-term

challenges that demand a major

shift in how care is planned,

delivered, and experienced.

Rising demand, an ageing population,

increasing health inequalities, and

financial and workforce pressures

mean that continuing with our current

models of care is not sustainable.

The NHS in Devon must remain

attentive to the evolving national policy

landscape, including changes to

organisational structures and system

footprints, while also recognising and

responding to the expectations of our

population.

Our population want to experience

services that are easier to navigate,

more joined-up, and more responsive

to their individual needs. They wish to

be supported to maintain their health,

live independently for longer, and

access care as close to home as

possible.

Our population

Devon is undergoing a significant

demographic transformation. Over the

past decade, the population has grown

by 9.7%. However, this growth is not

evenly distributed across age groups.

While the number of young people

aged 0–19 has increased by less than

1%, the population aged 75–84 has

surged by over 40%. This

disproportionate growth in older age

groups is reshaping the landscape of

public service demand, particularly in

health and social care.

Two primary factors are driving this

shift. First, the legacy of the post-World

War II baby boom continues to

influence population structure. The

birth rate in 1947 was approximately

50% higher than in 1937, and those

born during this peak will turn 78 in

2025. This cohort is now entering the

age range associated with higher

health and care needs.

Second, Devon experiences consistent

inward migration, particularly among

individuals aged 35–70, drawn by the

region’s quality of life, environment,

and retirement appeal.

This migration pattern results in a

lower proportion of residents under the

age of 53, except for a temporary spike

in the 19–22 age group due to the

presence of two major universities.

Beyond age 53, Devon has a

significantly older population profile

compared to national averages.

Looking ahead, official projections

indicate that Devon’s population will

continue to grow at a steady rate of

approximately 0.7% per year, adding

around 68,000 people over the next

decade. Crucially, this growth will be

concentrated among those aged 65

and over.

The baby boom generation will begin

to enter the 85+ age bracket, while

their children transition into later life,

contributing to a substantial increase in

the 65–74 age group. This

demographic shift will have profound

implications for the design, delivery,

and sustainability of health and care

services across the county.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy13 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Strategic implications

for health and care

services

As the population ages, we anticipate a

corresponding rise in mortality rates

and an increase in the intensity of

health and care service usage. It is

well established that the final years of

life are associated with

disproportionately high service

demand. Previous estimates suggest

that approximately one-third of a

person’s lifetime care costs are

incurred in the last two years of life.

This underscores the urgency of

strategic planning and resource

allocation to ensure that services

remain responsive, resilient, and

financially sustainable.

To support this planning, the Devon

System Demand Model has been

developed. This model provides a

comprehensive framework for

understanding and forecasting service

pressures, built around three

interrelated components: health needs,

demand, and supply.

• Health Needs are measured using

Disability Adjusted Life Years

(DALYs), a metric that captures both

the prevalence and severity of

illness, as well as premature

mortality. Health needs increase

significantly with age — a person

aged 90 or older typically has health

needs eight times greater than

someone in their twenties.

• Demand reflects the actual

utilisation of health services and

the system’s capacity to respond. It

is shaped by population behaviour,

accessibility of services, and system

responsiveness.

• Supply encompasses the full

spectrum of resources required to

meet demand, including workforce,

hospital beds, medications,

equipment, and infrastructure.

Together, these components enable a

strategic understanding of how

demographic trends will impact service

delivery and provide a foundation for

evidence-based decision-making.

Changing patterns of

health need

Analysis of DALYs over time reveals

that health needs in Devon remained

broadly stable between 2000 and

2015. However, since then, the system

has entered a phase of accelerated

growth in health needs, closely linked

to the increasing number of people

aged 75 and over. While demographic

change is a key driver, other factors —

including technological advances,

evolving clinical practices, and non-

demographic growth — also contribute

to rising demand.

Conditions most affected by ageing

show the highest annual growth rates.

These include:

• respiratory infections (+3.4%)

• dementia (+3.3%)

• falls (+2.8%)

• diabetes (+2.7%), and

• stroke (+2.4%).

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy14 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Additionally, in line with national

statistics around 2.16% of the Devon

population, approximately 26,000

people, are known to have a learning

disability, with 8,000 registered in

primary care. Since COVID-19,

referrals for autism and ADHD support

have quadrupled, driven by increased

public awareness and demand. This

surge has placed exceptional pressure

on health services, highlighting a

critical gap in capacity and access for

neurodivergent populations.

Addressing deprivation

and health inequality

Devon’s demographic challenges are

further compounded by persistent

health inequalities and pockets of

deprivation. Urban centres such as

Plymouth, Torbay, and Ilfracombe

experience the highest levels of

deprivation, with additional hotspots in

Exeter and Barnstaple.

Notably, Plymouth has more residents

in the lowest deprivation quintile than

the rest of Devon combined. Rural and

coastal areas, particularly in North and

West Devon, also face significant

deprivation, driven by low wages,

limited employment opportunities, and

a high cost of living. These

socioeconomic factors have a direct

impact on health outcomes and service

utilisation. Neurodivergent individuals,

particularly autistic people, face

significantly poorer health outcomes

and higher risks of early mortality.

Analysis of acute hospital spending

reveals clear variation by deprivation

level, with differences evident across

both urgent and planned care services.

Addressing these inequalities is

essential to delivering equitable care

and ensuring that all communities

across Devon benefit from strategic

investment and service transformation.

This will require a coordinated

approach across health, social care,

housing, and economic development

sectors.

Plymouth

Torbay

Ilfracombe

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy15 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Protected

characteristics

People with protected characteristics

whether related to race, religion,

sexuality, gender, or other aspects of

identity often face distinct health needs

and systemic barriers that result in

poorer outcomes.

Tackling these disparities is a core

commitment of NHS Devon and a

fundamental principle of integrated

care. All NHS-commissioned services

will be expected to embed equity

principles into their design and

delivery. These include:

• Proportionality: Resources and

interventions should be targeted

according to need, recognising that

some groups require more support

to achieve equitable outcomes.

• Accessibility: Services must be

physically, culturally, and

linguistically accessible to all,

removing barriers to entry and

engagement.

• Participation: Communities must

be actively involved in shaping the

services they use, ensuring lived

experience informs decision-

making.

• Transparency: Data on outcomes

must be collected, analysed, and

shared to monitor progress and

hold the system accountable.

• Sustainability: Equity efforts must

be embedded into long-term

planning, not treated as short-term

initiatives.

Commissioned outcomes will be

measured at Neighbourhood level,

where care is delivered closest to

communities, and monitored at Place,

where strategic oversight ensures

consistency and accountability.

To support this, NHS Devon has

developed a nationally pioneering set

of AI-generated personas realistic,

data-driven profiles that reflect the

lived experiences, demographics, and

health conditions of diverse

communities across Devon.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy16 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

These personas are used to inform

impact assessments, public

engagement, and service design,

helping to embed equity into every

stage of planning and delivery.

By incorporating these personas into

strategy development, service

redesign, and Equality and Quality

Impact Assessments (EQIAs), the

system can better understand and

respond to the needs of

underrepresented groups. They will

also be used iteratively in design

workshops and decision-making

processes to test service accessibility

and equity.

Inclusion of health groups such as

people experiencing homelessness

face some of the most severe health

inequalities. These individuals often

experience multiple, compounding risk

factors including stigma, poverty,

trauma, and discrimination, leading to

significantly poorer health outcomes

and reduced life expectancy.

This strategy places equity, inclusion,

and lived experience at the heart of

system transformation. By embedding

these principles into commissioning,

service design, and workforce

development, NHS Devon will build a

health and care system that works for

everyone, especially those who have

historically been underserved.

Financial sustainability

In line with the Model ICB Blueprint,

ICBs are now positioned as strategic

commissioners, responsible for leading

system-wide reform and optimising

resource allocation. The Medium-Term

Financial Plan (MTFP) plays a

foundational role in this shift,

supporting the development of leaner

operating models and enabling ICBs to

live within their means while delivering

improved outcomes. It is a critical

strategic tool for the ICB, designed to

bridge the gap between long-term

ambitions and short-term operational

delivery.

Its core purpose is to provide a shared

financial framework across system

partners, enabling coordinated

planning over a five-year horizon. This

approach supports the delivery of the

NHS 10-Year Plan by translating

strategic goals into actionable financial

trajectories, identifying the resources

required to meet population health

needs, and ensuring systems remain

financially sustainable and together

with our new contracting model, it will

help rebalance system relationships.

It must be triangulated with workforce,

activity, and quality plans, and co-

produced with system partners to

reflect shared priorities. This ensures

that financial planning is not conducted

in isolation but is embedded within

broader strategic and operational

frameworks.

The new operational planning

guidance reinforces this alignment by

setting out a focused set of national

priorities, including improving access to

timely care, increasing productivity,

and addressing health inequalities.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy17 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Medium-term financial

plan (MTFP) model in

Devon

A Devon five-year Medium Term

Financial Plan (MTFP) is being

developed which fully aligns with the

Health and Care Strategy. It will show

how the financial challenge will be met

across Devon as it drives towards

achieving financial sustainability and

sets the guard rails from within which

the Devon Health and Care Strategy

will be delivered.

The MTFP will set out investment

strategies that allocate resources over

time that are aligned with population

needs. These investments will be

focused on ‘left shift’ supported by

equity analysis that will help ensure

that resources are allocated towards

improving equitable access, delivering

care in the most appropriate setting

and reducing health inequalities. They

will be driven by data and population

insights, with a strong focus on

prevention, equity, and outcomes.

Current position

The Devon system is financially

challenged and is both overspending

and overfunded. This results in debt

repayments being required annually to

repay deficits and allocation reductions

known as convergence being made to

bring Devon back within the tolerance

of the target needs-based population

allocation. This, together with an

underlying deficit in excess of £200m,

leads to a challenging road to

recovery.

Equity

Based on national funding formula,

NHS Devon has reviewed its spend

against programme area and locality to

establish where inequity sits in funding

of our services, this also identifies how

our total overspend (or Distance from

Target) is split.

Overall this shows an under-resourcing

of Prescribing and Primary care whilst

we spend £112m more than expected

on community care, £66m more than

expected on our Acute care and £30m

more than expected on Mental Health.

The analysis also shows variation

between locality with only one locality

(Northern) showing as requiring a total

spend below that which would be

expected.

There should be a note of caution in

interpreting these numbers as given

current lack of Electronic Patient

Records in Torbay and South Devon

Hospital and University Hospital

Plymouth there is a gap in current

activity coded which will have

implications for Devon’s allocation of

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy18 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

resource based on the National

Formula.

Devon providers will need to address

coding issues to ensure the system

receives its fair share of resources. In

the meantime the equity analysis will

be used as a directional tool alongside

other benchmarking data to inform

local allocation of resource as part of

our commissioning plan and full MTFP.

Future delivery

To deliver the medium-term financial

plan (MTFP), financial sustainability

and return on investment discipline will

be at the core of our financial

framework, underpinned by advanced

population health management, value-

based healthcare and a

neighbourhood-first approach.

We will develop insights into cost

behaviour and value achieved from

commissioning services to inform

healthcare planning and the better

allocation of resources over time.

Productivity improvements will be

required to achieve financial

sustainability and free up funding for

investment and service transformation.

Services will be reviewed to ascertain

whether they can be stopped, shifted

into a different service model or

environment, or completely

transformed but without the need for

large capital investments, which will be

limited. This will be supported by

maximising digital transformation to

reduce cost and improve productivity.

As the population ages, particularly

with a sharp rise in those aged 65 and

over, the burden of disease intensifies,

leading to greater and more complex

service demand. At the same time, the

capacity to meet this demand through

workforce, infrastructure, and clinical

resources is limited, creating a

mismatch that directly impacts financial

sustainability.

We need to respond to the underlying

inequity of spend on our population.

The overall spend per person varies by

7.5% (£54 per person) from the lowest

spend in the most deprived quintile to

affluent quintile.

Urgent care spend per person is higher

in more deprived areas, but planned

care spend is higher in the more

affluent areas. In the most deprived

areas, urgent care makes up 47.5% of

the total acute hospital tariff spend per

person, but this reduced to 39.5% for

the most affluent. Most of the higher

urgent care tariff per person in the

deprived communities is linked to

higher type 1 ED attendances that are

nearly double the rate seen in the most

affluent areas (£53 compared to £28)

Core ICB Funding Sth Devon

Eastern Northern Plymouth & Torbay Western Total

25/26 plan expenditure £m £m £m £m £m £m

G&A and maternity 557.8 235.3 437.4 534.6 68.4 1,833.6

Community 133.0 49.6 93.9 121.2 16.5 414.3

MH 113.5 43.2 83.9 91.1 11.5 343.3

Prescribing 74.6 34.2 58.9 63.7 10.2 241.7

Primary Care 14.2 5.9 11.3 10.9 1.7 43.9

Total 893.2 368.2 685.4 821.6 108.3 2,876.8

25/26 expected expenditure

G&A and maternity 568.6 251.1 412.5 470.3 65.0 1,767.5

Community 97.1 43.4 66.4 84.5 11.4 302.7

MH 96.9 42.0 81.6 83.1 9.8 313.3

Prescribing 77.3 33.8 59.0 65.9 9.5 245.5

Primary Care 15.4 6.2 10.7 11.9 1.7 45.8

Total 855.3 376.4 630.1 715.7 97.3 2,674.9

25/26 inequity

G&A and maternity -10.8 -15.7 24.9 64.3 3.4 66.1

Community 36.0 6.1 27.5 36.8 5.2 111.6

MH 16.7 1.2 2.3 8.1 1.7 29.9

Prescribing -2.7 0.4 0.0 -2.3 0.8 -3.8

Primary Care -1.2 -0.2 0.6 -1.0 0.0 -1.9

Total 37.9 -8.2 55.3 105.9 11.0 201.9

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy19 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

How the strategy was

developed

The journey so far

We embarked on a journey to develop

and deliver a comprehensive,

inclusive, and future-focused strategy

that ensures safe, effective, and

sustainable health care for all people in

Devon. This is aligned to national NHS

direction and policy framework of

focusing on population health,

prevention, recovery of core NHS

services, improving access, and

reducing health inequalities though a

lifecycle. It includes:

• Whole-population focus

• Care across the continuum

• Responding to system pressure

and sustainability

The development of Devon’s Health

and Care Strategy has been guided by

a structured Discover–Design–

Deliver methodology. This approach

ensures that transformation is not only

evidence-based and strategically

sound, but also inclusive and co-

produced with the people who use and

deliver services across the system.

Discover phase:

Building a shared

understanding

The Discover phase focused on

developing a rich understanding of the

current health and care landscape in

Devon, completed through:

• Reviewing existing

intelligence through the system’s

insights library, which collates data

on population health, service

performance, and inequalities.

• Drawing on the 10-Year Plan

engagement, which involved over

3,400 participants across Devon.

This provided a robust evidence

base, particularly around the three

strategic shifts:

o From hospitals to community

and primary care

o From treatment to prevention

o From analogue to digital

services

As part of the 10 Year Plan

engagement, a committed cohort of

over 200 individuals expressed interest

in ongoing involvement were identified.

This presents a valuable opportunity to

establish a citizens’ panel or bespoke

reference groups to support continued

co-design and accountability.

The One Devon People and

Communities Framework

demonstrates how we will work

together across the One Devon

System to widen engagement

opportunities to the whole Devon

population.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy20 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

The Framework ensures that the

voices of those who experience health

inequalities, or those who live in rural,

coastal or remote communities, have

an equal chance to be heard and

influence decision making.

The Devon 10 Year Plan Engagement

programme proves the effectiveness of

this approach. This was recognised by

regional colleagues as a leading

example.

To support the Framework, NHS

Devon has developed a service

change process. This has been agreed

by leaders from across Devon to

provide a consistent approach to

managing service change.

Key findings from the

Discover phase

The Discover phase has provided a

rich understanding of the current

position of the Devon Integrated Care

System (ICS). Drawing on population

data, system analysis, and extensive

stakeholder engagement, we have

identified the key pressures,

opportunities, and priorities that

ultimately shaped the development of

NHS Devon’s Health and Care

Strategy.

While many of the findings may not be

unexpected, they offer a clear and

compelling evidence base from which

the strategy can confidently move

forward. They validate long-standing

concerns, reinforce national policy

direction, and highlight the areas

where transformation is most urgently

needed.

Demographic and population

insights

Devon’s population is undergoing

significant demographic change,

marked by an ageing population and

increasing diversity in health and care

needs. Older age groups are growing

rapidly, driving demand for more

complex and long-term care, including

end-of-life support. Alongside this,

there is a sharp rise in neurodiversity-

related needs, particularly autism and

ADHD, and Learning Disabilities with

more individuals seeking diagnosis and

support than ever before. This surge

reflects growing public awareness and

changing expectations around access

to timely, personalised care.

Cultural attitudes and population

expectations are also evolving, with

people increasingly seeking proactive,

inclusive, and responsive health

services that reflect their lived

experiences and identities. These

shifts present a major challenge for the

health and care system, which must

adapt to meet rising demand, reduce

inequalities, and deliver care that is

both person-centred and culturally

competent.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy21 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

System pressures and

infrastructure challenges

Devon is operating within a

significantly challenged financial

environment, having ended 2024/25

with a substantial deficit despite

receiving support funding, and facing a

much larger underlying financial gap

that signals the need for strategic

reform. Our unique geography adds

further complexity, with remote rural

and coastal communities facing

persistent accessibility barriers.

Although deprivation levels are

relatively low overall, health outcomes

vary widely, with stark differences in

healthy life expectancy across the

county.

Infrastructure across IT and estates is

inconsistent, with some facilities in

good condition and others in urgent

need of repair—posing risks to

business continuity, safety, and service

quality.

These pressures reflect a system that

must evolve to meet growing and

changing population needs, while

ensuring resilience, equity, and

sustainability.

Stakeholder engagement

insights

Stakeholder engagement has been

central to the Discover phase, ensuring

that the strategy is shaped by the

voices of our communities and

professionals.

To support the Government’s 10-Year

Health Plan, NHS Devon led a

comprehensive engagement

programme involving staff, patients,

the public, and partners across Devon.

Over 3,400 participants contributed to

Devon’s 10-Year Health Plan

engagement, providing a robust

evidence base for strategic

development.

Described nationally as ‘the biggest

conversation about the future of the

NHS since its inception,’ this

programme aimed to capture local

voices on the three big shifts shaping

healthcare.

NHS Devon tailored this engagement

locally, ensuring the views of Devon’s

diverse communities informed both

local priorities and the national plan.

Co-designed with Healthwatch Devon,

Plymouth, and Torbay, and supported

by the Devon Engagement Partnership

(DEP), the programme aligned its

questions with the national framework

to maintain consistency.

The objectives were to:

• Reach the right people, in the right

places, at the right time—especially

those in Core20PLUS5 groups and

seldom heard communities.

• Encourage ongoing public

involvement in NHS transformation.

• Drive participation in the national 10

Year Plan survey.

• Maintain clarity and creativity in

engagement to minimise confusion.

• Collaborate with neighbouring ICBs

in Cornwall and Somerset.

The success of this approach relied on

strong partnerships and using trusted

networks across Devon to maximise

reach and impact.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy22 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Three main engagement tools were

used:

• An online survey for workforce and

public (hosted on the One Devon

website)

• A locally adapted “Workshop in a

Box”

• Engagement postcards distributed

at events

While survey and workshop questions

mirrored the national programme,

workshop content was adapted to

resonate with Devon’s communities,

making conversations meaningful and

relevant. Though the survey was

primarily online, phone responses were

facilitated by Healthwatch and

promoted in all communications.

Engagement postcards were also

distributed at local events. NHS

Devon’s communications and

engagement team led the programme,

supported by providers, local

authorities, South Western Ambulance

Service NHS Foundation Trust

(SWASFT), Healthwatch, voluntary

sector organisations, and other key

partners. A communications toolkit

helped partners promote the

programme as trusted community

voices.

Five engagement days across Devon

raised awareness, encouraged survey

completion, hosted workshops, and

supported postcard responses—with

strong backing from Healthwatch,

voluntary sector groups, and provider

colleagues.

To reach those most affected by health

inequalities, NHS Devon invested in

the voluntary, community and social

enterprise (VCSE) sector through a

small grants scheme. This enabled

community organisations to hold

targeted workshops, including:

• Yes Brixham (Homelessness)

• Adventure Therapy (Young People)

• Headway Devon (Learning

Disability/Acquired Brain Injury)

• Age Concern (Carers and Older

People)

• Hikmat Devon (Ethnically Diverse

Communities)

• Citizens Advice (People with

Physical Disabilities)

• Devon Communities Together

(Coastal Communities)

Devon’s approach was recognised

regionally as a model of best practice,

with many other South West ICBs

adopting similar methods.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy23 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Our thorough approach generated

strong participation and broad

representation:

• Over 3,400 individual feedback

responses

• 2,353 survey completions

• 50 workshops (10% of all national

workshops) with 358 attendees

• Over 700 written postcards

completed

• More than 220 people signed up for

ongoing engagement

Key themes

• Strong support for the NHS being

free at the point of access

• The NHS workforce is seen as the

system’s most valuable but

vulnerable asset

• Appreciation for the wide range of

services and their personal impact

• Urgent need to improve access to

primary care, mental health, A&E,

and elective services

• Generally positive experiences

when accessing care, despite low

satisfaction with overall NHS

management (reflecting national

trends)

• Need for adequate NHS funding

• A call for better integration and

communication between services

• Emphasis on prevention,

diagnostics, and earlier intervention

to reduce illness

• Desire for greater investment in

frontline services and a reduction in

management costs

• Recognition of technology’s

potential to improve efficiency and

care coordination, balanced by

concerns over AI, data privacy, and

digital exclusion

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy24 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Learning from local,

national, international

examples

Since its inception, the NHS has

undergone numerous system-wide

reorganisations in response to

changing demographics, cultural shifts,

advances in medical science, and the

need for financial sustainability.

It continues to evolve to deliver care

that is more personalised, effective,

preventative, and sustainable—an

imperative in today’s complex

healthcare environment and emerging

policy landscape. In this section, we

highlight examples of innovative and

effective approaches to managing

patients with complex needs and

multiple long-term conditions.

These case studies illustrate how

Primary Care, Community Services,

and Acute Settings are working

collaboratively to improve outcomes for

our populations.

Local examples of good

practice

Integrated care and health

inequalities (including primary care)

Delivery of one-off hospital discharge

Personal Health Budgets (PHB) as part

of discharge planning have now been

embedded with a centralised support

model to simplify payment processes

and minimise impact and workload

forward-based staff. Leads in the local

system are working with the Southwest

Integrated Personalised Care Team to

support to embed training offers

centred on the ‘what matters to you’

conversation as part of the discharge

planning process.

One Northern Devon’ is a partnership

of the NHS, social care, local housing

authorities, police, fire service, local

businesses and voluntary and

community groups working together to

reduce inequalities and improve health

and well-being. The partnership has

devised the ‘Flow programme’ to bring

teams together to work in a more

integrated way to support people with

complex needs. Focussing on what

matters to the person – which

frequently relates to housing, finances

and debt, it utilises a ‘Team around the

Person’ and ‘Community around the

Person’ approach. As well as the

positive impact this has on people’s

lives, it has also been shown to reduce

demand on the system. ‘High Flow’

focusses on the most frequent users of

A&E and other emergency services

and has resulted in a 60% reduction in

A&E visits from these service users

alongside reductions for SWAST,

Police and Devon Partnership Trust. In

one year, for 6 service users, this

demand reduction equated to:

£103,831.92.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy25 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Plymouth City Council has created

the Creative Solutions Forum (CSF) to

meet the needs of people who do not

fit into standard care settings.

Practitioners, managers and

commissioners across public health,

adult social care and mental health

work together to provide integrated and

bespoke offers for people and support

workers. Staff report better risk

management, less anxiety over high-

risk cases and huge improvements in

inter-service relationships, trust and

co-operation. Around 70% of cases are

resolved in one visit and almost all

cases in 3 visits. Bespoke approaches

have begun to replace standardised

care, there are fewer inter-service

hand-offs, better understanding of risk

and inter-service co-operation has

become the default, rather than the

exception. Most importantly, culture

right across the system has changed.

PCNs in Devon are also planning to

deliver anticipatory care and

personalised care more systematically

and will be working to expand focus on

CVD diagnosis and prevention to

reduce demand on other community

and hospital services.

National examples of

good practice

Tackling Fuel Poverty in Cheshire

and Merseyside: A Population

Health Management Approach

Rising energy costs and wider cost-of-

living pressures have driven more

households into fuel poverty, which is

strongly linked to worsening health

outcomes. Cold homes increase the

risk of respiratory and cardiovascular

disease, poor mental health, and

unintentional injury. The Institute of

Health Equity estimates thousands of

unplanned hospitalisations are directly

associated with cold homes, while

NICE suggests that preventative

measures could avoid up to 28,000

deaths each year.

To address these risks, Cheshire and

Merseyside Integrated Care Board

(ICB), supported by NHS England’s

Innovation for Healthcare Inequalities

Programme (InHIP), has adopted a

population health management (PHM)

approach. This involves using data to

identify, engage, and support those

most at risk, particularly people with

respiratory illness living in fuel poverty.

Working with NHS, voluntary and

community sector (VCS), and local

authority partners, the ICB has

launched several “trailblazer” projects

across the integrated care system

(ICS). These multidisciplinary initiatives

use targeted interventions to improve

health outcomes and reduce the wider

impact of fuel poverty.

The trailblazers aim to:

• Rapidly identify and engage high-

risk patients

• Reduce the number of

exacerbations experienced

• Improve adherence and

effectiveness of inhaler therapies

• Enable quicker eligibility checks for

patients suitable for remote

monitoring pathways

• Reduce fuel poverty debt by

signposting sources of financial

support

In the longer term, these interventions

are expected to ease pressure on local

health services by reducing GP visits,

A&E attendances, unplanned

admissions, and emergency calls

linked to respiratory conditions

aggravated by cold homes.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy26 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Bromley by Bow

The Bromley by Bow Centre, once

described by former health minister

Lord Mawhinney as “one of the most

impressive displays of social

entrepreneurship anywhere in Europe,”

has grown from a small East End

initiative into an internationally

recognised charity. Based in Tower

Hamlets, one of England’s most

deprived areas—with nearly 40% of

children in low-income households and

a 10-year life expectancy gap between

rich and poor men—the centre was

founded in the 1980s by a local priest,

his congregation, and volunteers to

address deep social inequalities.

Initially, it offered childcare, adult

learning, welfare advice, a café, and

community space.

By the 1990s, it was clear that

conventional health and social care

models were failing local residents. In

response, the charity established its

own GP practice, joined in 1997 by Dr

Sam Everington and Dr Julia Davis,

pioneering a model of care centred on

the social determinants of health.

Remarkably, this was the first British

GP practice owned by patients and

rented to the NHS. It later evolved into

the Bromley by Bow Health

Partnership, now employing 110 staff

and serving more than 28,000 patients

across three practices, including a

walk-in clinic for 500 unregistered

patients weekly.

The centre combines primary care with

community services and research,

empowering patients to engage

actively in their health. Located in

Bob’s Park, its design embraces green

space and creativity, with projects like

therapeutic horticulture for adults with

disabilities and public art to foster

community pride. Services extend

beyond health into housing, welfare,

employment, and money management,

reflecting its philosophy of “health by

stealth.” This holistic approach not only

addresses immediate needs but also

supports education, employment, and

local enterprise development,

contributing to the regeneration of East

London.

A cornerstone of its work is “social

prescribing,” enabling GPs to refer

patients to non-clinical, in-house

experts tackling root causes of poor

health, from debt to isolation. This

frees doctors to focus on clinical care

while addressing wider health

inequalities. Evidence of impact is

strong: in 2014, Tower Hamlets ranked

highest nationally for cholesterol and

blood pressure control in patients with

diabetes and heart disease.

The Bromley by Bow Centre

demonstrates how integrated,

community-led health and social

services can transform lives and

reduce inequalities at scale.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy27 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

End of life care service for

people with dementia living in

care homes in Walsall

NHS Walsall Clinical Commissioning

Group commissioned Dementia

Support Workers (DSWs) to provide

evidence-based advice, development

sessions, and practical support to care

home staff. Their aim is to promote

best practice in dementia and end of

life care, working closely with staff,

residents, and families to identify

improvements that enhance outcomes

and quality of life.

This initiative was developed in

collaboration with Pathways 4 Life

(Accord Group and Age UK Walsall)

and St Giles Walsall Hospice,

responding to the pressing need for

better dementia care, particularly at

end of life. Many people with dementia

continue to die in acute hospitals rather

than in their care home, despite a

preference to remain in familiar

surroundings.

Two community-based DSWs work

across Walsall, promoting person-

centred care while fostering strong joint

working with hospice teams, nursing

case managers, ambulance staff,

occupational therapists, voluntary

organisations, and community groups.

Their engagement begins with

observation studies in care homes,

assessing person-centred practice,

communication, and use of assistive

technology. They deliver development

sessions to build staff skills and create

improvement plans with managers

using Care Fit for VIPS.

Recommendations often include better

signage, orientation aids, and

opportunities for socialisation and

meaningful activity.

DSWs also support adoption of the

Namaste Care approach, delivering

tailored sessions to improve staff

communication, understanding, and

role modelling. Signs of pain or

depression are escalated to GPs.

The guiding principles of the service

are to:

• make sure people with dementia are

always at the centre of everything

• maximise partnership working

• utilise an evidence-based practice

approach

• empower and engage volunteers,

staff and families to maximise

contribution

• Early evaluation has found the

service has:

• decreased unnecessary hospital

admissions

• increased resident engagement in

activities

• improved staff confidence and skills

• strengthened links between Health

and Social Care

• enhanced continuity of care through

better communication

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy28 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

• improved staff understanding of

what constitutes an emergency

• introduced more effective and

efficient documentation

• This integrated, evidence-based

model is helping to transform

dementia and end of life care across

Walsall.

International examples

of good practice

How GRAND Mental Health

reduced psychiatric

inpatient hospitalisations

by 93%

The organisation GRAND Mental

Health is a Certified Community

Behavioural Health Clinic (CCBHC)

that offers behavioural health services

in addition to support with diet, physical

health, housing, and employment. The

organization operates facilities in

thirteen Oklahoma counties, including

three crisis centres.

To reduce inpatient hospitalisations

and create lower levels of care for

people experiencing behavioural health

crises, GRAND Mental Health created

dedicated 24/7 crisis stabilisation

services and extended virtual care

access points into the community. The

model changed the way crisis care in

the region works.

With GRAND’s new crisis care

strategy, police can quickly and easily

connect people with clinicians at the

urgent recovery centre to assess

patient need. Patients can also

communicate directly with clinicians

when in crisis or if they need support.

The result Compared to the baseline

year of 2015, the model has shown the

following results for GRAND’s adult

clients:

• Reduced inpatient hospitalizations

at any Oklahoma psychiatric

hospital by 93.1% (from 959 in 2015

to 66 in 2021)

• Reduced inpatient hospitalizations

at Wagoner Hospital by 100% (from

841 in 2015 to 0 in 2021)

• Reduced inpatient bed days at

Wagoner Hospital by 100% (from

1,115 in 2015 to 0 in 2021)

• Saved state and federal government

$62 million dollars (from 2016-2021)

• Increased number of adult clients

served by 163.5% (from 4,326 in

2015 to 11,401 in 2021)

When GRAND started the model, they

were a fee-for-service (FFS)

community mental health organization.

Under FFS, GRAND was able to

recoup the money spent from their

general revenue budget by reducing

the rate of no-show appointments.

While GRAND eventually transitioned

to a Certified Community Behavioural

Health Clinic (CCBHC) business

model, leadership believe this

approach would have continued to

bring a positive return on investment

under FFS.

Buurtzorg: revolutionising

home care in the

Netherlands

Home care in the Netherlands supports

the chronically ill, people with

dementia, and those needing end-of-

life care. It includes both medical

services, such as wound care and

injections, and personal support, such

as bathing and help with daily living. By

the mid-2000s, however, Dutch home

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy29 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

care faced serious challenges:

declining quality, rising costs, lack of

continuity, and a disillusioned nursing

workforce.

Frustrated by this situation, nurse Jos

de Blok left his job to found Buurtzorg

(“neighbourhood care”), a radical

alternative centred on patient needs

and frontline autonomy. Rejecting

centralised management, Buurtzorg

empowered small nursing teams to

integrate families and neighbourhood

resources into holistic care solutions.

This approach aimed to simplify the

system, deliver higher quality care at

lower cost, and improve job

satisfaction among nurses.

• Buurtzorg’s model consists of three

key components:

• Self-governing teams of 10–12

nurses providing both medical and

supportive home care

• An IT system to reduce

administration and allow teams to

self-monitor performance

• Regional coaches offering advice

and promoting best practice without

performance targets

Each neighbourhood-level team covers

around 10,000 people and 40 patients.

Nurses act as “health coaches”,

coordinating care with GPs, involving

families, and mobilising community

support. Objectives include:

• Creating a financially sustainable,

holistic model of care

• Boosting nurse satisfaction through

autonomy

• Maintaining or restoring patients’

independence

• Training patients and families in self-

care

• Building neighbourhood networks of

support

The outcomes have been notable:

• Patient satisfaction scores are 30%

above the national average;

• between 2008–2013 the average

rating was 9.1/10

• Patients stay in care for 5.5 months

on average versus 7.5 months

elsewhere, with 50% receiving care

for less than three months –

suggesting greater independence

• However, Buurtzorg patients are

admitted to nursing homes at a

younger age compared to others

By 2018, Buurtzorg had 10,000 nurses

in 900 independent teams, caring for

70,000 patients annually. At its peak,

60% of Dutch community nurses

worked for Buurtzorg, influencing

national elderly care policy and

inspiring competitors to adopt self-

steering models.

While overall savings are debated, it is

estimated that nationwide adoption of

Buurtzorg could save the Dutch

economy €2 billion annually. Its impact

on patient satisfaction, independence,

and nurse morale has been profound,

offering a globally recognised model of

sustainable, community-based care.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy30 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Design Phase: Co-

creating the future

Building on the insights gathered, the

Design phase focused on

collaboratively shaping the strategy’s

content, priorities, and delivery models.

Key activities included:

• Ten targeted design workshops,

each aligned to a chapter of the

strategy, involving stakeholders

from across the system—health,

care, voluntary sector, and

community representatives.

• Interactive and iterative

engagement, where stakeholders

tested ideas, refined options, and

helped identify barriers and

enablers to change through the

Design Steering Group and

engagement with localities.

• Validation of emerging models,

ensuring that proposed solutions

are grounded in lived experience

and operational reality.

Over 125 individuals participated in

one or more of the strategic workshops

held to inform the development of this

health and care strategy. These

workshops were aligned with the

following thematic chapters:

• Population health and prevention

interventions

• Neighbourhood health services and

primary care

• Community services and the

bridging neighbourhood system

• Secondary and tertiary care

• Implementation via enabling plans

The workshops generated valuable

insights and outputs. The initial round

focused on assessing the current state,

envisioning the future state, identifying

system-wide gaps, and defining the

necessary "bridges" to transition from

the current to the desired future state.

The second round of workshops built

upon this foundation, using the

identified bridges to shape detailed

workplans, define intended outcomes,

and establish measurable metrics.

These contributions are reflected

throughout this strategy document and

will continue to inform future planning,

development, and commissioning

activity.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy31 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Design principles

Four core design principles serve as strategic guardrails for the development and implementation of our system-wide strategy.

These principles have been rigorously tested and refined through extensive engagement during the Design phase. They underpin

the delivery model and shape the anticipated impact of the transformational changes required to improve outcomes, enhance

equity, and ensure sustainability across the Devon system.

Sustainable

Quality and value

People-centred

Accessible to all

• Sustainability means being able

to live within our means and

being conscious of the health

system we leave to future

generations.

• Be deliverable within the

financial resources available to

us, eliminating the reliance on

deficit support or funding above

the fair shares allowance

• Develop services that can be

delivered using current estate

• Deliverable with the projected

available workforce

• Support a shift from treatment to

prevention to increase healthy

life expectancy

• Reduce the environmental

impact of healthcare services

• Deliver nationally and regionally

agreed performance standards

• Quality and value means

ensuring that we are balancing

maximising the outcomes we get

from our investment with

delivering what is right.

• Consider how it maximises

outcomes: patient experience,

financial, and patient and

population health outcomes

• Be honest about what cannot be

delivered or where difficult

decisions on resource allocation

need to be made

• Be considerate of its impact on

all parts of our population, with

clear impact assessments to

help us understand any

unintended consequences

• Deliver on nationally and

regionally agreed quality

standards

• People-centred means being

considerate of all the people

impacted by our decisions.

• Involve patients and the wider

public in the design of their

services

• Involve patients and the wider

public in the design of their

services

• Build services that cater for the

needs of people and not the

service

• Enable the health workforce to

deliver, and invest in them to

retain and develop skills within

the system

• Involve partners from other

organisations wherever there is

an impact on them

• Accessible to all means

ensuring ease of access to

services and clear navigation

through the health system.

• Have clear access points that

are understood by our

population and partner

organisations

• Ensure a consistency of

approach and service regardless

of the access point to receive

healthcare services

• Minimise the number of

handovers between

organisations, and where they

occur ensure that the patient

journey is not affected by them

• Navigate people to the right

service for their needs as quickly

as possible

• Commission services which

reduce health inequalities

especially for the most

disadvantaged groups

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy32 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Neighbourhoods

1. Primary care

2. Proactive primary

prevention

3. Population Health

Management

4. Urgent care response

services

5. Mental health services not

requiring a specialist setting

outpatient services

6. Planned care not

requiring specialist

settings

Specialist settings

1. Emergency care

2. Planned care requiring specialist

settings

3. Bed based mental health services

4. Maternity

Place / Community

1. Urgent Care front door

(UTC)

2. Community diagnostics

3. Non-bed based mental

health services

4. Specialist community

services

Our model of care

• Neighbourhood – Supporting

integrated, community-based care

tailored to local populations, with a

strong focus on prevention, early

intervention, and personalised

support. This is community-based

care across a population of

between 30,000–50,000 people.

Delivery is led by Integrated

Neighbourhood Teams (INTs) that

use combined resources to deliver

joint outcomes. Outcomes are

commissioned from a lead provider

who will collaborate with other

health services (including primary

care), social care and VCSE

organisations to deliver contracts.

• Place – Enabling coordination

across services within localities,

ensuring that care is joined-up

across primary, community, mental

health, social care, and voluntary

sector partners.

• Specialist settings – Providing

strategic oversight, specialist

services, and infrastructure to

support consistency, equity, and

sustainability across Devon.

Accessible

to all

Sustainable

People centred

Quality

and value

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy33 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Building on this foundation, we have

collaboratively developed a care Model

for Devon that is tailored to our local

context, responsive to population

health needs, and aligned with our

collective ambitions.

This model outlines a coherent

framework for organising and

delivering care across three integrated

levels, ensuring consistency,

coordination, and community

relevance, though: care that cannot be

delivered in non-specialist settings and

high-volume interventions that can

benefit from economies of scale.

Services should be commissioned to

deliver national best practice to

maximise cost and quality outcomes.

This layered approach will enable a

shift toward more integrated, proactive,

and person-centred care, ensuring that

services are designed around people,

not organisations, and that care follows

the individual across settings and life

stages.

The emerging model is not a fixed

blueprint, it is a living framework for

ongoing collaboration, innovation, and

refinement. It will continue to evolve

through engagement, testing, and

learning, utilising the voices of our

communities and the expertise of our

workforce.

This approach ensures that Devon’s

health and care system remains

responsive, resilient, and aligned to the

needs of today’s population and future

generations.

Applying a population

health management

methodology –

treatment to prevention

Our Delivery Model is dependent on

the application of a Population Health

Methodology for all service delivery.

Population Health Management (PHM)

is how we work collaboratively to

understand and improve the health of

people and communities, using joined-

up data and intelligence. It goes

beyond data analysis to include

community engagement, clinical and

financial input, evidence-based

planning, and ongoing evaluation.

PHM enables us to identify and reduce

health inequalities through proactive

and preventative care, targeting

resources where they will have the

greatest impact. Techniques such as

segmentation, risk stratification, and

impact modelling help identify local ‘at

risk’ cohorts, allowing us to design

tailored interventions that prevent ill-

health, improve care for those with

long-term conditions, and reduce

unwarranted variation in outcomes.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy34 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

This approach is central to delivering

more equitable, effective, and

sustainable health and care services

across Devon and will be central to

transformation.

Devon’s population is aging faster than

the national average, leading to a rise

in long-term conditions and increasing

demand on secondary and urgent care

services. Without a shift toward

prevention and early intervention, the

system will face growing pressure and

financial strain.

A population health approach enables

us to respond proactively supporting

people to live healthier for longer and

reducing the number of years lived in

poor health.

This approach is especially critical in

areas of deprivation, where life

expectancy is shorter and poor health

begins earlier. It also helps address

the significant variation in healthy life

expectancy and service demand

across Devon.

Aligned with national PHM principles—

including those set out in the NHS

Long Term Plan, Core20PLUS5, and

the ICB Model Blueprint, we are

focusing on:

• Reducing health inequalities by

targeting early intervention and

prevention in communities with the

greatest need.

• Improving outcomes through

personalised care, healthy lifestyle

promotion, and support for self-

management.

• Enhancing cost-efficiency by

reducing reliance on reactive, high-

cost services through earlier,

community-based support.

• Increasing quality of life by

helping people maintain

independence and wellbeing

throughout their lives.

• Supporting sustainability by

easing the burden of chronic

disease and enabling better

resource allocation.

This population health approach is

embedded within our success

measures framework, which tracks

progress through a combination of

quantitative indicators (e.g. waiting

times, admission rates, workforce

data), qualitative feedback (e.g. lived

experience, staff and community

engagement), and independent

evaluation.

These measures will evolve as the

strategy is implemented, ensuring we

remain responsive to emerging needs.

Population health

management in Devon

Using a learning cycle, Population

Health Management (PHM) in Devon

will enable us to work collaboratively

across health, care, and community

systems to better understand and

improve the health of our population.

By integrating joined-up data and

intelligence, PHM helps us identify

patterns in service use—highlighting

where care is sub-optimal, where

people are not accessing services in a

timely way, and where there may be

overuse or underuse. This insight

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy35 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

supports more effective service

planning and resource allocation.

This continuous cycle of learning

ensures that PHM remains dynamic,

responsive, and embedded in our

wider strategy to create a healthier,

fairer, and more sustainable Devon. A

PHM methodology will help us in:

• Identify patterns – who is

accessing services, where is care

sub-optimal, who isn’t accessing

services in a timely manner

• Risk stratify, segment population,

identify high risk cohorts and plan

specific interventions, services and

pathways

• Shift from hospital to community

with earlier interventions and

prevention

• Population health – role of wider

determinants (e.g. through social

prescribing) instead of, or as well

as, healthcare

Digital transformation –

analogue to digital

Digital transformation will be a central

driver of change across Devon’s

Health and Care Strategy Delivery

Model, and it is aligned to the

ambitions set out in the national 10-

Year Health Plan. We will harness

digital innovation to respond to rising

demand, an aging population, and

increasing financial pressures

delivering care that is more proactive,

efficient, and resilient.

Through the implementation of

integrated care records, virtual

consultations, remote monitoring, and

data-driven planning, we will reshape

how services are delivered and

accessed.

Our strategy commits to embedding

digital solutions at scale, investing in

infrastructure, building digital capability

across the workforce, and ensuring

inclusive access for all communities.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy36 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

System-wide data-

sharing

Standardised and

Unified Infrastructure

Shared EPR and

Operational Systems

Person centred care

Harnessing new technology

1. Shared patient data

to support health and

care across settings

(NHS, care and

community partners)

1. ‘Staff Passport

Technology’ for cross-

border team working and

movement

1. Optimised single electronic

patient record (EPR) across

Devon acute hospital settings

1. NHS App

1. AI to improve productivity and

decision making through AI-

enabled and AI-delivered health

care

2. A quality-led

approach to IG to

resolve data-sharing

barriers

2. Cyber secure

infrastructure

2. Devon and Cornwall Care

Record (DCCR)

2. Single Patient Record

to enable joined up care

and patient engagement

/ activation

2. Wearables technology to

support neighbourhood health

and care

3. Systems that enable

a real-time linked data

set

3. Standardise and

rationalise technology

3. A connected Devon and

Cornwall Laboratory

Information Management

System

3. Personalised care

plan

3. Surgical efficiency via Robotics

4. Optimisation of local

instance of the

Federated Data

Platform

4. Maximise economies of

scale through converged

contracts

4. Medication optimisation

capabilities

4. Digital inclusion

strategy

4. Digital decision-making based

on patient outcomes and value to

person and System

5. Dynamic System-

wide Demand

Management and

Forecasting

Capabilities

5. Digital Collaborative

Corporate Service

5. Automated end-to-end

Pathway management for

visibility and alerts

5. Enabling easy

navigation for patients,

carers, teams

6. Single data architecture

and consistent data

management processes

6. Converge systems to

support corporate functions

6. Safe adoption of

virtual therapists, triage

and remote monitoring in

mental health

7. Neighbourhood health

technology offer for

wearables

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy37 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

In a system under pressure, digital

transformation will be a core part of

how we deliver sustainable, high-

quality care now and into the future.

The following are principles of the

digital innovation for Devon:

Quality in all we do

We will put quality at the heart of

achieving best value in health and

care. Delivering safe, effective, and

person-centred services ensures that

required outcomes are achieved and

resources are used in the most

impactful way. Our understanding of

quality is shaped both by the voices of

our population—who tell us what

matters most to them in their care—

and by the expertise of our clinicians,

who bring evidence, professional

standards, and frontline insight.

This partnership between clinical

leadership and lived experience gives

us a rounded view of what high-quality

care truly means. By listening to

patients and staff, and by embedding

clinical judgement into our decision-

making, we can design and deliver

services that are responsive, viable,

and represent the best value for our

communities.

By building trusted relationships with

clinical care and professional leaders

we are able to create a unified

approach to quality that is intelligence

driven, clinical informed that drives

innovation and transformation. We will

use global best practice knowledge

that can be adapted and adopted to

drive high value commissioning and

delivery.

We will lead a culture of continuous

improvement, clinical excellence and

evidence-based practice by using total

quality management methodology and

use of the national quality board

frameworks.

With quality as our guiding principle,

this strategy commits us to building a

system that delivers:

• Safe care – risks are anticipated,

and harm is minimised through

strong clinical governance and

leadership.

• Effective care – good outcomes

are consistently achieved, informed

by clinical evidence, clinical

leadership, innovation, and

research.

• Positive patient experience –

people feel respected, listened to,

and supported

• High value – resources are used

responsibly to deliver the greatest

possible benefit for patients,

customers, communities, and

taxpayers.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy38 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Neighbourhood health

service and primary care -

hospital to community

What is a neighbourhood?

Neighbourhoods are geographic areas

with populations of 30-50,000 and are

a way of working in which self-defined

and often hyper-local, and statutory

services, work together to improve the

health and wellbeing of their

population.

Neighbourhood working involves

statutory and non-statutory

stakeholders bringing their assets,

capability, capacity and experience to

a common goal.

Devon has not yet fully defined its

Neighbourhoods, though work to do so

is underway. Our Place arrangements

in Devon, the five Locality Care

Partnership’s (LCPs), are being

supported to define neighbourhood

boundaries to ensure full coverage

across the county. Within a

Neighbourhood, Integrated

Neighbourhood Teams (INTs) will be

established to deliver health and care

outcomes. Establishing our

Neighbourhood footprints is essential,

but we anticipate that our initial

configuration will need to evolve over

time. In some areas initial alignment

with Devon’s 31 Primary Care

Networks (PCNs) will enable the

development of services given their

essential role as the clinical backbone

of INTs, however it is essential that

Neighbourhood footprints should be

determined by local needs, local

community demographics, and the

existing assets in each area.

Aligning with PCN boundaries is a

starting point, but INTs may need to

work across them to provide effective,

person-centred care. There are several

essential foundations that our LCPs

will take forward in order to establish

our Neighbourhoods and foster a

collaborative approach to successfully

deliver our ambitions.

These include, ensuring the right

representation and engagement with

local stakeholders, strengthening the

voice of the citizen, applying PHM

methodology and risk stratification to

understand local need, developing a

clear local vision, and supporting

system leadership development that

will enable collaboration between

partners to enable delivery.

Integrated Neighbourhood

Teams (INTs)

Our Integrated Neighbourhood Teams

(INTs) will become the primary

interface for our population with health

care services. Bringing together

health, social care and VCSE partners,

taking a multidisciplinary team

approach using shared patient-level

data, INTs will identify people at

greatest risk, proactively reviewing and

supporting interventions to keep them

healthy.

Neighbourhood working is not just

about the location of services but

improving the population’s health. Our

neighbourhood teams will operate at

the scale that makes the most sense

for their populations.

Where it works most effectively, they

will respond quickly to emerging

needs, mobilise resources, and build

strong, trusted relationships within their

communities. Citizens and

communities should be at the centre of

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy39 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

these teams, as active partners in the

design and ongoing delivery of

services.

Once established, INTs will be formally

commissioned, via a lead provider, to

deliver a wider range of physical and

mental health services.

The commissioning arrangements will

move away from paying for activity

within these services, to paying for

outcomes, allowing flexible use of

resource to deliver the right

interventions for the Neighbourhood

population.

INTs will be encouraged to commit

resource to reflect need, delivering

more for those that have greatest

need, rather than relying on delivering

a standard, universal offer to all.

We will develop a risk stratification tool

that can be used by the INTs to identify

and understand local population need.

Applying a PHM approach, the INTs

will initially focus on developing

multidisciplinary team approaches to

support the identification and

supportive interventions for individuals

with multiple long-term conditions in

line with the national Neighbourhood

guidance, making reasonable

adjustments for individuals as required.

Through our Place arrangements,

commissioning relationships will be

further strengthened with local

authority partners to align

commissioning plans and give a clear

steer on agreed outcomes to INTs. The

commissioning approach will be

permissive enough to allow INTs to

use resources collectively, regardless

of source. This will remain in place for

as long as the INT is delivering

commissioned outcomes.

INTs will also be supported to build

relationships with private enterprise in

order to develop income streams and

outside investment that can be

reinvested into health and social care

services.

INTs will establish a physical hub for

services to be co-located. While this

may be within current NHS estate,

where possible this should be within

the heart of the neighbourhood, and

consideration will be given to how

partners collectively use their resource

to support INTs.

INTs will be asked to take an all-age

approach and will need to consider

how to plan services around different

groups, for example: services for

children being delivered outside of

school hours.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy40 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Moving activity from

hospital to neighbourhood

Wherever services do not need to be

delivered within a specialist setting,

there will be consideration given to

transferring to Neighbourhoods for

delivery.

Primary care

Primary care will be central to the

delivery of INTs. General practice and

Primary Care Networks (PCNs) will

expand to improve access for patients

via telephone and digital means, in

addition to face-to-face access.

Patients can expect to receive clinically

appropriate inputs from a variety of

clinical and non-clinical staff delivered

in an appropriate timeframe,

dependant on their needs. There will

be greater promotion of self-

management and use of community

assets within their Neighbourhood.

INTs will continue to focus on

improving the dental offer to our

population, particularly for those with

urgent needs, those requiring

stabilisation of their oral health, and

with a strong focus on prevention and

ensuring lifelong good dental health.

Community pharmacy will further

expand its service offer, often

localising delivery for patients and

supporting partner providers.

Recognising pharmacy is not immune

from delivery pressures, we will seek to

commission a broader range of

services on a longer timeframe, giving

providers the confidence to grow their

businesses and extend their offer.

Ophthalmic services will be required to

ensure excluded groups are able to

access the care and services they

need. Initially this will be by ensuring

that those within Special Educational

Settings (SEND) have a robust and

comprehensive offer, and where that is

not readily accessed, work with SEND

providers to identify and remove

access barriers.

A problem-based approach to

innovation will be established, using

technology to help improve primary

care. By understanding the challenges

and through use of case studies, we

will explore the best options to address

these challenges at scale, which we

know will include enabling safe,

appropriate, and timely information

exchange between system partners.

Urgent care response and

virtual wards

INTs will be expected to develop a

service that responds rapidly to those

with an urgent care need (all age,

physical or mental health) to support

them to remain within the

Neighbourhood, rather than need

admission into a specialist setting.

This should include ‘hospital at home’,

which will replace the current virtual

ward model.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy41 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Supporting discharge

INTs will be expected to deliver models

to support early discharge from

specialist settings. They will work with

specialist providers to identify patients

where support plans can be enacted to

complete non-specialist treatment

within a neighbourhood setting.

Outpatient services

INTs will deliver follow-up care to those

that have had interventions in

specialist settings.

This will be proportionate to the need

of the individual and follow-up activity

will be stopped where it is adding little

to no clinical value.

Women’s health

INTs will deliver integrated

reproductive, preventative, and early-

intervention services where these

services do not require specialist

settings. The aim is to improve

women’s health outcomes, reduce

health inequalities, and prevent

escalation to specialist gynaecological

interventions wherever possible.

Mental health, learning

disabilities, and neurodiversity

INTs will remove barriers between

mental and physical health at a

neighbourhood level, delivering

primary prevention to their population

based on totality of health need. INTs

will work collaboratively to develop

local support networks and peer-to-

peer offers that will support those with

mental health needs to avoid crisis.

Support for patients and families

When individuals are escalated to

more specialist services, either

community or bed–based,

neighbourhood teams will remain the

primary care navigators for that patient,

working with specialist services to

revert to neighbourhood wherever

possible, including for patients that

have a Learning Disability and or

neurodiversity.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy42 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Children and young people

INTs will deliver universal and

preventative services that are

embedded within the environments

where children live, learn, and grow.

Neighbourhood delivery for children

and young people will include strong

alignment with schools, early years

settings, and local authority locality

structures. This integrated approach

ensures that services are coordinated,

equitable, and responsive to the

diverse needs of children and families.

It also enables early identification of

health and developmental concerns,

allowing for timely intervention and

support.

The children’s clinical workforce is

highly specialised and often lacks the

critical mass required for hyper-local

delivery. As a result, while services

must be accessible and community-

based, they also need to be delivered

at a scale that ensures quality and

sustainability.

This necessitates close collaboration

with services such as primary care,

hospital-based care, and community

health teams. The strategy adopts a

whole-age approach, recognising the

need for seamless transitions from

childhood to adulthood—particularly for

children and young people with special

educational needs and disabilities

(SEND), who may access services

from birth up to the age of twenty-five.

At the heart of neighbourhood-level

children and young people delivery is a

commitment to prevention and health

promotion. Health visitors and early

years practitioners play a critical role in

supporting families during the first

1,001 days (from conception to age

two) laying the foundation for lifelong

health and development.

School nurses will work in partnership

with education settings to deliver

immunisations, sexual health advice,

and mental health screening. GPs will

provide accessible care with strong

links to paediatric expertise and

multidisciplinary teams.

Community-based parenting

programmes and peer support

networks further strengthen protective

How will this feel different for our

patients

• Those with greater need will be

prioritised and interventions will be in

place to keep people with long term

conditions healthy.

• People will be able to have multiple

needs met at once rather than making

separate appointments with different

agencies

• People will be able to access health

services as part of their day-to-day

routine instead of travelling to NHS

settings

• People will only need to give their

information once and not repeat this

when using other local services

• People will need to access Hospital

settings less and receive more care

closer to their home

• When people have an urgent care crisis

they will be supported to stay at home

and have their needs met locally instead

of travelling to other settings

• People with greatest need will receive a

more “fair share” of available funding,

increased outside investment in NHS

services will mean more services

available for all

• When services are not delivering for

people the ICB will be able to intervene

using contractual levers to support

improvement

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy43 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

factors within families, promoting

resilience and wellbeing. Digital tools

are increasingly used to enhance early

identification and access to support,

offering families timely advice and

resources through an online platform.

Place and Community

In the integrated care landscape, the

concepts of Place and Community are

central to delivering health and care

services that are both strategically

coordinated and locally responsive.

These two dimensions operate across

multiple neighbourhoods, each

contributing uniquely to the design and

delivery of care.

Place refers to a defined geographical

footprint typically serving populations

between 250,000 and 500,000 within

which health and care organisations

collaborate to plan, commission, and

deliver services.

Place-based partnerships will align

with Locality Care Partnerships

(LCPs), and provide the infrastructure

and governance needed to support

neighbourhood development and

delivery. They aim to enable

coordination across neighbourhoods,

particularly where services benefit from

economies of scale, such as treatment

centres, diagnostics, and workforce

planning.

Place also plays a critical role in

resource management, including

estates, digital infrastructure, and

innovation funding. Acting as the

operational layer for Devon ICS, they

will be pivotal in ensuring that

neighbourhood teams are supported

with the tools, investment, and

strategic oversight required to deliver

integrated care effectively.

Place is the structure that will support

Neighbourhood development and

delivery and sits across a geographical

footprint that aligns with LCPs. Some

services will be delivered across this

footprint where there is benefit of

economies of scale for this to be done

across multiple neighbourhoods.

Community is defined not by

geography, but by shared identity,

experience or need, or protected

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy44 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

characteristics. Communities may be

demographic (such as children and

young people, older adults), clinical

(such as people with mental health

needs or neurodiversity), or

experiential (such as carers, veterans,

or LGBTQ+ individuals).

While communities often reside within

a place, their boundaries are shaped

by social connection and lived

experience, rather than administrative

borders.

Community-based approaches are

essential for addressing health

inequalities and ensuring that services

are culturally competent, trauma-

informed, and co-produced. By

listening to and working with

communities, the system can design

care that reflects lived experience and

builds trust.

Community is less structural, based

around our people and their shared

characteristics. While this may be

around people who live in a similar

geographical place, this will primarily

be groups with similar demographic

features or clinical needs.

Together, Place, Community and

Neighbourhoods form a tri-level model

that enables the health and care

system to be both strategically

coherent and locally responsive. This

integrated approach ensures that

services are designed around people,

not organisations—delivering better

outcomes, reducing inequalities, and

building stronger relationships between

services and the populations they

serve.

How will we work at Place?

Locality Care Partnerships (LCPs) will

serve as the primary delivery

mechanism for neighbourhood-level

health and care transformation.

Embedded within the broader

framework of Integrated Care Systems

(ICSs), LCPs are designed to bring

together NHS organisations, local

authorities, voluntary and community

sector partners, and other stakeholders

to co-design and deliver services that

reflect the unique needs of local

populations.

With support from NHS Devon, each

LCP will be tasked with identifying and

establishing core priorities at the

neighbourhood level. These priorities

will be informed by population health

data, local intelligence, and community

engagement.

Where appropriate, LCPs will

collaborate across neighbourhoods to

deliver services at scale—particularly

in areas where specialist expertise,

economies of scale, or infrastructure

investment are required to ensure

sustainability and equity of access.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy45 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

To support this, a place-based estate

available assets for neighbourhood

use. This aligns with national ambitions

to repurpose underutilised NHS estate

and maximise value for money.

The 10-Year Health Plan highlights the

need for neighbourhood teams to have

access to appropriate facilities,

technology, and working environments

to deliver integrated care effectively.

Strategic capital investment will be

essential to modernise infrastructure

and support the development of

neighbourhood health centres.

Urgent care services will be

coordinated through a dual-level

approach. While urgent care response

– such as community-based crisis

teams and same-day access – will be

delivered locally within

neighbourhoods, the urgent care “front

door”, including Urgent Treatment

Centres (UTCs) and walk-in hubs, will

be strategically managed at the place

level.

This ensures consistency, efficiency,

and equitable access across the

county, in line with NHS England’s

neighbourhood health guidelines.

Innovation will be a cornerstone of

neighbourhood transformation. Each

place will hold Innovation Funds to

support the piloting of new services,

technologies, and models of care.

These funds will be accessible through

neighbourhood-led bids and will be

governed by a clear framework of

desired outcomes, including health

equity, service integration, and

sustainability.

Where pilot projects require longer-

term evaluation or development, multi-

year funding arrangements will be

considered to ensure continuity and

impact. National guidance encourages

the use of innovation funding to

support projects that are co-produced

with communities, digitally enabled,

and aligned with broader NHS priorities

such as the Net Zero Carbon Plan and

population health improvement.

Additionally, any national or regional

pilot programmes with allocated

resources will be channelled through

these local innovation funds to ensure

alignment with local strategies and

continuity of funding. This approach

reflects a broader shift in NHS policy

from centralised service delivery to

place-based, community-led

transformation.

By empowering LCPs to lead at the

neighbourhood level, supported by

strategic coordination at place, we can

build a health and care system that is

agile, inclusive, and responsive to the

needs of the people it serves.

LCP

NHS

Local

authorities

Voluntary

partners

Community

partners

Other stake

holders

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy46 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Delivering for our

communities

Mental health, learning

disabilities, and neurodiversity

Mental health services across Devon

will undergo a strategic shift—from a

predominantly bed-based model to one

that prioritises prevention, early

intervention, and recovery. This

transformation aligns with NHS

England’s national direction to move

care from hospitals into communities,

reduce reliance on inpatient beds, and

embed mental health within broader

integrated care systems.

At Place level, NHS Devon will

commission a comprehensive suite of

recovery and aftercare services

designed to support individuals

transitioning out of acute care.

These services will be co-produced

with service users and community

partners, ensuring they are responsive,

trauma-informed, and focused on long-

term wellbeing. The goal is to reduce

readmissions, promote independence,

and enable people to live well in their

communities.

Mental health will be fully integrated

into Neighbourhood services,

alongside physical health, as part of a

whole-person approach.

This includes both proactive prevention

and urgent care response, ensuring

that mental health needs are

addressed in the same way as physical

health—timely, locally, and holistically.

Clear and consistent access points to

mental health services will be

established across the county. These

will be designed to reduce

fragmentation, improve navigation, and

ensure equitable access regardless of

location or background.

Secondary prevention at Place-based

delivery will also focus on secondary

prevention, targeting early detection

and timely intervention:

• Mental Health Support Teams

(MHSTs) in schools will continue to

expand, offering evidence-based

interventions for mild-to-moderate

mental health issues, supporting

whole-school approaches, and

linking education settings with

specialist services. These teams

are a cornerstone of the NHS Long

Term Plan’s ambition to improve

access for children and young

people.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy47 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

• Annual health checks and physical

health checks for people with

Severe Mental Illness (SMI) will be

commissioned and monitored at

Place. These checks are vital for

identifying preventable conditions

early and addressing the significant

health inequalities faced by people

with SMI, whose life expectancy is

15–20 years shorter than the

general population. Checks will

include cardiovascular disease risk

assessments, metabolic screening,

and lifestyle support, with follow-up

interventions embedded into

personalised care plans.

Children and young people

At the community level, services are

designed to support children and

families through targeted, multi-agency

coordination. This tier of delivery sits

across multiple neighbourhoods and is

aligned with local authority-defined

localities and school clusters, enabling

a joined-up approach to meeting

complex needs.

Delivery at Place will focus on

commissioning and sustaining

integrated services that bring together

education, social care, community

health, and voluntary sector partners.

These services are essential for

children and young people who require

more than universal support, including

those with Special Educational Needs

and Disabilities (SEND), mental health

needs, and neurodiversity.

Multi-disciplinary teams comprising

early help practitioners, school nurses,

social workers, educational

psychologists, therapists, and

community nurses will work

collaboratively to provide coordinated

care. These teams will operate within

locality-based structures to ensure

consistency, reduce duplication, and

improve access to support.

Community-level services will include:

• Targeted support for children with

additional needs, including SEND

and neurodevelopmental

conditions.

• Community-based mental health

and therapy services, designed to

be accessible and responsive.

• Integrated locality teams, offering

wraparound support for families

through coordinated case

management.

• School-based mental health

interventions, including drop-in

clinics and early access to

psychological support.

• Data-sharing protocols to identify

and support children at risk, such

as those with poor attendance,

safeguarding concerns, or

emerging health issues.

• Partnerships with youth services

and voluntary organisations,

ensuring holistic development and

continuity of care.

Services will be commissioned and

monitored at Place, ensuring strategic

alignment, equitable access, and

consistent standards across Devon.

The aim is to reduce escalation to

statutory services, improve school

attendance and mental wellbeing, and

ensure early identification of issues.

By embedding targeted support within

communities and aligning it with local

systems, NHS Devon will reduce

health inequalities and ensure that

every child and family has access to

the right help, at the right time, in the

right setting.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy48 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Maternity

NHS Devon will commission perinatal

services that reduce health

inequalities, provide care within

communities, manage social and

medical complexity, and improve

outcomes for the most vulnerable.

Services designed to be holistic,

accessible, and person-centred and

recognise the profound impact of social

determinants on maternal and infant

health and work to address systemic

barriers that disproportionately affect

marginalised populations.

At their core, these services will be

community-based and culturally

responsive, ensuring care is delivered

in local settings that are familiar and

trusted by those who use them.

By co-locating services within

community hubs, outreach centres, or

via home visits, care will become more

accessible to underserved groups,

including ethnic minorities, refugees,

young parents, and those experiencing

poverty, trauma, or unstable housing.

To manage social and medical

complexity, multidisciplinary teams;

including midwives, obstetricians,

mental health professionals, social

workers, and community health

advocates will collaborate seamlessly.

These teams will identify and respond

to multiple needs early, offering

personalised care plans that integrate

clinical treatment with social support,

safeguarding, and mental health

interventions.

Importantly, these services will adopt a

data-driven approach to monitor

disparities and evaluate outcomes,

ensuring that interventions are tailored

and targeted. Community voices,

especially those with lived experience,

will be embedded into service design

and delivery, ensuring care is not only

for communities, but with them.

Through these approaches, perinatal

services will work to close the gap in

health outcomes, improve maternal

and infant wellbeing, and provide

dignified, respectful care that

empowers all families, especially those

facing the greatest challenge.

How will this feel different for

our patients

• People will receive the same level

of service regardless of which

urgent care centre they attend

• People with mental health needs

will be supported to remain in their

community instead of in inpatient

services

• People will be able to access

innovative services earlier without

risk that funding gets pulled based

on the annual funding cycle

• Children will be supported to

maintain social and educational

requirements alongside delivery of

interventions for health needs

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy49 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Care within specialist

settings

Specialist settings deliver interventions

that cannot be provided in the

community. This includes physical and

mental health hospitals delivering

acute care such as:

• University Hospital Plymouth

• Royal Devon and Exeter Hospital

• North Devon District Hospital

• Torbay Hospital

• Mental health facilities provide a

range of care from single-sex

mental health hospitals, acute care

and medium – low secure services:

o Wonford House (Exeter)

o Torbay Mental Health Unit

(Torquay)

o Glenbourne (Plymouth)

o Langdon Hospital (Dawlish)

o Lee Mill

o Franklyn Hospital (Exeter)

o The Moorings

o Plymbridge House

Delivering care within

specialist settings

Care within specialist settings is high

costs and requires scarce clinical

resource. Distribution of this resource

too widely can risk reducing quality of

care through unsustainable and

inefficient services. Devon will embed

not only the new model of delivery but

also enable the shift from acute to

community. Options for consolidating

some services onto fewer sites where

it is safe and makes sense to do so will

also be considered.

The level of specialisation of staff

within acute settings can lead to a false

assumption of greater skill and that

specialist centres are a better place to

receive care.

In most cases, better outcomes can be

achieved within Neighbourhoods.

However, for those that need

specialised resource and especially

bedded care (for physical or mental

health needs), the only place this can

be delivered is within one of our acute

hospitals and other bedded settings.

To establish what activity needs to be

delivered within a specialist setting, a

value-based commissioning review of

all specialities will need to be

undertaken to establish:

• Activity that can stop

• Activity that can be transferred to

Neighbourhoods

• Activity for which there needs to be

a transformed model

How will this feel different for our

patients

• Stays in hospital will be shorter and more

services will be provided closer to home.

• People may need to travel further to

access services if they are delivered on

fewer sites. The quality of the service will

increase as specialist resource is

consolidated, and people will wait less

time for an intervention.

• Those who have an emergency care

need will have this addressed sooner.

Those with emergency care needs will be

addressed sooner.

• People will experience a seamless

handover between organisations

• People will experience a seamless

handover between organisations.

• People will be seen by the right service

and professional for their need,

irrespective of the hospital site that they

are on People will be seen by the right

service and professional to meet their

need, irrespective of the hospital site

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy50 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Making it happen

To deliver NHS Devon’s Health and

Care Strategy, we will establish a

coordinated and outcome-driven

delivery framework that aligns system

leadership, operational planning, and

local implementation.

The initial priority will be to embed the

new model of delivery, with a particular

focus on the development and

mobilisation of Neighbourhood teams

as the core delivery vehicle for

integrated, person-centred care.

This will be supported by a robust

success framework, which defines

clear outcomes across strategic

priorities such as improved population

health, reduced inequalities, enhanced

access and experience, and financial

sustainability.

These outcomes will be tracked

through a transparent performance

dashboard, enabling continuous

learning, accountability, and system-

wide alignment.

Delivery will be enabled by a suite of

supporting plans including

organisational structure, culture, teams

and partners, empowering patients and

citizens, digital transformation, estates,

finance, and ongoing engagement

ensuring the system has the capacity,

capability, and infrastructure to

implement change.

We will adopt a life-course approach to

service design, ensuring that care is

responsive to the needs of people at

every stage of life.

Governance will be streamlined to

support agile decision-making, with

neighbourhood teams, place-based

partnerships, and system-level boards

working in alignment.

Success measures

framework

Devon’s Health and Care Strategy will

deliver meaningful and lasting change,

and this change needs to be monitored

through a clear set of outcomes and

measures.

These will help us understand whether

we are improving health and wellbeing,

reducing inequalities, and building a

more integrated, sustainable system.

Aligned with the Model ICB Blueprint,

NHS Devon will act as a system

convenor, architect, and steward

moving from transactional oversight to

transformational, strategic leadership.

This approach will guide the future

development of healthcare services to

meet the needs of our residents, which

will be reflected in our commissioning

intentions paving the way for the ‘left

shift’ is service delivery and in how we

allocate resources and measure

success.

The success measures framework has

been developed collaboratively through

extensive engagement during the

Design phase, ensuring it reflects the

priorities, insights, and aspirations of

all stakeholders involved.

This framework outlines the key

outcomes we aim to achieve and the

metrics by which progress will be

measured. It serves not only as a tool

for accountability, but also as a guide

for continuous improvement, helping

us to track impact, celebrate

successes, and identify areas for

further development.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy51 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Working with our partners, we will use Population Health Management approaches to

establish a life-cycle delivery approach

Take a Neighbourhood-first approach

• Ensure an equal voice for decision, design and delivery for the voluntary

sector, local authority and community partners in line with the shift ‘From

Hospital to Community’

• Develop an inclusive approach to digitally enabled care to make sure it

can expand neighbourhood capacity and enhance local capabilities

• Use patient access and demand insights to better plan specialist care

across neighbourhood, place and secondary/tertiary for optimal outcomes

Embed a focus on equity and prevention

• Reduce inequity to narrow gaps in health outcomes between the most

and least advantaged communities

• Improve access to care for underserved groups, including rural, coastal,

and deprived populations

• Increase uptake of preventative services in areas of greatest need and

focused on local disease profiles to shift ‘From Sickness to Prevention’

Improve health and wellbeing outcomes

• Provide accessible and equitable universal services including vaccination

and screening programmes

• Enable and evidence joined-up working across health, care and

voluntary sectors to deliver ‘whole person’ care

Co-design and co-deliver accessible, joined care

• Increased delivery of care through a neighbourhood and place-based

model to enable the shift ‘From Hospital to Community’

• Drive up consistent use of personalised care plans and shared decision-

making in line with national goals

• Improved navigation and continuity of care across services

Strong, consistent leadership

• Clearly define compassionate working and leadership/management process

• Develop a shared purpose that can underpin all planning, delivery and

evaluation approaches

• Shift from transactional management to transformational leadership in line

with the three shifts of the 10 Year Plan

A culture of collective responsibility

• Establish a positive culture; behaving, communicating, acting collaboratively

for our communities

• Build a system-wide joint workforce plan to build the right competences

within a health and social care setting

• Commit to a real ‘no blame’ transparent culture with ‘bridge’ relationships

dedicated to fostering collaboration

Ensure financial and operational sustainability

Ensure Financial and Operational Sustainability

• Deliver care within the system’s financial envelope

• Reduce unwarranted variation and duplication of services

• Improve productivity and value for money across the system

• Rebalance financials based on need and equity

Support workforce resilience and a shared culture

Support Workforce Resilience and a Shared Culture

• Take a deliberate and robust approach to shifting our culture, reducing

organisational barriers, and placing patients at the heart of delivery

• Improve recruitment, retention, and staff wellbeing

• Expand roles and training to support new models of care

• Double down on collective leadership, collaboration, and organisational

culture development

Innovate for digital and infrastructure transformation

Innovate for Digital and Infrastructure Transformation

• Increase use of digital tools to support access, self-management, and

remote care, shifting ‘From Analogue to Digital’

• Reduce service disruption due to estate or IT failures

• Investment in modern, fit-for-purpose facilities and technology

Ensure quality across everything we do

• Embed a transparent and consistent impact assessment process in

decision-making across and between system partners

• Support the most vulnerable in our populations with a robust system-wide

safeguarding approach

• Define quantitative and qualitative outcomes and measures at the start of

all service (re)design to enable honest evaluation

Embrace a value-based care approach

• Define and account for value through multiple lenses including person-

centred and population health outcomes, financial balance, responsible

resource and estate planning

• Develop an evidence-based framework that commits to changing or

stopping investment when anticipated value is not realised

Clear governance and accountability

• Develop relationships built on strong foundations of trust to support the

shift ‘From Hospital to Community’

• Ensure clarity on where decisions are made, by whom, and how

• Establish risk management approaches to recognise and reward

innovation without compromise on quality and safety

Success Measures

Framework

Sustainable

Quality &

value

People-

centred

Acessible to

all

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy52 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Tracking progress and

delivering outcomes

We have developed desired

outcomes and associated metrics

that form the foundation for how we

monitor and evaluate progress

throughout the lifecycle of the

Strategy in line with our success

framework. It not only identifies the

key outcomes we aim to achieve but

also sets out the metrics that will

help us assess whether we are on

track and delivering meaningful

change.

Crucially, it enables us to monitor

the impact of our new model of care

delivery, ensuring that the changes

we expect—across population

health, service quality, equity, and

system sustainability—are being

realised.

To ensure these measures are both

actionable and reflective of system-

wide impact, we will adopt a balanced

approach that includes:

• Quantitative indicators – such as

waiting times, admission rates, and

workforce data to provide a clear

and objective view of system

performance.

• Qualitative feedback – including

lived experience, staff insights, and

community engagement – to

capture the human impact and

ensure our work reflects what

matters most to people.

• Regular reporting – to system

partners, stakeholders, and the

public, supporting transparency,

shared accountability, and

continuous dialogue.

• Independent evaluation – to

validate outcomes, assess the

effectiveness of our interventions,

and inform ongoing learning and

improvement.

These metrics are dynamic and will

evolve as the Strategy is implemented,

enabling us to remain responsive to

emerging needs, challenges, and

opportunities.

By embedding this monitoring

framework into our governance and

delivery structures, we are committing

to a culture of openness, learning, and

accountability—ensuring that our

collective efforts lead to a healthier,

fairer Devon for all.

This approach complements, rather

than replaces, the system’s ongoing

responsibilities to meet national and

local requirements under business-as-

usual operations.

Alongside the transformative ambitions

of the Strategy, providers are expected

to continue delivering all mandated

operating plan targets and pursue

internal improvement programmes as

part of their core functions. They

should:

• Meet the requirements set out in

the national operating planning

guidance

• Meet the requirements set out in

the national elective reform plan

• Meet the requirements set out in

the national Urgent and Emergency

Care plan

• Deliver within the context of the

national 10 Year Health Plan

• Deliver within the context of the

national neighbourhood health plan

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy53 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

High level-outcomes

Metric

• Take a

Neighbourhood-

first approach

• Embed a focus on

equity and

prevention

• Improve health and

wellbeing outcomes

• Access and navigation

• % urgent care demand met

same day

• Digital triage success rate

• Access equity for

Core20PLUS5+

populations

• Social prescribing uptake

• Caseload coverage

• Anticipatory care plan

completion

• Personalised Care Plan

completion

• Elective waiting times

(referral to treatment (RTT)

compliance)

• A&E 4-hour target

performance

• Referral to treatment (RTT)

metrics

• Length of stay (LoS)

• Bed occupancy rates

High Level-Outcomes

Metric

• Ensure financial and

operational sustainability

• Support workforce

resilience and a shared

culture

• Innovate for digital and

infrastructure

transformation

• % of GP practices connected to

Shared Care Record (SCR)

• Digital maturity index scores

• % of staff using integrated digital

systems (e.g. Devon and Cornwall

Care Record (DCCR)

• Data sharing compliance (GDPR

readiness)

• Use of AI and advanced analytics in

care pathways

• Utilisation rate of estate (clinical and

non-clinical)

• % of estate meeting functional

suitability standards

• Carbon footprint and energy efficiency

of estate

• Staff survey results (engagement,

morale, safety culture)

• Sickness absence rates

• Vacancy rates and turnover

• Workforce equality metrics (e.g.

WRES, WDES)

• Training uptake and continued

professional development (CPD)

participation

• Governance maturity assessments

• Annual ICB statutory assessment

results

• Financial performance (surplus/deficit)

Domain: Accessible to all

Domain: Sustainable

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy54 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Domain: Quality and value

High level-outcomes

Metric

• Ensure quality across

everything we do

• Embrace a value-based

care approach

• Develop clear

governance and

accountability

processes

• Cross-sector

multidisciplinary team

(MDT) participation

• Rotational staff roles

established

• Referral response

times across sector

• % of contracts with

outcome-based

commissioning

• % of pooled budgets

across system partners

Level-Outcomes

Metric

• Co-design and

co-deliver

accessible,

joined care

• Enable a

strong,

consistent

leadership

• Create a

culture of

collective

responsibility

• Home discharge rate from recovery

pathways

• Readmission within 30 days

• Friends and Family Test (FFT) scores

• Patient experience survey results

• Complaints and compliments data

• Carer-reported experience measures

• Patient Activation Measure (PAM)

scores

• Smoking prevalence, obesity rates,

alcohol-related admissions

• Vaccination coverage (e.g. flu, COVID-

19)

• Screening uptake (e.g. cervical, bowel,

breast)

• % of budget allocated to prevention

• Population health management (PHM)

indicators

• Avoidable mortality rates

• Health-related quality of life for people

with long-term conditions

• Emergency readmission rates within 30

days

• Patient-reported outcome measures

(PROMs)

• Life expectancy at birth and at 75

• Early cancer diagnosis rates

Hospital Standardised Mortality Ratio

(HSMR

Domain: People-centred

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy55 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Enabling plans

Empowering patients and

citizens

Through a focus on citizen and patient

engagement, we will co-develop a

community contract that clearly

outlines mutual roles and

responsibilities, fostering shared

ownership of health outcomes.

A new Engagement Framework will be

launched to strengthen how we listen,

involve, and respond to our

communities, supported by enhanced

training for staff in patient

communication and engagement.

We will also audit and improve our

communication methods to ensure

they are inclusive, accessible, and

effective. In parallel, our

Neighbourhood Shift approach will see

the creation of a ‘Patient Partnership’

plan to guide the transition of services

into community settings, ensuring that

changes are co-designed and

responsive to local needs.

A dedicated workforce transition plan

will support staff through these

changes, enabling a smooth and

sustainable shift in how care is

delivered.

• Co-develop a Community

Contract Engage citizens and

patients in structured dialogue to

define mutual roles, responsibilities,

and expectations around health and

care.

• Launch a new Engagement

Framework Establish clear

principles, processes, and tools for

listening, involving, and responding

to community voices across all

service areas.

• Develop a ‘Patient Partnership’

Plan Co-design service transition

plans with communities to ensure

local relevance, responsiveness,

and sustainability.

• Implement a Workforce

Transition Plan Support staff

through the shift to community-

based care with tailored guidance,

role clarity, and change

management support.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy56 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Culture, teams and partners

Creating a thriving, collaborative

culture across our health and care

system is essential to delivering

meaningful change.

Under the workforce planning strand,

we will develop a system-wide, skills-

based workforce plan with a five-year

horizon, ensuring we have the right

capabilities in place to meet future

needs.

We will also reignite the Staff Passport

initiative to enable greater cross-site

mobility and flexibility, supporting

integrated working.

Through a comprehensive review of

organisational development (OD) and

training, we will establish Strategic

Education Groups to provide

governance and oversight to create a

unified training and leadership

development plan that reflects shared

priorities.

A collective training purchasing

strategy will help maximise value and

consistency across the system. At the

leadership level, we will strengthen

alignment and collaboration through

the development of a Committee in

Common across statutory and partner

boards to deliver joint executive

training with a focus on compassionate

leadership, ensuring our leaders are

equipped to guide transformation with

empathy and purpose.

• Develop a system-wide, skills-

based workforce plan Create a

five-year roadmap that aligns

workforce capabilities with future

service needs across the health

and care system.

• Reignite the Staff Passport

initiative

• Establish multi-agency

agreements to enable this plan

• Create a Unified Training &

Leadership Development Plan

Design a shared curriculum that

reflects system-wide priorities and

supports consistent professional

growth.

• Deliver Joint Executive Training

in Compassionate Leadership

Equip senior leaders with the skills

to lead transformation with

empathy, purpose, and system-

wide perspective.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy57 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Enabling functions

Digital and data

Harnessing the power of digital

innovation and data intelligence is vital

to transforming health and care

delivery across our system.

We will enhance the Devon and

Cornwall Shared Care Record (DCCR)

to support outcomes-based planning

and enable clustering across the

Peninsula, laying the groundwork for a

single Shared Care Record that

facilitates seamless, person-centred

care.

A unified Information Governance (IG)

approach will be developed, including

a sign-up strategy for GP practices and

a shared policy and leadership

structure across Devon and Cornwall,

ensuring trust, transparency, and

compliance.

Crucially, we will capture the patient

voice to guide how data and digital

tools are integrated into care.

Through the development of a

Common Technical Infrastructure

(CTI), we will enable cross-border

working and interoperability across the

Peninsula.

Our approach to Artificial Intelligence

(AI) will prioritise staff engagement,

training, and early evaluation of return

on investment.

Finally, we will co-develop Digital

Inclusion plans with VCSEs, local

authorities, and ICS partners to

address barriers to access and ensure

that no one is left behind in the digital

transformation.

• System wide data sharing

Patient information will be shared

with those who need access from

different health, care and VCSE

settings using a unified platform.

• A unified Information

Governance (IG) approach will be

developed, including a sign-up

strategy for GP practices and a

shared policy and leadership

structure across Devon and

Cornwall.

• Standardised and unified

infrastructure Development of a

single data management and

reporting architecture by the

system-wide business intelligence

(BI) shared service.

• Shared EPR and operational

systems The implementation of a

single Electronic Patient Record

(EPR) across all Devon acute

hospitals and the Devon and

Cornwall Care Record (DCCR) will

continue to be the shared care

record for sharing patient

information across health and care

settings.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy58 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Organisational structure

A coherent and agile organisational

structure is essential to delivering

integrated, neighbourhood-focused

care.

We will begin with a comprehensive

pan-system review of structures across

NHS organisations and partners to

identify opportunities for alignment,

simplification, and improved

collaboration.

Using business intelligence (BI) and

Population Health Management (PHM)

insights, we will support the strategic

Neighbourhood ‘Left Shift’, enabling

services to move closer to

communities and better reflect local

needs. This will be shaped in

partnership with VCSE and community

experts to define tailored

neighbourhood offers.

To support understanding and

engagement, a targeted Change

Communications plan will be

developed to clearly explain structural

changes and their benefits to staff,

partners, and the public.

Finally, we will establish a Whole

System Planning approach, including a

system-wide structure and training plan

underpinned by co-designed metrics,

ensuring that transformation is

measurable, inclusive, and

sustainable.

• Leverage BI and PHM Insights to

guide service shift Use data-

driven intelligence to support the

strategic ‘Left Shift’ of services into

community settings, tailored to local

population needs.

• Workforce plan.

• Incorporate a detailed system

workforce plan that support

neighbourhood and place

development.

• Co-design metrics to measure

transformation Develop inclusive,

meaningful indicators to track

progress, impact, and sustainability

of structural changes

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy59 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Estate and infrastructure

Modernising our estate and

infrastructure is key to enabling care

that is accessible, integrated, and

future ready.

In community services, we will design

place-based estate models that reflect

local needs and support virtual care

through mapped digital infrastructure.

Asset consolidation will continue to

ensure efficient use of resources, while

a hub-and-spoke model will be

developed around 5–6 strategically

located community hubs to anchor

neighbourhood care.

For primary care, we will review estate

quality and develop a Primary Care

Network (PCN) estate plan, alongside

exploring new funding models and

NHS ownership options to secure long-

term sustainability.

Within acute services, we will maintain

a steady-state approach to existing

estate, while planning for service

consolidation.

Future ward design—including virtual

wards—will be co-led by digital and

data teams to ensure alignment with

technological capabilities.

A dedicated funding plan will be

developed to support the reduction of

outpatient activity, enabling a shift

toward more proactive and community-

based care.

• Design place-based estate models

• These models will inform the

development and infrastructure to

deliver services at place and in the

most appropriate setting

• Map digital infrastructure for virtual

estates planning

• Develop hub and spoke model

• Continue asset consolidation

Funding model

Transforming how we fund, and

resource care is critical to enabling a

shift from reactive to proactive,

community-based services.

We will plan for a strategic resource

shift from acute to community settings,

addressing key challenges such as

capital versus revenue funding to

ensure financial sustainability.

We will develop delegated budgets for

Integrated Neighbourhood Teams,

empowering local decision-making and

fostering accountability.

A comprehensive contract review will

extend contract durations and embed

outcomes-based commissioning,

aligning incentives with population

health goals.

In parallel, we will undertake a

strategic commissioning review to

assess statutory funding flows and

evaluate the role of block contracts in

supporting system-wide priorities.

We will create a Population Health

Management (PHM)-informed funding

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy60 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

model for preventative care, ensuring

that investment is targeted where it can

have the greatest long-term impact on

health and wellbeing.

The next phase of this work will focus

on collaboration with relevant teams

and stakeholders across the system to

co-develop and implement each of the

six enabling plans.

This will ensure that the plans are fully

aligned with our overarching health

and care strategy, grounded in

operational realities, and shaped by

the expertise and insight of those

delivering and receiving care.

Through inclusive engagement, clear

governance, and phased delivery, we

will translate strategic intent into

meaningful, system-wide change.

We will design a fair and equitable

funding model that is:

o Fair

o Based on outcomes

o Provides equity

o Incorporates deprivation and

protected characteristics

o Aligned to contractual

models

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy61 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Looking forward

As NHS Devon moves into the delivery

phase of this strategy, we reaffirm our

commitment to working in genuine

partnership with our communities,

providers, and system partners.

This is not just a principle it is a

foundational approach embedded in

our People and Communities

Framework, which sets out a system-

wide ambition to ensure that every

voice, especially those from

marginalised and Core20PLUS5

communities, is heard and influences

decision-making.

Through the Devon Engagement

Partnership (DEP), we will continue to

nurture inclusive, coordinated, and

transparent relationships. The DEP

provides the governance and

assurance that our system is

meaningfully listening to and working

with people and communities.

Engagement will be continuous,

visible, and aligned to the four aims of

the Integrated Care System—

improving outcomes, tackling

inequalities, enhancing value, and

supporting broader social and

economic development.

In parallel, we are implementing

a renewed contract management

framework, as outlined in our contract

management approach blueprint. This

framework introduces a structured,

risk-based model for oversight and

collaboration with NHS providers.

Key features include:

• Monthly contract review meetings

(CRMs) chaired by senior ICB

executives, providing a formal

platform to monitor performance,

quality, finance, and risk.

• Joint technical working groups

(JTWGs) that underpin CRMs with

detailed analysis of activity,

referrals, waiting times, and financial

impacts.

• A delivery management report

(DMR) and Power BI dashboards to

ensure a single version of the truth

across the system.

• Clear governance and escalation

routes to ensure accountability and

alignment with strategic

commissioning intentions.

This approach is designed to be

proportionate, transparent, and

focused on continuous improvement. It

supports the development of

commissioning intentions, service

transformation, and financial

sustainability, while ensuring that

patient safety and experience remain

central to all discussions.

Evaluation and learning will be

embedded at every stage. We will use

structured reporting, action tracking,

and feedback loops to assess impact,

adapt our approach, and ensure that

our strategy remains responsive to the

needs of our population. This includes

formal reporting into NHS Devon’s

governance structures and assurance

committees, and alignment with

national planning and oversight

frameworks.

Together, through inclusive

engagement, robust contract oversight,

and a culture of learning, we will

deliver a strategy that is ambitious,

accountable, and rooted in the lived

experiences of the people we serve.

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy62 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Tab 1 Item 3.2 - NHS Devon Health and Care Strategy63 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

South West Peninsula Green Plan 2025-2030

Our Strategy towards Net Zero

October 2025

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh64 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Contents

Foreword………………………………………………………………………………………………………………………………………………………………………………………………………………………………….........................................................

About us……………………………………………………………………………………………………………….…………………………………………………………………………………………………………………………………………………………………………

Introducon…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Naonal Strategic and Local Context ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Developing a Joint Green Plan ……………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………….

Working together as a system……………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………..

What are we seeking to achieve?………………………………………………………………………..…………………………………………………………………………………………………………………………………………………………………..

Areas of focus……………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………………………………....

Workforce and System Leadership……………………………………………………………………………………………………………………………………………………………………………………………………………………………….

Digital Transformaon……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Care Model Transformaon…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Medicines……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Primary Care………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….…….

Travel and Transport…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Estates and Facilies…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Supply Chain and Procurement……………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Food and Nutrion……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……

Adaptaon………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….………..

Prevenon and Health Creaon……………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Social Value and Anchor Instuons……………………………………………………………………………………………………………………………………………………………………………………………………………………………

Governance and Accountability………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………..

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh65 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Foreword

Climate change presents an immediate and growing threat to health. The UK is already experiencing more frequent and severe floods and heatwaves, as well as

worsening air pollution. Up to 38,000 deaths a year are associated with air pollution alone, disproportionately affecting the most deprived and further exacerbating

health inequalities. The impact of climate change will also be expensive for society and the NHS, with the costs of heat-related mortalities from climate change

estimated at £6.8 billion per year in the 2020s, rising to £14.7 billion per year in the 2050s.

Conversely, action to tackle climate change brings direct benefits for public health, health equity and taxpayers. Reducing the NHS’s environmental impact will help

to build an NHS fit for the future that provides world-leading healthcare and supports the government’s mission to make Britain a clean energy superpower,

including through:

• supporting high-quality, preventative and low-carbon care, in line with the NHS’s goal to boost out-of-hospital and digitally enabled care, improve prevention

of ill health and reduce health inequalities

• reducing air pollution by decarbonising the NHS fleet, which is set to save the NHS over £59 million every year and deliver a range of health benefits valued at

over £270 million.

• modernising and decarbonising the NHS estate, which is expected to reduce energy costs while creating a better environment for both patient care and staff

wellbeing

• minimising waste through circularity – where reusable, remanufactured or recycled solutions are used – which is often cost-saving and helps protect against

external supply disruptions

As part of the NHS, the South West Peninsula Integrated Care System Cluster must play its part in reducing the environmental impact and carbon footprint of their

operations. To protect the health of people in the South West Peninsula we must:

• limit our contribution to the climate crisis, reducing carbon emissions and damage to our environment

• prepare for and build resilience to respond to increasingly more extreme weather patterns

• invest in keeping people healthy to reduce preventable diseases, improve the general health of our people and communities, and reduce the demand for

healthcare

By reducing emissions, improving air quality, and creating greener, more resilient communities, the cluster will not only meet its Net Zero targets but also reduce

preventable illness, improve health equity, and deliver better value for money. This is not just about meeting statutory targets, it is about shaping a healthier, fairer,

and more sustainable future for the people of Cornwall, Devon and the Isles of Scilly.

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh66 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

About us

Devon

Devon is the fourth largest county in England with a diverse and growing population at currently just over 1.2 million. It includes the cities of Plymouth and Exeter,

more than 45 towns – both rural and urban – and several hundred parishes. The Devon ICS is a partnership of health and social care organisations working together

with local communities across Devon, Plymouth and Torbay. Through working together, it aims to transform health and care services, so they are clinically, socially

and financially sustainable.

Delivering a plan that meets the needs of the populations across Devon requires the partnership of health and care organisations across the county: NHS Trusts and

Integrated Care Boards, local authorities, GPs and primary care colleagues, voluntary and independent sector partners, can only provide the type of care that people

really need by working together.

Figure 1: Map of Devon and the 5 Local Care Partnerships

The health and social care organisations involved in the Integrated Care System

for Devon (ICS) are:

•NHS Devon Integrated Care Board, operating as a South West peninsula

cluster with Cornwall and Isles of Scilly ICB

•University Hospitals Plymouth NHS Trust (UHP)

•Royal Devon University NHS Foundation Trust (RDU)

•Torbay and South Devon NHS Foundation Trust (TSD)

•South Western Ambulance Service NHS Foundation Trust (SWAST)

•Devon Partnership NHS Trust (DPT)

•Five Local Care Partnerships which contain approximately 130 GP practices

•Devon County Council

•Plymouth City Council

•Torbay Council

•Livewell Southwest

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh67 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

About us

Cornwall and the Isles of Scilly

Cornwall and the Isles of Scilly are unique in their respective geographies. Healthcare access is a challenge within our ICS and infrastructure – the county has no

motorway, comprehensive rail, or consistent rural bus routes. The Isles of Scilly are separated by 25 miles of sea which is uncrossable in unfavourable weather

conditions. Care needs in our system are complex and becoming increasingly so as our population is ageing and seeing an increase in co-morbidities. Our geography

creates distinct and intersecting patterns of coastal, rural and urban deprivation, each associated with their own access and healthcare challenges. Our communities

include those in the 20% most deprived across England and, as we are a peninsula, are uniquely at risk to the effects of climate change.

The system consists of three Integrated Care Areas (ICAs), the North and East, Central, and West (also incorporates the Isles of Scilly) which serve populations of circa

150,000-200,000, making local decisions to address the specific local need.

Our system is a collaborative of various health, community, and voluntary sector organisations, and local

authorities. These partners are organised to work together to ensure we can deliver all aspects of care to an

excellent standard for our patients. The Integrated Care System for Cornwall and Isles of Scilly (ICS) is

comprised of:

• Cornwall and Isles of Scilly Integrated Care Board (ICB), operating as a South West Peninsula cluster

with Devon ICB

• Royal Cornwall Hospitals Trust (RCHT) – providing acute care

• University Hospitals Plymouth NHS Trust – providing both

• Cornwall Partnership Foundation Trust – providing mental health and community services

• 55 General Practices (GPs) practices plus dentistry, ophthalmology, community pharmacy services

and Community Hubs

• Cornwall Voluntary and Community Sector (VCSE).

• Cornwall Council

• The Council of the Isles of Scilly

• South Western Ambulance Service NHS Foundation Trust (SWAST)

Figure 2: Map of Cornwall and the Isles of Scilly 3 Integrated

Care areas

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh68 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Introducon

A Net Zero NHS

In England, the NHS is estimated to account for 5.4% of the country’s greenhouse gas emissions. The health and social care system reduced its carbon footprint by an

estimated 62% between 1990-2020, however, drastic action is now required. In October 2020, the Greener NHS Programme published its strategy, Delivering a Net

Zero National Health Service. This report highlighted that left unabated, climate change will disrupt care, resulting in poor environmental health contributing to

major diseases such as cardiac problems, asthma and cancer. The strategy sets out the key targets and actions required for the NHS to reach Net Zero carbon

emissions as outlined below. The NHS must decrease its carbon footprint by approximately 15% per year, year on year, if we are to achieve the target of 80%

reduction by 2028-2032. Figures 3 and 4 illustrate the key areas of focus that the NHS must deliver on to reduce its carbon footprint.

For the emissions we control directly (NHS Carbon Footprint), Net Zero by

2040, with an ambition to reach an 80% reduction (from 1990 levels) by 2028

to 2032.

For the emissions we can influence (NHS Carbon Footprint Plus), Net Zero by

2045, with an ambition to reach an 80% reduction (from 1990 levels) by 2036

to 2039.

Figure 3: Greenhouse Gas Protocols (GHGP) scopes in the context

of the NHS

Figure 4: Sources of carbon emissions by proportion of NHS

Carbon Footprint Plus

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh69 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Naonal strategic context

The Darzi report highlights: “Given the global health imperatives, the NHS must stick to its Net Zero ambitions. There is no trade-off between climate responsibilities

and reducing waiting lists.” Following the Darzi report, the recently released 10-Year Plan for the NHS reconfirms the NHS’s commitment to Net Zero, and describes

three major shifts in the way we deliver care required to transform the NHS into a health service that is fit for the future:

• From hospital to community - moving care from hospitals to communities, creating a ‘Neighbourhood Health Service’, accessibly designed

• From analogue to digital - making better use of technology, harnessing the digital revolution to create the most digitally accessible health system in the

world, whilst carefully mitigating against digital exclusion

• From illness to prevention - focusing on preventing sickness, not just treating it and empowering people to make healthy choices

Maximising the opportunities to build a more sustainable healthcare system through these three big shifts is essential if we are going to maintain and improve

patient care now and in the future. At the same time, delivering on these priorities will not only help us to achieve positive transformative change for health and care

services, but also for the environment.

Local strategic context

Devon

In 2022, the One Devon partnership was formed, which is a collaboration of the NHS and local councils, as well as a wide range of other organisations like the

voluntary sector, who are working together to improve the lives of people in Devon, to better support people living with multiple and long term conditions, prevent

illness, tackle variation in care and deliver joined up services while getting maximum impact for every pound spent. Its vision is: “Equal chances for everyone in Devon

to lead long, happy and healthy lives” and its route to achieving this is set out in the Devon Long Term Plan and Joint Forward Plan. The One Devon partnership brings

together NHS organisations, local authorities, and the voluntary sector to improve the lives and health of people in Devon as well as progress shared carbon

reduction goals.

Cornwall and the Isles of Scilly

In Cornwall and the Isles of Scilly, the ICS has worked collaboratively across the NHS, local authority and Cornwall Voluntary and Community Sector (VCSE) to align

health and climate strategies, ensuring that health creation, nature recovery, and climate resilience are embedded in system-wide planning. The local strategic

framework for improving health outcome is set out in their Health and Wellbeing Strategy and NHS Joint Forward Plan. Its vision is: “Connected, healthy, caring

communities for One and All”. These plans shift focus towards prevention through keeping people healthy and well in our communities throughout each stage of

their lives. These are systemic shifts in the way we deliver care so acting as a system and focussing our plans on where we can have the most impact is essential.

Successfully supporting this transition will support wider Net Zero goals.

These local strategies align in their shared purpose to create healthier, more inclusive and greener communities across the South West Peninsula.

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh70 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Developing a joint South West Peninsula Green Plan

In early 2022, the first Devon and Cornwall and the Isles of Scilly (CIOS) Green Plans were published, setting the strategic direction for reducing the NHS's

environmental impact and achieving Net Zero in line with the Greener NHS programme. NHS England published new national guidance in February 2025 which

outlines a requirement to refresh our green plans. This has given us the opportunity to incorporate local and national policy changes that have been introduced over

the last three years.

Reflecting broader changes in the NHS and encouraging closer collaboration across Integrated Care Systems, Devon and CIOS Green Plans have been consolidated

into one joint plan moving forward. This refreshed Green Plan builds on our joint strategic objectives and the great work already underway in primary care, trusts,

local authorities and other key non-NHS partners across Cornwall, Devon and the Isles of Scilly.

The purpose of this document is to outline how we will contribute to the NHS’s overall goal of becoming Net Zero carbon emissions. It sets out the strategic

framework for local action to reduce the environmental impact of our healthcare services and outlines some key system-level actions that will help us to support

progress.

The key focus areas for action outlined in this plan follow Greener NHS guidance and have been further developed in partnership with NHS organisations across the

peninsula through engagement via our existing collaboration and governance arrangements such as the CIOS Climate Collaboration and Devon Sustainability groups.

This plan ensures that all South West Peninsula NHS organisations have increased awareness, knowledge of, and understanding of our objectives and responsibilities,

sharing our impact in reducing carbon emissions produced by our activity.

As a high-level, evolving document, the Green Plan will adapt over time. As the functions of the ICBs become clearer and work programmes mature, the areas of

focus of this Green Plan will be further developed with the aim that sustainability is embedded into business as usual across the health system.

This document aims to outline our overall strategic intention as a peninsula. However, more detailed delivery plans and actions will need to be developed at local

and organisational level to deliver against the overall ambitions aligned with wider system priorities in the local areas as they develop.

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh71 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Working together as a health and care system

For us to achieve the ambitions and objectives of a Net Zero NHS, collaboration across multiple disciplines is crucial for success. This includes within the NHS, but also

working with key stakeholders, strategic partners, public and VCSE sector organisations, local communities and suppliers. Building on the strengths of both systems,

we will continue a collaborative, cross-sector approach to sustainability which will be underpinned by:

• Clear governance and accountability structures, including board-member Net Zero leads and sustainability leads across partner organisations.

• System-wide assurance processes to track progress against Green Plan actions and ensure clear ownership.

• Collaborative working through forums such as through expanding our existing CIOS Climate Collaboration and Devon Sustainability Groups into a South West

Peninsula meeting with a joint chair.

• Identifying funding opportunities to drive action, for example through government schemes, application to the National Institute for Health and Care

Institute (NIHR) Decarbonising the health and social care system fund and other grants as they become available.

Our role as strategic commissioners

The ICBs are responsible for commissioning health and care services to meet the needs of our population. We have an important role in transforming our local health

and care systems to improve the health and lives of our local community, now and in the future. We therefore have an opportunity to leverage our roles as strategic

commissioners to shape a future where care is more joined-up, equitable, preventative, and environmentally sustainable.

We will use our commissioning powers to embed sustainability and health creation priorities into every stage of service planning and delivery. This includes:

• embedding sustainability that is accessible into service design, procurement and contract oversight, ensuring that commissioned services actively contribute

to carbon pollution reduction, progressively increasing our ability to adapt to climate impacts, and embed social value.

• aligning Green Plan priorities with broader system strategies, ensuring that sustainability is a core principle of health system transformation.

• engaging with patients and staff to understand what is important to them and embed this into our plans and strategies.

• ensuring a continued focus on health creation, neighbourhood health and the 3 strategic shifts described in the 10 Year health plan, as we plan and allocate

resources within our financial envelope for the benefit of our communities and the environment.

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh72 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Supporng our partner trusts

Our NHS hospital, community and mental health care providers have made great strides in delivering towards our joint Net Zero ambitions. NHS South West

Peninsula Integrated Care Board Cluster will support all our partner trusts in the delivery of their green plan objectives and overseeing progress against the actions

and targets in this strategy across the peninsula. In future, this will be supported through a joint South West Peninsula Sustainability Group Meeting which will

provide a forum to share best practice, encourage collaboration and facilitate engagement with relevant research and innovation activities.

Some of the key areas that require targeted action to reduce the impact of trust operations in the next 3 years include:

• Travel

• Energy, waste and water

• Medications (such as but not limited to high-carbon inhalers and anaesthetics)

• Procurement

Some key areas of opportunity for joint action across trusts and the wider health and care system include:

• Workforce engagement - promoting “Net Zero action” across the ICSs, supporting our staff to act, contribute innovative ideas and recognising staff

effort.

• Transformation - continuing to review opportunities for joint working across providers to reduce duplication and drive efficiencies

• Estates Strategy - ensuring green plans align with ICSs 10-year infrastructure strategies

• Adaptation - identifying interdependencies between services and establishing the necessary mutual aid requirements to prevent service disruptions

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh73 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Supporng Primary care

Devon

NHS Devon will support primary care providers to contribute to system wide emissions reductions and provide strategic leadership by working with the Primary Care

networks through the NHS Devon Primary Care team. The Devon ICS Sustainability Staff Development Programme, which focuses on developing staff awareness and

skills around sustainability, has recently been launched which offers GP practices the opportunity to participate in workshops and develop projects or actions they

can implement within their practice or Primary Care Network (PCN).

NHS Devon has an extensive NHS Property Services portfolio that our providers rely on, and support has been offered through their sustainability programme to help

direct investment in the buildings that we deem to be our core long term assets.

Cornwall and the Isles of Scilly

The award-winning Primary Care Climate Resilience Team based at Volunteer Cornwall, funded by NHS Cornwall and Isles of Scilly ICB, has been supporting general

practice over the last few years and has recently widened their scope to include dentistry, ophthalmology and community pharmacy The innovative work of the team

has been recognised nationally as an example of best practice accelerating awareness, inspiring action and supporting resilience within primary care across Cornwall

and the Isles of Scilly. Their extensive work and progress so far is showcased in more detail in their Atlas of Progress. The key aim of this programme is to support

primary care to contribute to the overall system goals described in this plan. More information on the work planned for 2025-2030 can be found in the Primary Care

section of the key focus areas for action. We aim to spread the good practice and learning from this team across the clustering arrangement to support GP practices

in Devon.

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Collaborang with our health and care system partners outside of the NHS

Our health and wellbeing partners at the local authorities Devon Council, Cornwall Council and Council of the Isles of Scilly, Plymouth City Council, and

Torbay Council and other important local organisations are also working towards to the same goals.

Devon

Devon County Council has declared a climate emergency and has committed to facilitating the reduction of Devon’s carbon emissions. They are leading the Devon

Climate Emergency Partnership, made up of local authorities, healthcare and emergency services, businesses and voluntary organisations, dedicated to acting on

climate change in Devon. Their mission is to empower Devon to reduce greenhouse gas emissions to net-zero by 2050 at the latest, prepare communities for a

warmer world and improve the resilience of Devon's environment to the effects of climate change.

• The Devon Climate Emergency Partnership, in conjunction with the Net Zero Task Force, have produced an evidence-led Devon Carbon Plan that outlines the

goals and objectives to reach Net Zero by 2050 at the latest. One of the key principles is that multiple benefits for health, wellbeing and resilience of

communities and nature must be delivered. Unitary councils within Devon have their own Net Zero plans, outlining their local goals and objectives to meet

their targets: Plymouth City Council; Exeter City Council; Torbay Council.

• Devon County Council’s Strategic Plan 2021 – 2025 focuses on how they will help the county to recover from the COVID-19 pandemic, build on the resilience

of local people and communities to create a fairer, healthier and more caring place, and grasp the opportunity to create a greener, more prosperous and

inclusive future for all.

• The Devon, Cornwall and Isles of Scilly Climate Impacts Group is coordinating Peninsula action on climate adaptation. This is preparing communities and

organisations for a changing climate and improving resilience. The Climate Adaptation Strategy, published November 2023, helps communities and

organisations better understand the risks their area might face in the future as climate change increasingly affects the UK. It will help them to adapt to these

changes, thereby improving their resilience and community safety.

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Cornwall and the Isles of Scilly

Health system partners in Cornwall and the Isles of Scilly, partner organisations such as Cornwall Council and the Council of the Isles of Scilly, along with other local

organisations, volunteering and community groups all form part of a shared ambition to act against climate change.

• Our local strategic framework for jointly improving health outcomes is set out in our Cornwall and Isles of Scilly Health and Wellbeing Strategy. This highlights the

importance of the built and natural environment on health and the need to transform our care to respond to changing needs of our population and a changing

climate.

• The Cornwall Plan 2020 - 2050 is the Cornwall and Isles of Scilly Leadership Board’s shared vision for Cornwall. It describes a future Cornwall with a creative Net

Zero economy and environmentally sustainable communities.

• The Cornwall & Isles of Scilly Climate Commission is an independent organisation that brings together people and organisations from public, private and

voluntary sectors to work together and help drive, guide, support, and track climate action.

• The Cornwall Council Climate Change Action Plan and The Council of the Isles of Scilly Climate Change Plan recognise the health impacts of the changing climate

and set key actions to mitigate and adapt. We also have a regional Adaptation Strategy for Devon, Cornwall and Isles of Scilly, which identifies a strategic action

to ‘ensure the region is ready for, and resilient to, flooding and coastal change.’

• There are already some areas of great progress and collaborative working. A paper presented to the Joint Health and Wellbeing Board in October 2024 outlined

existing areas of shared action across NHS, council, and community partners to reduce emissions, build climate resilience, and deliver health co-benefits through

cleaner air, active travel, greenspaces, warm homes, and access to fresh, locally grown food.

These local strategies and initiatives align in their shared purpose to create healthier, more inclusive and greener communities across Cornwall and Isles of Scilly.

Some key areas of opportunity to align strategies and take joint action with health and care partners beyond the NHS include:

• Health creation – continue to work together to improve the wider determinants of health of our local populations. This includes opportunities for joined up

thinking around food for health through the Cornwall and Isles of Scilly Food Charter and taking action on improving housing, action on improving air quality and

tackling air pollution in line with Cornwall’s Clean Air Strategy.

• Infrastructure planning – maximising funding and infrastructure opportunities around travel and transport and estates planning. For example, being sighted on

and aligning where possible on electric vehicle (EV) infrastructure and public transport plans and ensuring estate decarbonisation planning aligns with the

Cornwall and Isles of Scilly Local Area Energy Plan (LAEP)

• Climate risk adaptation – working together on climate risk adaptation planning, ensuring adaptation strategies align with and make best use of existing local

authority climate resilience plans

• Green spaces – improving natural spaces and biodiversity in line with Cornwall and Isles of Scilly Nature Recovery Strategy, for the benefit of the planet as well as

our communities.

• Research and innovation – collaborating on research and innovation into Net Zero initiatives. Cornwall Partnership Foundation Trust and Volunteer Cornwall are

core organisations in the new UKRI “One Health” Net Zero Hub initiative for research led by Exeter University.

Through collaborating with local authorities, the volunteering sector and other local organisations, we can maximise our joint impact and make the most of finite

resources available to achieve our shared vision of creating healthier, more inclusive and greener communities across the South West Peninsula.

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What are we seeking to achieve?

Our Green Plan vision

Our key aims

Our ambition for the South West Peninsula NHS is to:

1. Reduce our environmental impact: we will reduce the environmental impact of how we deliver care to reduce emissions and pollution.

• Achieving Net Zero carbon emissions by 2040 for the emissions we can control

• Achieving Net Zero carbon emissions by 2045 for the emissions we can influence

• In Cornwall and the Isles of Scilly we have rephased our original 2030 target to align to the wider NHS 2040 target for the emissions that we control. Aligning

towards a common target across the region will allow us to combine resources and maximise opportunities to achieve our joint goals. However, wherever

possible we will strive to meet reductions targets sooner. For example, achieving reductions in carbon emissions from our anaesthetic gases and inhalers.

However, decarbonising our buildings will take longer.

2. Adapt to a changing climate: we will ensure our services and operations are resilient and can adapt to the impacts of climate change such as extreme weather

events.

3. Create healthier communities: we will create thriving places where is it easier for people to stay well throughout their lives, reducing preventable diseases,

improving the health of our population and reducing demand for more acute healthcare.

Reaching these aims will require health system partners across the South West Peninsula to:

• Work collaboratively to reduce our impact on the environment and pioneer more sustainable ways of working.

• Act as role models and exercise our role as anchor institution in our community.

• Enable staff and patients to make more sustainable choices and minimise their impact on the environment.

• Learn from each other and rapidly spread good practice.

• Proactively promote illness prevention and health creation to enhance the health and wellbeing of the community

• Reduce dependency on our health and care services in the first instance.

The responsibility for making this vision a reality rests with everyone within the health and care services within the South West Peninsula.

“Our vision is to enable people to start well, live well, and age well. Creating places where it is easy to be healthy, connected and environmentally

sustainable within caring communities. Reducing the overall demand for healthcare and reducing the environmental impact of the care we provide.”

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The roadmap to Net Zero emissions

In the context of the NHS's "Delivering a Net Zero National Health Service" report, "Net Zero" refers to balancing the amount of greenhouse gases emitted by the

NHS with an equivalent amount removed from the atmosphere. This means we are aiming to reduce our emissions and remove as much carbon as possible in the

way we deliver care. Identifying a trajectory to Net Zero emissions for the NHS is a complex challenge and NHS England does not expect individual organisations and

systems to measure their carbon footprint individually. In developing the ‘Delivering a Net Zero NHS’ strategy, an expert panel identified a trajectory and set of high-

level actions and interventions which will help get us to Net Zero. It is through delivering these actions and interventions at a local level and monitoring their delivery

that we will contribute to achieving Net Zero across very part of the NHS. The main areas of action for the NHS and its partners can be categorised into:

• direct interventions within estates and facilities, travel and transport, supply chain and medicines

• enabling actions, including sustainable models of care, workforce, networks and leadership, audit, monitoring, funding and finance mechanisms

The graph below shows how these high-level interventions and action areas will help us meet our 2040 Net Zero target for our direct emissions in the NHS.

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Areas of focus

Our vision is to achieve a Net Zero NHS healthcare system within the South West Peninsula in line with the NHS ambitions. Achieving this ambition will require

targeted action across key focus areas supported by appropriate funding and resources. The key opportunity areas and high-level actions we will take as a system

over the next three years are outlined in the following section. These are aligned with the ‘Building a Net Zero NHS’ intervention areas and more detailed recent

Green Plan guidance. More detailed actions, delivery timescales, and success measures to support us in achieving these ambitions will be outlined in individual Green

Plans and supporting delivery plans for our NHS partner organisations at a local level.

Area

Ambition

Workforce and System Leadership

Engage with all staff to learn, innovate and embed sustainability into everyday actions.

Digital Transformation

Use sustainable digital technology to support the transformation of how we deliver care.

Care Model Transformation

Move to health creation, out-of-hospital and digitally enabled care where clinically appropriate, improving prevention of ill health and reducing health

inequalities.

Medicines

Deliver high-quality, environmentally sustainable care in line with clinical guidelines, reducing emissions and waste from the medicines we prescribe whilst

improving patient care.

Travel and Transport

Work with partners to reduce emissions from travel and transport in line with the Net Zero Travel and Transport Strategy, encouraging sustainable travel or

digital alternatives where clinically safe to do so.

Primary Care

Work with primary care providers to reduce carbon emissions and pollution and develop healthier communities.

Estates and Facilities

Modernise the NHS estate, reducing emissions, lowering costs, improving climate resilience and providing a more therapeutic environment for staff and patients.

Supply Chain and Procurement

Implement the NHS Net Zero supplier roadmap and milestones to support reductions in emissions from our suppliers and purchased goods and services.

Food and Nutrition

Ensure we promote high-quality, healthy and sustainable food that minimises waste and meets the National standards for healthcare food and drink.

Adaptation

Build climate resilience and adaptation into business continuity and longer-term planning to avoid climate-related disruptions to health care delivery.

Prevention and Health Creation

Create healthier communities where it is easier for people to stay well, for example through taking joint action on air pollution and encouraging healthier lifestyles.

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Workforce and System Leadership

We recognise that to meet the Net Zero targets, system leadership and staff engagement is key. Our ability to deliver on this

ambitious Green Plan will be dependent upon all parts of the system pulling together as one team, realised through the

actions of our thousands of staff members. The role of our leaders in role modelling and demonstrating a clear commitment

to sustainability and Net Zero will be crucial. We will support staff by working towards setting expectations in staff inductions

and training. There will be additional support for specific roles to enable them to help further embed sustainability as the

business-as-usual approach for everything we do. In addition, we will share learning across NHS organisations to inspire and

offer new ways of working.

Action

Appoint a designated board-member Net Zero lead to oversee green plan delivery with clearly identified operational support and all executives and senior

leaders have actions within their annual objectives.

Assess workforce capacity and skill requirements for delivering the green plan, including identified leads for each workstream, considering good practice

examples such as hybrid roles, apprenticeships, fellowships, NHS estates sustainability career pathways and the use of the Voluntary and Community Sector

(VSCE).

Set uptake targets for core training offers set out on the Greener NHS Training Hub and a staff sustainability training package to be available to all staff and

added to the mandatory training schedule.

Promote specialist training, including carbon literacy training, for staff groups who underpin the delivery of green plans, such as board members,

procurement, finance, estates and facilities staff and clinicians.

Encourage staff to provide suggestions and ideas on how sustainability can be improved in all areas across the organisations.

Ensure our Net Zero targets are embedded into processes, procedures, policies and strategies, and into cost improvement programmes, where appropriate

Use communications tools and resources to promote ‘Net Zero action’ across the peninsula, including regular staff ‘temperature check’ surveys, supporting

staff to act and recognise staff effort

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Workforce & System Leadership: Work underway across Devon ICS

Workforce & System Leadership: Work underway across Cornwall and Isles of Scilly ICS

CFT have an active Greener Healthcare

Collaboration staff network and have

promoted Net Zero / Health Creation events

and initiatives to show how reducing carbon

emissions can also reduce costs and system

pressure. This included delivering a Net Zero

Board Away Day session.

RCHT successfully delivered a volunteering

scheme which allowed staff one day of

volunteering leave. This was taken up by over

500 staff who supported various conservation

and nature-based initiatives and projects

including beach cleans, local community

gardens and growing spaces and supported the

upkeep of the hospital grounds.

The award-winning Volunteer Cornwall Primary

Care Climate Resilience team continue to support

GPs and have begun to expand support and

engagement into the wider primary care sector

through staff networks, engagement surveys, a

newsletter and public website.

Staff networks and engagement

Volunteering

Primary Care Engagement

Trusts have continued to grow

their Green Champions networks

and embed sustainable practices

at departmental level.

The Devon ICB has agreed a staff

hybrid working arrangement to

enable staff to utilise some of their

working time at home which helps

reduce emissions produced from

staff travel. The other Trusts have

similar arrangements in place, for

example, RDU have facilitated a

greener pilot to

encourage/improve sustainability

at work and home as a part of our

workforce development.

RDU and UHP have increased

sustainability training available to

staff by introducing Carbon

Literacy Training. Over 500

members of staff have also

completed the ‘Building a Net Zero

NHS’ training programme. RDU

have also introduced a

sustainability section in new job

descriptions and promoted

sustainability objectives in

appraisals.

UHP have implemented a

Sustainability Quality Improvement

Framework which continues to

support departments in adopting

greener, evidence-based practices

across the Trust.

Green Champions

Staff Hybrid Working

Inductions, training and

appraisals

Sustainability Quality

Improvement Framework

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Digital Transformaon

Digital technologies can play a leading role in meeting the NHS Net Zero targets. The COVID-19 pandemic accelerated digital transformation across

the NHS, and our Digital and Data Strategies aim to build on that progress. By streamlining services, improving resource use, and reducing emissions,

digital systems will support more efficient and sustainable care. Digital programmes will align with NHS England’s What Good Looks Like (WGLL)

framework, ensuring safe, secure digital transformation. We are committed to digitally optimised, connected care that is patient-accessible and

efficient. This approach mitigates against rurality, promotes efficiency and maximises productivity, e.g. reducing Did Not Attends (DNAs) and

supporting innovative working. Examples include implementing Electronic Patient Records (EPRs) which will streamline digital processes, enabling

safer, more accurate care, rollout of digital communications such as digital appointment letters, electronic prescriptions, telephone and virtual

consultations (where clinically and patient appropriate), and remote monitoring of conditions and use of virtual wards. These efforts will deliver

both environmental and patient benefits through reducing travel, paper use; unnecessary tests; and medicine waste.

Digital transformation is essential to improving care quality, empowering patients, and creating a more modern and efficient NHS. However,

digital services can also have a negative impact on the environment through increasing emissions, creating waste and using up resources. For

example, data centres used to power our applications, systems and to host our data require a lot of energy and water. We want to harness the opportunities of

digitalisation to improve the way we deliver care, whilst aiming to reduce the overall environmental impact of the technology required to do this.

Action

Maximise the benefits of digital transformation to prevent health issues and support management of long-term health conditions and reduce emissions and the

environmental impact of care.

Supported by the Digital Maturity Assessment, embed sustainability in digital services and implement the objectives in the Sustainable ICT & Digital Services

Strategy 2020-2025 by:

• using circular and low-carbon approaches to IT hardware management, which may include longer device lifetimes, leasing models, buying refurbished or

remanufactured equipment and PC power down configuration

• considering low carbon hosting, promoting good data hygiene (such as, deduplication and archiving) and engaging digital suppliers

• reducing the use of paper records printing and postage, through awareness and practice such as e-signatures and digital sharing

Increase flexibility to allow for staff to work remotely where feasible.

Ensure the introduction of new digital tools for digital inclusion are monitored and assessed.

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Care Model Transformaon

The NHS is committed to moving to out-of-hospital and digitally-enabled care where clinically appropriate, improving prevention

of ill health and reducing health inequalities in line with the NHS 10-Year Health Plan. These changes also underpin our

commitment to Net Zero. Future care model transformation should ensure high-quality, preventative, integrated care is provided

to patients at every stage. Transforming the way we deliver care also means achieving efficiencies in our corporate and back-

office functions to deliver value-for-money services. The NHS 10-Year Health Plan sets out a commitment to deliver care in new

ways for the 21st century. This must also include a focus on reducing carbon emissions and will involve using environmental

impact as an additional factor in care design. Other principles that improve quality of care and patient experience can also help to

decarbonise care pathways:

• Optimising the location of care

• Earlier and quicker detection, diagnosis and

treatment

• Embedding the best clinical practice

• Treating for the long-term

• Digital technology

Through the development of a Net Zero framework and a focus on integrated healthcare for care pathways, carbon emissions and wider pollutants will be reduced

through reduced presentations in emergency care, primary care and outpatients, reduced staff and patient mileage, reduced bed days, fewer pharmaceuticals

prescribed, and avoidable investigations and treatment. It is also important to recognise the importance of prevention of ill health and build preventative medicine

into our long-term health strategy. We will deliver the best quality of care while being mindful of its social, environmental and financial impact and take a whole

systems approach to the way it is delivered.

Action

Identify clinical leads at Trusts with oversight of Net Zero clinical transformation, with formal links into board-level leadership and governance.

Support work to reduce emissions across patient pathways, spanning primary, secondary and community care and VCSE to drive out unnecessary stages and low

value activities.

Consider Net Zero principles in all service change, reconfiguration programmes and pathway redesign, focussing on reducing hospital visits and providing care

closer to home.

Support Trusts in their use of the Sustainability in Quality Improvement (SusQI) Framework and GPs in their use of the Greener Practice Network QI Platform.

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Work with place-based partnerships to produce targeted campaigns for healthy eating, smoking cessation, and elderly care, with accompanying signposting to

services.

Care Model Transformation: Work underway across Devon ICS

Care Model Transformation: Work underway across Cornwall and Isles of Scilly ICS

An enhancement in clinical transformation

sustainability:

• Progression of virtual wards

• PSA home finger prick test pilot

• Diabetes and Urology projects

• Green Wards, Green Theatres, My Green

Lab (Pathology)

• LEAF (Genomics)

• NOAH (Neonatal antibiotics)

UHP’s Emergency Department achieved Bronze

accreditation in the Royal College of Emergency

Medicine’s (RCEM) GreenED programme, a

significant step in reducing the environmental

impact of acute care.

The Green Theatres programme at UHP

advanced several projects, including a shift to

reusable equipment, theatre pack

rationalisation, and the introduction of a Green

Plastics initiative, all aimed at reducing waste

and single-use items.

Green ED

UHP Green Theatres Programme

RDU One Northern Devon Active Travel Group

CFT are the lead organisation in the

county for the Virtual Wards

project and have other

consultation options in place such

as Attend Anywhere.

A GP practice in Cornwall has

switched away from single use

plastic equipment by using funding

from the Nature Save Trust to

invest in reusable equipment for

coil fitting and removal. This avoids

the use of single use plastics which

had to be disposed of after each

patient using sterilization

processes instead.

Cornwall Partnership NHS FT and

Royal Cornwall Hospitals Trust

have an existing shared

procurement team and IT services

this helps reduce duplication and

optimise opportunities to drive

efficiencies.

Virtual Wards and Digital

Consultations

Reusable clinical equipment

Shared business services

RCHT is working towards My Green

Lab certification and Royal College

of Emergency Medicine GreenED

Bronze Award.

Green Accreditations

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Medicines

Medicines account for about 25% of emissions within the NHS in England. A small number of medicines account for a substantial

proportion of these emissions, particularly anaesthetic gases and nitrous oxide which account for around 2% of NHS emissions, and

inhalers which account for around 3%. Many medicines have long-term polluting impacts across our water networks and natural systems,

as well as creating packaging waste. The long-term NHS plan pledges to reduce the negative effect the NHS has on the environment to

help to build a more sustainable NHS. Part of this negative effect can be managed through the identification and encouragement to

prescribe medicines which limit damage to the environment.

Anaesthetic Gases

Anaesthetic gases have extremely high global warming potential, for example one litre of Desflurane has the equivalent CO2 emissions of

driving a diesel car from Lands’ End to John O’Groats and back seven times. In addition to this issue: less than 5% of inhalational anaesthetic gases are metabolised

by the body. This means that 95% of the administered gas goes into the atmosphere. All Trusts in Devon and Cornwall have now decommissioned desflurane,

eliminating the use of this gas. Nitrous oxide (N2O), commonly known as ‘laughing gas’, is a greenhouse gas with a global warming potential 310 times that of carbon

dioxide. Over the past 150 years, increasing atmospheric N2O concentrations have contributed to ozone depletion and climate change. A third of the NHS use of N2O

use comes from theatres, with the remaining two-thirds from use in obstetrics and emergency care, and N2O wastage contributes significantly to the carbon

footprint of the NHS. All Trusts in Cornwall, Devon and the Isles of Scilly are now reviewing the use of this gas to reduce and/or decommission where appropriate.

Inhalers

The NHS Long Term Plan has set an ambitious target to reduce inhaler emissions by at least 50% by 2028. Certain inhalers contain a potent greenhouse gas as a

propellant, to administer the medicine into the patient’s lungs. These types of inhalers are known as metered dose inhalers (MDIs). While the gas itself is not harmful

to users, the emissions from exhalation and in disposal of the devices is high. Dry powder inhalers (DPIs) are a greener option which can reduce the carbon footprint

of inhalers by up to 95%, the equivalent of a journey of 175 miles for an MDI, to a journey of 4 miles for a DPI.

Green and blue social prescribing

Green and blue social prescribing involves activities that connect people with the natural environment with multiple physical and mental health, and environmental

benefits. An increasing range of organisations across the South West peninsula are currently delivering various nature-based activities. The UKRI “One Health” hub

will help identify optimum low carbon and pollution benefits of green and blue prescribing for mental health conditions.

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Action

Work with primary care to support high-quality, lower-carbon respiratory care in line with clinical guidelines for asthma and chronic obstructive pulmonary

disease, including:

• optimising inhaler choice (considering clinical appropriateness, the environmental impact of inhalers and patient preference)

• improving inhaler use and adherence

• encouraging patients to return their used or expired inhalers to community pharmacies for appropriate disposal

• work as a system to reduce the use of pressurised metered dose inhalers

In line with national medicines optimisation opportunities, address overprescribing and oversupply while supporting patients in greatest need, taking a shared

decision-making approach and personalising care e.g. through conducting medication reviews for example through programmes such as ‘Please Show Me Your

Meds’

Support Trusts to reduce emissions from nitrous oxide and mixed nitrous oxide waste

Reduce medicine wastage and ensure best available technology is used for disposal, including recycling anaesthetic gases

Where clinically appropriate, prioritise evidence-based therapies over pharmaceutical interventions and focus on the reduction of carbon emissions by medicines

optimisation. (Supported by GP Prescribing Scheme, (2021))

Medicines: Work underway across Devon ICS

All Trusts have projects underway to

decommission the use of nitrous oxide. Some

areas have been exempted from this such as

RDU and UHP in areas such as maternity and

paediatrics which will be explored in due

course.

Trusts will switch to mobile nitrous oxide

cylinders with regulators where required

which will enable decommissioning of the

piped manifolds.

RDU and TSD have a ward waste reduction of

medication project underway.

DPT is utilising admitted patients’ own medication

on to reduce waste and supply new medication in

paper bags.

DPT have reduced spending on drugs through

Pharmacy and Green ED projects and estimate

that this change will save around 244 tonnes of

CO2 a year and reduce harmful gas releases by up

to a factor of 300 times.

DPT’s green prescribing project at Langdon Hospital

has expanded with trees planted donated by NHS

Forest and charitable trust donations to install

habitat homes crafted at New Leaf in Exminster.

TSD has produced guidance quoting the annual

carbon impact of each available inhaler to support

prescribers and members of the respiratory team.

In addition, all used metered dose inhalers are

returned to pharmacy to dispose of in an

environmentally safe way.

Medicines Reduction

Nitrous Oxide

Green Prescribing

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Medicines: Work underway across Cornwall and Isles of Scilly ICS

One of the key action areas for

the Cornwall Climate Resilience

team is offering support to GP

practices to reduce emissions

from inhalers prescribed. 81% of

practices are now active on low

carbon inhaler support leading to

149,463kg of carbon savings from

2022-24.

Waterproof bags are being

provided to homeless patients

across Cornwall to keep their

medication dry and safe and allow

for DPI’s to be prescribed. These

bags ensure that medication is

always available to patients

without water/ environmental

damage, and reduction

medication waste.

Royal Cornwall Hospitals Trust has

decommissioned Desflurane.

Work is ongoing to decommission

Nitrous Oxide piped manifolds in

favour of using mobile cylinders.

ED department have made

reductions in the use on Entonox.

GPs have been working with local

organisations to refer patients

with to spend time outdoors in a

natural environment for gentle

activity, such as through

participation in woodland wellness

sessions, walking groups,

gardening and growing projects

and accessing the benefits of the

sea.

Primary Care Inhalers

Cornwall Health for Homeless

Anaesthetic Gases

Green and Blue Social

Prescribing

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Primary Care

Primary care is responsible for 25% of the total NHS greenhouse gas emissions, and whilst general practice sites are significantly smaller than those of provider trusts,

90% of patient appointments take place in primary care each year. To put it in perspective, across England over 358 million appointments were delivered by general

practice in 2023 with hospital outpatient appointments sitting at roughly a third of that total.

However primary care extends beyond general practice and from 1st April 2023, integrated care boards assumed responsibility for also commissioning pharmacy,

general ophthalmic, and dental services. As a result, we face a significant and increased challenge in meeting Net Zero commitments, but primary care partners are

advantageously positioned to reduce greenhouse gas emissions and enact change at the grassroots level.

General Practice in Devon

The average footprint of general practice in England can be shown as a 40/60 split between non-clinical and clinical activity. A quarter of all NHS carbon emissions

derive from medicines, over 55% of which are prescribed by practitioners in general practice. Pharmaceuticals and prescribing account for at least 60% of primary

care emissions and reducing this impact continues to be a priority for primary care action.

There are 137 GP practices across Devon, making up 31 Primary Care Networks (PCNs), split into four groups (Northern, Eastern, Western and Southern). To deliver

carbon emission reductions in this sector, actions will be supported by the ICBs as appropriate to maximise the benefits of collaboration, shared learning and

minimise duplication and effort.

Action

Calculate the carbon footprint of primary care practices

Monitor and reduce energy use. Practices to move to 100% renewable energy tariffs where practicable

Procurement: primary care to reduce unnecessary purchasing and to choose sustainable options where appropriate

Primary Care buildings to have transitioned from fossil fuels

Work with Volunteer Cornwall to expand the existing award-winning work to extend support to primary care in Devon.

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Primary care providers in Cornwall

The award-winning Primary Care Climate Resilience Team based at Volunteer Cornwall has been working with local GP surgeries, supporting them on their own

sustainable healthcare journeys. They have identified 15 key priority areas and accompanying targets to reach by 2030 (See Appendix 3).

Some of the key areas for action in GP practices include:

• Optimising our energy – Undertaking energy audits across our GP practices to help identify opportunities to decarbonise and reduce the energy they use.

• Activating our travel – Promoting and enabling active travel for staff and patients.

• Green space for health – Developing green spaces for staff, patient, visitor and planetary health.

• Food for people and planet – Offering food, learning and activity in community based growing spaces as part of health care and health creation.

• Better Prescribing – Encourage de-prescribing, reduce polypharmacy, and optimise non-clinical interventions, where appropriate.

• Learning and leading – Actively investing time in learning training and communication on climate resilience.

• Engaging our patients, activating our community and advocating for health creation – Actively working and communicating with staff and patients on climate

resilience and health creation.

Action

Share best practice across the integrated care system on climate mitigation, adaptation and resilience.

Support and enable primary care providers (including general practice, dentists, community pharmacy and ophthalmology) to adopt health creation and

sustainable delivery practice.

Expand the adoption of the Green Impact for Health Toolkit, Greener Practice QI Platform, and Greener Pharmacy Toolkit for primary care.

Build on the existing primary care support networks on active travel, green spaces for health, sustainable food, energy and waste reduction.

In conjunction with Public Health, build on and expand the WellFed programme, enabling GP practices to link with local community growers to support patients

recently diagnosed with diabetes.

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Primary Care: Work underway across Cornwall and Isles of Scilly ICS

Working with our GP practices

Since the work began, the Climate Resilience team are working with 47 / 55 surgeries across Cornwall and the Isles the Scilly. Of these, 67% practices in Cornwall

have signed up and are using the Green Impact for Health Toolkit. As a result of this engagement, GP practices have also achieved the following:

• 22% of practices have declared a climate emergency.

• 29% of practices are engaged in carbon foot-printing.

• 81% of practices are now active on low carbon inhaler support leading to 149,463kg of carbon savings from 2022-24.

• 42% of practices supported via energy audits through Cornwall Energy Plus with 456 tonnes of CO2 saved and £88,319 recurrent yearly savings identified

so far.

• 74% of practices are working on optimising prescribing and reducing waste.

• 70% practices are using green social prescribing to support patients. 12 practices are using funding secured by Volunteer Cornwall to improve social

prescribing options.

• 71% practices are actively working with staff and patients on climate resilience.

• 76% are working on active travel, 36 new bike sheds and types of cycling kit have been installed in practices for staff and patients.

• 35% of practices, alongside RCHT and CPFT are developing green spaces for health for their staff and patients as part of the Green String of Pearls local

network.

• 47% of practices are involved in low carbon food initiatives for staff and patients such as the WellFed programme.

• £32k applied for, secured and invested in primary care active travel to improve existing infrastructure.

Work with wider Primary Care such as Community Pharmacy, Ophthalmology and Dentistry

Volunteer Cornwall is working with primary care across Cornwall and the Isles of Scilly (GPs, Community Pharmacy, Dentistry, Ophthalmology and Community Hubs

which are funded by the NHS) to collate baseline data of progress towards Greener NHS across the sector. The data collected will help the ICB track what progress

has been made and where further support is required to prioritise work streams. Some fantastic local projects are already underway including “Show me your

Meds” and “Inhaler Recycling Projects”.

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Travel and Transport

Approximately 3.5% (9.5 billion miles) of all road travel in England relates to

patients, visitors, staff and suppliers to the NHS, contributing around 14% of the

system’s total emissions. In addition, the NHS fleet is the second largest in the

country, consisting of over 20,000 vehicles. It directly contributes to harmful air

pollution. On 31st October 2023, NHS England (NHSE) published its Net Zero

Travel and Transport Strategy which describes the interventions and modelling

underpinning the commitments that the NHS will have fully decarbonised its

fleet by 2035, with its ambulances following in 2040, examining each of the

major components of the NHS fleet and outlining the cost saving and health

benefits to patients and staff. Key steps marking the transition of NHS travel and

transportation are shown at Figure 5

Sustainable travel plays a significant part in reducing traffic on the roads, promoting health and

wellbeing through exercise, and improving local air quality. Therefore, it is important, wherever

possible, that we follow the sustainable travel hierarchy shown in Figure 6 and ensure the locations

from which our NHS services operate are well-served by bus, rail, and other public transport links,

have good and accessible pedestrian facilities and are reachable by safe cycle routes, have secure

cycle storage and provide charging points for electric vehicles. Throughout the peninsula we offer

cycle to work schemes and a lease car scheme. In addition, home working is promoted (where it is

possible to balance needs of the business and our way of working) to reduce the carbon footprint

caused by travel. This strategy summarises the commitments and outlines the journey ahead in

helping staff, patients, and visitors to reach our sites and communities safely, sustainably and with the

benefit of improved health and reduced cost both in monetary and in environmental terms. All

initiatives will be Equalities Impact Assessed to ensure we are preventing widening of inequalities and

take account of the needs of all people, especially those with Protected Characteristics.

Figure 5: NHS Travel and Transport Roadmap

Figure 6: NHS Travel and Transport Sustainable Travel Hierarchy

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh91 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Action

Develop a sustainable travel plan by December 2026, focusing on implementing the sustainable travel hierarchy, use of digital communication, active travel,

public transport and zero-emission vehicles, supported by a clear understanding of staff commuting.

Offer only zero-emission vehicles through vehicle salary sacrifice schemes from December 2026 onwards (for new lease agreements).

Make arrangements to purchase or enter new lease arrangements for zero-emission vehicles only from December 2027 onwards.

Form partnerships with local authorities and local transport authorities to maximise funding and infrastructure opportunities.

NHS trusts and ICSs to plan deployment of EV infrastructure by identifying local/regional grid capacity and work with local network operators and/or local

authority to plan for increased capacity where necessary.

Work with local authorities and transport providers to improve public transport links and access to healthcare sites.

Work to minimise the environmental and health impacts of patient transport from the Voluntary and Community Sector (VCSE).

Work with our suppliers to minimise the environmental and health impacts associated with the movement of goods and through ICS activity.

From 2029, all new ambulances will be zero emission vehicles.

Travel & Transport: Work underway across Devon ICS

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Travel & Transport: Work underway across Cornwall and Isles of Scilly ICS

RDU now have 6 EV’s and infrastructure

installed, including 17 charging points for fleet

and 4 for clinicians.

91% of UHP’s Fleet are ZEV and ULEV. New EV

chargers are planned, and patients, visitors and

staff have access to e-bikes to travel around

Plymouth, with one of the hubs based at

Derriford Hospital.

TSD are increasing their fleet of EV vehicles with

the purchase of a further five vehicles and EV

charging points.

Devon ICB and Trusts can use a salary sacrifice

scheme to benefit from a fully electric vehicle. 80%

of cars ordered through the scheme at DPT are

EVs.

RDU now have e-bikes for staff to trial, e-bike

charging installed and have introduced more

foldable electric bikes for staff to ‘try before you

buy’ and encourage sustainable travel practices.

TSD have introduced personal travel plans which

are available for all staff to access. A free e-bike

scheme has been implemented for staff.

Sustainable Travel for Staff

NHS Fleet

CFT actively promotes low emission or EV vehicles through

the Trust’s green car leasing scheme and are continuing to

upgrade sustainable travel infrastructure for example,

through securing funding for bike shelters, and use of a

Green Travel planning tool.

CFT have been successful in a grant bid submitted to NHS

England for EV chargers. The total award is for £270,000 and

will install of 30 dual headed EV chargers across several

sites.

RCHT have developed a Travel Plan for their main Truro site.

Sustainable Travel

A key action area for GP practices in Cornwall has been to

support active travel with staff and patients. £32k has been

secured and invested to improve existing infrastructure.

More than 30 e-bikes are being used by practices for patient

visits; more than 25 travel surveys completed; 11 Beautiful

Day Out maps (which show active travel routes to and from

practices) commissioned; more than 10 'Dr. Bike'

maintenance sessions hosted by practices; 2 sites using

Modeshift to create working travel plans; many practices

with Bike to Work and/or EV salary sacrifice schemes in place

for staff.

Sustainable Travel in Primary Care

TSD has introduced annual data mapping of

staff locations to support sustainable travel

options, influencing public transport providers

to provide additional transport routes to

hospital sites. In addition, on an annual basis

they record the average staff commuter

emissions. This rating is the only standardised

methodology for benchmarking and comparing

commuter emissions. This rating system

empowers the TSD to understand, benchmark

and improve their commuting emissions.

Staff Travel Habits

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Estates and Facilies

There are significant opportunities across the NHS estate to reduce emissions and lower costs, while improving energy

resilience and patient care. The NHS Estates and Facilities Net Zero Carbon Delivery Plan, published in 2021, sets out a

clear, sequential four step investment approach to decarbonising NHS sites, as shown at Figure 7.

Emissions relating to the estates and facilities services span both the NHS Carbon Footprint and the NHS Carbon

Footprint Plus, accounting for over 60% of the NHS Carbon Footprint (mostly due to emissions from energy use) and also a significant proportion of the Carbon

Footprint Plus, through staff travel, construction, catering plastics and capital spend, food and the wider £9 billion estates and facilities annual supply chain spend.

Across the South West Peninsula work is ongoing to develop our

infrastructure strategies, which will include the review and ongoing

prioritisation of our capital projects across the region. Environmental

sustainability of the estate will be considered as a part of this process.

Building Energy Use

Rising energy costs continue to have a real impact on NHS finances, adding

increased pressure to already pressurised services. £1 in every £187 spent

in the NHS is on building energy, and as this makes up 41% of the NHS

carbon footprint, this is the single biggest area estates and facilities can

influence. It is our ambition to ensure that green energy and renewable

energy sources are being used at NHS buildings across the peninsula,

including solar panels, wind turbines, ground-source pumps, biomass

installations, air source pumps, and solar water heating, which have

already been incorporated within several provider trusts and in general

practices in the South West Peninsula.

Figure 7: Four step approach to decarbonisation of the NHS estate by 2040

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Asset Management and Utilities

We have an opportunity to improve our existing operational assets, buildings, critical infrastructure and the equipment which is essential to the smooth running of

the hospital through carefully considering the sustainability credentials of assets and utilities yet to be procured. Improvements and opportunities can stem from

relatively large capital investments, or from individuals identifying simple changes which can be implemented across similar departments, or indeed the estate as a

whole. The development and implementation of relevant plans and strategies will see sustainable development integrated into facilities management activities

within the ICSs.

Waste Segregation

Every year, NHS providers produce approximately 156,000 tonnes of clinical waste that is either sent to high temperature incineration (HTI) or for alternative

treatment (AT), which is equivalent to over 400 loaded jumbo jets of waste. This has a significant environmental impact and is associated with high running costs and

carbon emissions. As one of the largest producers of waste in the country, it is vital that the NHS disposes it in a safe, efficient and sustainable manner, and we are

only creating waste when absolutely necessary. The NHS Clinical Waste Strategy was refreshed in 2023 to align with

the NHS Net Zero targets and reiterates the principles of the waste hierarchy, shown at Figure 8 and 9.

Figure 8: The Waste Hierarchy (adapted for clinical waste)

Figure 9: Clinical Waste Strategy

Measures of Success

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Biodiversity and Nature Recovery

Biodiversity is vital for healthy ecosystems, but in the UK, it is declining sharply, with 41% of species lost since 1970 and 15% now at risk of extinction due to habitat

loss. Managing the polluting impacts of our medicines brings benefits to biodiversity and the ecosystems we rely on for our health. Green spaces benefit staff and

patients alike, supporting mental and physical wellbeing. Nature reduces stress, boosts mood, and improves recovery. For staff, it enhances focus, creativity, and job

satisfaction, while for patients, it supports healing and a more positive treatment experience. According to the HM Government ‘Environmental Improvement Plan

2023’, communities should be able to access green or blue spaces within 15 minutes of their homes, and Natural England’s ‘30 by 30: a boost for nature recovery’, a

commitment was made by the UK government to protect and conserve a minimum of 30% of land and sea for biodiversity by 2030. This target will be a key driver in

reversing the decline of nature in the UK, by expanding and improving our protected areas and creating new areas for wildlife, allowing nature to spill over into the

wider landscape. The NHS can contribute to this by ensuring that patients and staff have access to, and improve and enhance green spaces on NHS estates, to

improve wellbeing and contribute to nature recovery.

Action

Make efficient use of our spaces and assets and optimise the use of our estates. This includes making every kWh of energy and m3 of water we use count.

Produce and implement Heat Decarbonisation Plans and replace fossil fuel heating systems with lower carbon alternatives, such as heat pumps where possible,

subject to available funding to support this transition.

Work with local partners to ensure estate decarbonisation planning aligns with local priorities, infrastructure plans (for example, heat networks) and funding

opportunities.

Increase use of renewable energy by investing in on- or near-site renewable energy generation to meet NHS energy demand.

Improve energy efficiency by installing measures such as LED lighting, insulation and double-glazed windows.

Identify opportunities to support primary care estates decarbonisation, such as through the Boiler upgrade scheme.

Implement the NHS Net Zero building standard where relevant and continue to aim for BREEAM Excellent rating for new builds and Very Good for refurbishments.

Collaborate with NHS Property Services and other relevant landlords to progress Carbon Reduction across our leased sites.

Explore how we can support system partners to access central funding and develop successful grant bids, including any joint bidding opportunities between partners

and identifying alternative funding streams.

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Ensure the Green Plan and our Estates strategies across organisations align with our ICS’s 10-year infrastructure strategies.

Ensure all sites meet the trajectories set out in the Clinical Waste Strategy.

In line with the UK Governments commitment to conserve a minimum of 30% of land and sea for biodiversity by 2030, work towards achieving 30% of green spaces

on the South West Peninsula NHS footprint for people and nature recovery. We will do this by:

• Undertaking baseline surveys to know what exists already and to be ready for any biodiversity net gain opportunities

• Identify suitable sites for tree planting, increasing the number of trees and shrubs

• Using nature-based solutions for flooding, heat and shade

Estates & Facilities: Work underway across Devon ICS

Energy Efficiency Projects

Most Trusts in Devon have been successful in being awarded funds to implement energy efficiency projects which will significantly reduce carbon emissions

associated with energy.

Devon Partnership NHS Trust

• Over £3million has been awarded from Great British Energy for the installation of a ground solar array at Langdon in Dawlish along with roof top arrays at six

other sites.

• Salix announced a £2.1 million award to connect Wonford House in the centre of Exeter to the Exeter Energy Network (EEN).

University Hospitals Plymouth NHS Trust

• Awarded £1.2million towards energy efficiency projects and renewable energy from the Department for Energy Security and Net Zero

• Awarded £637K for LED lighting and solar projects from the NHS National Energy Efficiency fund and £24K from the Heat Network Efficiency Scheme

• Phase 1 funding awarded for new Emergency Department which will be built to net zero building standards

Royal Devon University Healthcare NHS Foundation Trust

• £500k funding received via the NHS Energy Efficiency Fund (NEEF) to improve lighting, Building Management Systems and metering

• Secured a £6m grant from UKRI for a research hub in collaboration with the Health Economics and Health Policy team at the University of Exeter

• Participated in a specialist grant funding bid for solar PV and utility scale battery electricity storage

Torbay and South Devon NHS Foundation Trust

• Introduced a building management system (BMS) and sub metering in new developments, thus enabling profiling to review electricity efficiency from events

• Air sourced heat pumps have been installed in new developments within the Acute Medical Unit, new Theatres and Endoscopy unit.

• The Thorlux BMS provides a smart reporting system, scanning energy usage and effectiveness with further innovation opportunities for energy reduction.

• LED Lighting replacement programme is now within specifications for any new works and replacements.

• Solar PV Farm Tender process was completed in 2023, progress ongoing.

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Estates & Facilities: Work underway across Cornwall and Isles of Scilly ICS

Cornwall Partnership NHS Foundation Trust

• Almost £600,000 (inc. VAT) received in NHS Energy Efficiency Fund grant funding for additional solar PV systems, LED upgrades, Building Management

System upgrades for a selection of our freehold properties

• Almost £2.2 million bid secured from GB Energy through NHSE for additional solar PV and battery storage systems. By April 2026 it is estimated CFT will

have reduced the electricity bought from the grid each year by 34%

• Developing Green Spaces for Health and Wellbeing - A key objective in Cornwall Partnership NHS Foundation Trust ‘s recently updated Clinical Strategy is

to deliver half of clinical care outdoors or in non-clinical spaces by 2029. Healing By Nature and CAMHS Goes Wild projects are good examples of how

services will be transformed to do this.

• Healing By Nature project – Greener Communities funding for enhancement of the green spaces at Trevillis House

Royal Cornwall Hospitals Trust

• Have opened a new Outpatient building at West Cornwall Hospital, which is the first major building project at RCHT to have solar panels installed as part

of the design to generate sustainable energy.

• Awarded £1.4 million in funding from the NHS National Energy Efficiency Fund (NEEF) in February 2025. The money is for two energy efficiency schemes

that will help reduce carbon emissions at RCHT and deliver considerable financial savings on energy use.

• £1.1 million has been allocated to provide more than 8,300 additional LED lights to the Royal Cornwall Hospital in Truro, St Michael’s Hospital, and Marie

Therese House. This includes wireless automated self-testing emergency lighting.

• A further £300,000 grant is for Solar PV (Photovoltaic) panels. These will enable the Trust to install more than 900 roof panels to generate electricity

across all three sites, at Royal Cornwall Hospital, West Cornwall Hospital, and St Michael’s Hospital.

• The new Women and Children's Hospital will embed sustainability into project design, development and delivery. Guided by key NHS sustainability

policies; legal and planning requirements in relation to biodiversity net gain; and aiming to achieve Hospital 2.0 standards where practicable the project

will deliver:

o A high quality and efficient clinical environment.

o A building that promotes health, wellbeing and productivity for its users.

o Embedded / operational carbon efficiency savings when compared with current buildings.

Primary Care

• Volunteer Cornwall Climate Resilience Team has supported 42% of Cornish practices through subsidised energy audits by Cornwall Energy Plus with 456

tonnes of CO2 saved and £88,319 recurrent yearly savings identified so far.

• 35% of GP practices across Cornwall have been improving the natural spaces at their surgery sites, creating gardens and green spaces supported by

Volunteer Cornwall and in collaboration with wider local organisations for the benefits of patients and staff.

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Supply Chain and Procurement

The NHS uses products such as medical equipment, food and other business goods from more than 80,000 suppliers. Over 60% of the

current carbon footprint can be found in the NHS supply chain, making it important that the NHS support their suppliers in creating a

positive change, to meet the Net Zero target that has been set. In 2021, the NHS public board approved the ‘Net Zero Supplier

Roadmap’ which sets out environmental guidelines and expectations working with suppliers moving forward. A summary of the

roadmap is shown in Figure 9.

The ICSs need to lead a step change in education and awareness of

sustainability best practices across Trust service delivery staff involved

in procuring good and services. There will be a move to sustainable

procurement approaches, such as taking an active role in developing

the circular economy. In terms of direct sustainable use of resources,

unnecessary procurement and resource use will be minimised, and the

reuse of materials and equipment will be maximised, where

appropriate. Where we have an indirect use of resources, sustainable

procurement culture and processes will be adopted that shift

consumption to sustainable products and services and considers broad

criteria including materials, workforce, buying locally where possible,

and sustainable manufacturing and transport. We can achieve this by:

Fulfilling

obligations under

the NHS plastics

pledge

Promote a culture

of reuse and

refurbishment of

items

Include sustainability

criteria in

procurement, tender

evaluations,

framework design

and selection,

product selection

Use accreditation

programs to support

our procurement

strategy e.g. Soil

Association Food

Standards. Work

innovatively with NHS

partners and

suppliers on

sustainable

approaches

Meet NHSE/I

Greener NHS

immediate

interventions

targets

Develop robust

internal

procurement policy

and procedures

that support the

sustainability

agenda

Figure 9: The NHS Net Zero Supplier Roadmap

Net Zero Supplier Roadmap

• From April 2023: the NHS will adopt the Government’s ‘Taking Account of Carbon Reduction

Plans’ (PPN 06/21), requiring all suppliers with new contracts for goods, services, and/or works

with an anticipated contract value above £5 million per annum, to publish a carbon reduction

plan for their direct emissions. From April 2024, the NHS will expand this requirement for all new

contracts, irrespective of value.

• From April 2027: all suppliers with contracts for goods, services, and/or works for any value, will

be expected to publish a carbon reduction plan that takes into account the suppliers’ direct and

indirect emissions.

• From April 2028: new requirements will be introduced overseeing the provision of carbon foot-

printing for individual products supplied to the NHS. The NHS will work with suppliers and

regulators to determine the scope and methodology.

• From 2030: suppliers will only be able to qualify for NHS contracts if they can demonstrate their

progress through published progress reports and continued carbon emissions reporting through

the supplier framework.

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Action

Embed NHS Net Zero supplier roadmap requirements into all relevant procurements and ensure they are monitored via KPIs.

Encourage suppliers to go beyond minimum requirements and engage with the Evergreen Sustainable Supplier Assessment to support a single conversation

between the NHS and its suppliers on sustainability priorities.

Identify and report all single use plastics across ICS sites and replace with recyclable, low carbon alternatives.

All providers within the ICSs should only be purchasing 100% recycled paper and take action to reduce paper usage.

Take action to address single use plastics and specifically eliminate unnecessary catering plastics.

Develop a Green Impact Assessment / Checklist for all new policies and procurement.

Supply Chain & Procurement: Work underway across Devon ICS

As of early 2025, NHS Trusts in Devon

now have a shared procurement service,

specifically Devon Partnership NHS Trust,

Royal Devon University Healthcare NHS

Foundation Trust, University Hospitals

Plymouth NHS Trust and Torbay and

South Devon NHS Foundation Trust, to

deliver increased value from

procurement services, driving out waste

and unnecessary costs, and a reduction

in carbon emissions.

The Devon ICB has reduced its printing hub to one location

within the building which has naturally discouraged paper

use.

UHP has reviewed single use items and swapped some items

to reusable such as kidney dishes, jugs, gallipots, bowls and

patient belonging bags in theatres

TSD has introduced schemes such as reusable sharps bins,

gloves off campaign and ‘keep me cups’ enabling single use

plastic reduction from the supply chain.

DPT’s facilities team have implemented cleaning products

which have environmental benefits by providing

concentrated dosage allowing for more applications per

recyclable bottle.

RDU has introduced requirements for suppliers

to provide information about their social value

impact, including environmental credentials, in

public procurement tenders.

DPT tenders are now awarded with the 10%

sustainability scoring

RDU has introduced requirements for suppliers

to provide information about their social value

impact, including environmental credentials, in

public procurement tenders.

Sustainable use of resources

Devon Shared Procurement Service

Social Value

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Supply Chain & Procurement: Work underway across Cornwall and Isles of Scilly ICS

A GP surgery has invested in long lasting high-

quality scrubs for staff to launder at home instead

of using a commercial laundry to continue washing

lower quality scrubs. The practice has saved

£14,000 on an unnecessary laundry facility and

reduced regular scrub waste and replacement

costs, and the carbon emissions associated.

They also identified by switching to reusable ink

bags for use in their leased energy efficient

printers, they have made significant cost savings

and waste reduction.

The switch away from single use non refillable

hard cartridges is projected to save £55,000 over

3-5 years.

CFT Procurement Team has been briefed on

and is implementing the new NHS Carbon

Reduction Plan requirements set out in the NHS

Net Zero Supplier Roadmap.

All tenders across the system require at least

10% social value and sustainability as part of

quality scores.

Around a quarter of GP practices in Cornwall

are reviewing their banking providers and

considering moving to clean banking that

doesn’t invest in fossil fuels.

Reviewing purchased goods and services

Work with supply chain

RCHT has been reviewing their operations to

embed circular economy principles in some

of their processes, reducing costs and saving

waste and carbon emissions.

The Trust has invested in a Sterimelt

machine, enabling the hospital to recycle

wasted masks and other plastic equipment

which can then be re-made into new items

such as litter pickers and car bumpers.

Circular economy principles

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Food and Nutrion

It is estimated that food and catering services in the NHS accounts for approximately 6% the NHS’ Carbon Footprint Plus. UPF (Ultra processed food) has been shown

to be bad for our health, and bad for our surrounding ecosystems. A healthy balanced diet, with reduced processed foods high in sugar, salt and fats is also a low-

carbon and less polluting diet. The Greener NHS programme has worked closely with the Hospital Food Review and the National Review of NHS Food Standards and

collaborated with NHS catering leads, dieticians and suppliers to provide healthier, locally sourced food to patients, staff and visitors, while cutting emissions related

to agriculture, transport, storage and food waste across the supply chain and on our NHS estate. Our role in this is to ensure that organisations across Cornwall, Devon

and the Isles of Scilly will continue to implement the National standards for healthcare food and drink, and deliver high-quality, healthy and sustainable food, minimising

waste where possible. We will need to reduce the CO2 emissions from food made, processed, or served within organisations by ensuring food is from sustainable

sources, providing healthy food choices and reducing unhealthy foods on offer.

Action

Organisations should continue implementing the National standards for healthcare food and drink, requiring NHS organisations to deliver high-quality, healthy

and sustainable food and minimise waste.

Review and adapt menus to offer healthier lower carbon options for patients, staff and visitors.

Where possible, buy locally sourced, seasonal products.

Promote plant forward diets and healthy eating across the ICSs through encouraging community based growing spaces and other healthy eating initiatives as

part of health care and health creation.

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Food and Nutrition: Work underway across Devon ICS

Food and Nutrition: Work underway across Cornwall and Isles of Scilly ICS

Shop Local

DPT procure local ingredients where possible

which are prepared on site at Langdon Hospital,

supporting local businesses and reducing food

miles. Using the Waste Resource Action Plan

(WRAP) Guardian of Grubs methodology, waste

is measured on each ward to enable a

comparison and monitor where waste is

generated.

TSD have reduced their supply base to only use

reputable vendors that help meet their social

and environmental responsibility. They have

collaborated with key suppliers to ensure that

their fresh fruit and vegetables is sourced from

local suppliers, where possible.

Catering Transformation

A Catering Transformation Project is underway

at UHP to review patient menus options and to

reduce and dispose of food waste sustainably.

TSD have introduced a ‘CarteChoix’ plated meal

service throughout wards, which will result in a

significant reduction of food waste. These meals

are nutritionally balanced and created using

sustainable ingredients. The move from a multi

portion service to a single plated meal will

minimise unnecessary over ordering by caterers.

In addition, they have developed menus that

include greater quantities of plant-based foods.

Cornwall WellFed: Community growing and

healthy eating

GP practices in Cornwall have been referring

cohorts of patients with Type 2 diabetes to the

WellFed Project a local partnership project

offering weekly veg boxes, cookery skills and

hands on activities in community growing spaces

to promote healthier eating and wellbeing,

whilst also supporting local growers in the

county.

Sustainable and local food procurement

CFT procures local goods and services wherever

possible (e.g., fresh food from local companies). The

Trust’s food supplier uses MCS accredited fish, UK

farmers, and their packaging is recyclable.

RCHT are supporting the local economy and

reducing food miles. 70% of suppliers are based in

Devon and Cornwall, with 55% local to Cornwall.

Fresh food strategy

RCHT’s recently approved Food and Drink

Strategy describes how the Trust aims to

provide a high quality and nutritious food and

drink offering to support patients through their

recovery, and enable all to make healthy, and

nutritious food and drink choices.

Key to delivering this, is a thriving catering

service, which has strong relationships with

clinical teams, to plan and deliver an effective

food and drink offering.

Sustainable packaging

Tamar Fresh, who provide patient sandwiches to

both UHP and TSD, have committed to

introducing 100% sustainable packaging for

these products. This includes the clear film on

the cardboard sandwich pack. This demonstrates

a further benefit of collaborating with reputable

local suppliers.

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Adaptaon

As the NHS tackles climate change there is also a need to adapt to the immediate consequences it brings. As climate change accelerates globally, in England we are

seeing direct and immediate consequences of heat waves and extreme weather on our patients, the public and the NHS. Adaptation is the process of adjusting our

systems and infrastructure to continue to operate effectively while the climate changes. It is critical that the NHS can ensure both continuity of essential services, and

a safe environment for patients and staff in even the most challenging times. Many of the changes required to adapt to increasingly severe weather have the potential

to impact on carbon emissions positively in the long term, such as increased use of remote monitoring in the community, and more efficient cooling systems. However,

some changes needed to adapt may impact negatively, such as short-term increase in air conditioning units. The long-term ambition is most of these measures will

offer resilience not only to climate change but to other continuity risks, such as pandemic flu.

The ICSs will need to ensure our infrastructure, services, procurement, local communities and colleagues are prepared for the impacts of climate change, such as heat

waves and flooding. The impacts of climate change will be assessed and adapted to mitigate the negative effects of past and future climate-altering actions. The impact

on public health from climate change will be reduced as much as possible. This will be achieved by:

• Nominating an adaptation lead and incorporate adaptation into our sustainability governance structure, risk register and reporting processes

• The creation of a climate change adaptation risk and opportunities assessment

• Work with key internal and external stakeholders to develop a Climate Change Action Plan for the ICSs

• Ensuring that our emergency plans for extreme weather, consider support for vulnerable communities during any extreme weather events.

Action

Comply with the adaptation provisions within the NHS Core Standards for emergency preparedness, resilience and response (EPRR) and the NHS Standard

Contract to support business continuity during adverse weather events.

Complete an estates review, identifying whether changes are required to deal with extreme weather conditions such as floods and heatwaves, and set out

actions to prepare and improve climate resilience of local sites and services, including digital.

In partnership with EPRR colleagues and others, identify interdependencies between services and the necessary mutual aid requirements to prevent service

disruptions.

Share findings with resilience partners to ensure critical information is integrated into broader emergency planning and climate adaptation planning practices.

Update risk registers across partners to include climate related risks including floods and heatwaves.

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Prevenon and Health Creaon

One of our key aims is to create healthier communities where it is easier for people to stay well and avoid illness in the first place. This involves encouraging healthier

lifestyles and addressing the wider determinants of health. Public health strategies are central to this ambition. Initiatives such as promoting active travel, improving

air quality, ensuring access to quality housing, enhancing green spaces, and supporting climate-resilient communities demonstrate how environmental action can

deliver co-benefits for health and wellbeing. By working together, NHS services and public health teams can implement interventions that reduce emissions, improve

physical and mental wellbeing, and build resilience to climate impacts. This approach not only contributes to carbon reduction targets but also enhances social equity

and public health outcomes.

Air Quality

Air pollution is a major global health issue, causing around seven million premature deaths annually.

The WHO reports that over 99% of the global population breathes air exceeding safe pollutant

levels, with 9 in 10 people exposed to unhealthy air. In the UK, it's the biggest environmental health

risk, linked to 38,000 deaths a year. Costs to the NHS and social care from pollution-related health

issues are projected to rise from £42.88 million in 2017 to over £5.3 billion by 2035. Air pollution

comes from vehicles, domestic fuel burning, industry, and natural sources like wildfires. While

national government leads on air quality, the NHS is reducing its own pollution footprint, cutting

emissions from travel, procurement, construction, and energy use.

Through delivering the actions in this plan we can reduce our emissions and the air pollution we

create. Initiatives such as delivering more care virtually and redesigning care models to deliver care

in communities will reduce travel and improve local air quality leading to better respiratory health

and a reduced cancer risk for our populations. Likewise, encouraging more active travel such as

walking and cycling reduces air pollution and also contributes to improving health by reducing risks

of cardiovascular disease, cancer and dementia.

Warm Homes

The rising cost of living and increasing fuel poverty present significant challenges to both public health and environmental sustainability. Many homes and public

buildings across the South West Peninsula still rely on fossil fuel-based heating systems and lack adequate insulation, resulting in inefficient energy use and higher

Figure 10: How air pollution affects people throughout their lifetime

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emissions. These issues disproportionately affect vulnerable populations, exacerbating health inequalities and placing additional strain on health and care services.

Tackling fuel poverty through energy-efficient retrofitting, transitioning to low-carbon heating solutions, and supporting access to affordable renewable energy is

essential. Not only will this reduce carbon emissions, but it will also improve indoor air quality, reduce cold-related illnesses, and enhance resilience to climate change.

We are already working collaboratively with Councils to improve energy efficiency, promote low-carbon heating technologies, and support vulnerable households.

These joint efforts not only contribute to our Net Zero goals but also enhance community resilience, reduce health inequalities, and improve long-term wellbeing

across the peninsula.

Action

We will work collaboratively to improve the general health of our population through improving air quality and air pollution in line with Cornwall, Devon and the

Isles of Scilly Clean Air strategies.

We will work collaboratively across all partners across the peninsula including NHS, public health, local authorities, VCSE and other partners to create healthier

places and communities that support wellbeing in line with the 10-year plan for the NHS and wider public health strategies.

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Social Value and Anchor Instuons

Whilst this Green Plan primarily focuses on the environmental aspects of sustainability, it is equally important to recognise and align with the social and economic

dimensions. Reducing health inequalities is a core priority across the South West Peninsula, and this Green Plan will support and complement existing work in these

areas through collaborative action.

Social value and anchor institutions play a central role in how the NHS approaches sustainability. The concept of social value, requiring organisations to consider the

economic, environmental, and social impact of their activities, is underpinned by the Public Services (Social Value) Act 2012 and further reinforced by Policy

Procurement Note (PPN) 06/20. These regulations require suppliers to clearly demonstrate the social value delivered through their contracts. Within the NHS, this

became a formal requirement from 1 April 2022, following national guidance issued by NHS England.

As anchor institutions, NHS organisations are deeply embedded in their local communities. With significant influence through employment, procurement, and estate

management, we have a responsibility to use our resources to support inclusive local growth, improve wellbeing, and reduce inequalities. By leveraging our position

as anchor institutions, we can create lasting social and economic benefits, supporting the local economy, investing in community resilience, and ensuring our

sustainability efforts contribute to healthier, fairer places in line with local public health and community development priorities.

This approach aligns with the Net Zero agenda and the NHS supplier roadmap, bringing together environmental, social, and economic goals into a unified strategy for

sustainable development.

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Governance and Accountability

Clear leadership and accountability are needed to ensure progress against this strategy is delivered consistently, efficiently and at pace across our system. Therefore,

it is essential that we are accountable for delivering the Green Plan, and that policies, procedures, business cases and processes reflect this.

The Net Zero portfolio is currently led by the ICS Director of Estates in Devon and the ICS Chief of Staff in Cornwall

and the Isles of Scilly, acting as Senior Responsible Officers (SROs). Delivery of the Green Plan will be driven by NHS

partner members through the South West Peninsula Sustainability Group. This group will be formalised from the

two existing collaborative Sustainability groups in Devon and Cornwall and Isles of Scilly. The initial meetings of this

group will be focused on reviewing and developing, where required, local plans which outline in more detail the

timescales and ownership of the actions described in this strategic document and how we will meet the key

national milestones and targets (summarised in Appendix 1) across the peninsula.

Cornwall and Isles of Scilly ICB and Devon ICB working in partnership are developing their cluster governance

arrangements. Once the appropriate committee with oversight of the Green Plan is confirmed, progress updates

will be reported to the SROs and the designated assurance committee, which will report into to the newly

established South West Peninsula ICB Cluster Board as required. Formal governance arrangements will be agreed

and appended to a future iteration of the Green Plan to ensure clear accountability and effective delivery.

To measure progress we will continue to use existing data, metrics and reporting including:

• Monitoring of key Net Zero service requirements in the NHS Standard Contract Service Conditions.

• Submitting an annual summary of progress on delivery of green plans to relevant boards and publishing this in annual reports, including actions taken and

planned, with quantitative progress data.

• Completing the national Greener NHS quarterly and annual data collections on key national metrics (see appendix 2).

• Utilising other data sources and tools available such as the Green Plan support tool and dashboards to monitor progress.

We will use these key sources of data where possible to set targets and KPIs to measure progress against this strategy. Individual organisational Green Plans and local

action plans will also use more detailed metrics and KPIs as required to measure progress. This plan will be reviewed annually or sooner by the NHS South West

Peninsula Integrated Care Board Cluster and its partner NHS organisations as required to align to ongoing ICB operating model and regional changes.

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Appendix 1 – Naonal Roadmap

Key national targets and milestones

Date

Milestone

Strategy

By 2026

Vehicle salary sacrifice schemes must offer electric vehicles only; green travel strategies included in

Green Plans

Net Zero Travel & Transport Strategy

From 2027

All new NHS-owned or leased vehicles (except ambulances) must be zero-emission

Net Zero Travel & Transport Strategy

April 2027

All suppliers must report global Scope 1, 2 & 3 emissions and publish Carbon Reduction Plans

Net Zero Supplier Roadmap

From 2028

Suppliers must provide carbon footprinting for individual NHS products

Net Zero Supplier Roadmap

By 2028

All oil-based primary heating systems to be removed from NHS sites

Net Zero Estates & Facilities

By 2030

All new NHS ambulances must be zero-emission

Net Zero Travel & Transport Strategy

From 2030

Only suppliers showing emissions reporting progress will qualify for NHS contracts

Net Zero Supplier Roadmap

By 2032

Identify and begin phasing out all fossil-fuel primary heating systems

Net Zero Estates & Facilities

By 2032

NHS to cut 80% of emissions it controls directly

NHS Net Zero Goal

By 2033

Staff travel emissions reduced by 50% through active travel, shared/public transport, EVs

Net Zero Travel & Transport Strategy

By 2035

All non-emergency transport and all NHS-owned/leased vehicles (except ambulances) must be zero-

emission

Net Zero Travel & Transport Strategy

By 2036

50% of ambulance fleet must be zero-emission

Net Zero Travel & Transport Strategy

By 2039

NHS to cut 80% of emissions it can influence

NHS Net Zero Goal

By 2040

All NHS vehicles (including ambulances) and business travel must be zero-emission

Net Zero Travel & Transport Strategy

By 2040

NHS achieves Net Zero Carbon Footprint (emissions NHS can control)

NHS Net Zero Goal

By 2045

NHS achieves Net Zero Carbon Footprint Plus (emissions NHS can influence)

NHS Net Zero Goal

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Appendix 2 – Naonal Metrics

The table below sets out the national metrics for tracking progress against Green Plan delivery which are collated on a quarterly and annual basis as part of regular

data gathering by the Greener NHS team. The list is not exhaustive and may be updated as new data streams become available. This data will be used where applicable

for national, regional and organisational monitoring and benchmarking but will not be published in line with guidance.

Focus area

Metric

For use by

Data source

Workforce

Named board-level lead for green plan delivery

Trusts and systems

Greener NHS dashboard

(from Q1 25/26)

Medicines

Emissions (tCO2e) and volume (litres) of nitrous oxide by trust

Trusts and systems (aggregate of trust data)

Greener NHS dashboard

Medicines

Emissions (tCO2e) and volume (litres) of nitrous oxide and

oxygen (gas and air) by trust

Trusts and systems (aggregate of trust data)

Greener NHS dashboard

Medicines

Average inhaler emissions per 1,000 patients

Systems (aggregate of primary care data)

Greener NHS dashboard

(from Q1 25/26)

Medicines

Mean emissions of Short-acting beta-2 agonists (SABAs)

inhalers prescribed

Systems (aggregate of primary care data)

Greener NHS dashboard

Medicines

% of non-SABA inhalers that are MDIs

Systems (aggregate of primary care data)

Greener NHS dashboard

Travel and

transport

% of owned and leased fleet that is ultra-low emission vehicle

(ULEV) or zero-emission vehicle (ZEV)

Trusts and systems (aggregate of trust data)

Greener NHS dashboard

Travel and

transport

Total fleet emissions

Trusts and systems (aggregate of trust data)

Greener NHS dashboard

Travel and

transport

Does the organisation offer only ZEVs in its salary sacrifice

scheme

Trusts and systems (aggregate of trust data)

Greener NHS dashboard

Travel and

transport

Does the organisation operate sustainable travel-related

schemes for staff (for example, salary sacrifice cycle-to-work)

Trusts and systems (aggregate of trust data)

Greener NHS dashboard

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Focus area

Metric

For use by

Data source

Estates and

facilities

Emissions from fossil-fuel-led heating sources

Trusts and systems (aggregate of trust data)

Greener NHS dashboard

Estates and

facilities

Number of oil-led heating systems

Trusts and systems (aggregate of trust data)

Estates Return Information

Collection/Greener NHS

dashboard (from Q4 24/25)

Estates and

facilities

% of gross internal area covered by LED lighting

Trusts and systems (aggregate of trust data)

Estates Return Information

Collection/Greener NHS

dashboard (from Q4 24/25)

Estates and

facilities

% of sites with a heat decarbonisation plan

Trusts and systems (aggregate of trust data)

Estates Return Information

Collection/Greener NHS

dashboard (from Q4 24/25)

Supply chain and

procurement

Inclusion of Carbon Reduction Plan and Net Zero Commitment

requirements in all relevant procurements

Trusts and systems

Greener NHS dashboard

Supply chain and

procurement

Inclusion of requirements for a minimum 10% Net Zero and

social value weighting in procurements, including defined KPIs

Trusts and systems

Greener NHS dashboard

Food and

nutrition

Weight (tonnes) of food waste, with further break down by

spoilage, production, unserved and plate waste

Trusts and systems (aggregate of trust data)

Estates Return Information

Collection

Adaptation

Number of overheating occurrences triggering a risk

assessment (in line with trust’s “heatwave” plan)

Trusts and systems (aggregate of trust data)

Estates Return Information

Collection

Adaptation

Number of flood occurrences triggering a risk assessment

Trusts and systems (aggregate of trust data)

Estates Return Information

Collection

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Appendix 3 – Cornwall Primary Care Programme 2023-25

Action Area

2030 Target

01 – Declaring a climate emergency

100% of all Cornish Practices declaring the emergency and the action they are taking

02 – Optimising our Inhalers

100% of Cornish Practices supporting low carbon inhaler use and active lifestyles

03 – Controlling our carbon footprint

100% of Cornish Practices undertaking annual carbon footprints

04 – Optimising our energy

50% of Cornish Practices to be banking clean and investing their finances in a healthy future for all

05 – Greening up our banking

100% Cornish Practices working on decarbonising and optimising prescribing

06 – Optimising our prescribing

100% Cornish Practices working on decarbonising and optimising prescribing

07 – Engaging our patients

100% of Cornish Practices working with staff and patients on climate resilience

08 – Activating our travel

100% of Cornish Practices actively promoting active travel for staff and patients with messaging and kit

09 – Reducing, reusing and recycling

100% of Cornish Practices actively reducing clinical and non-clinical waste and supporting Only Order What You Need Campaign

10 – Toolkit for change

100% of Cornish Practices using the Toolkit and other emerging tools to reduce negative impacts, improve resilience to climate

breakdown and support health creation

11 – Creating green spaces for health

100% of Cornish Practices developing green spaces for staff, patient, visitor and planetary health

12 – Food for people and planet

100% of Cornish Practices offering food, learning and activity in our community based green growing spaces as part of

healthcare and health creation

13 – Connecting with our

communities

85% of Cornish Practices are actively working with their community on climate resilience and health creation

14 – Learning and Leading

85% of Cornish Practices are actively investing in learning, training and communication on climate resilience

15 – Advocating for health creation

100% of Cornish Practices are actively advocating for climate resilience and health creation

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Equality impact assessment

Name of plan or service to be assessed: Green Plan – strategic oversight of the

Green agenda

Department or section: EPRR

Date of assessment: 25 September 2025

Person(s) responsible for the assessment: Jess Child, head of EPRR

Is this a new or existing plan? New

Aims, objectives and purpose of the plan

Describe the aims, objectives, and purpose of the plan.

The Green Plan is designed to benefit all individuals and communities by outlining

the strategic aim for environmental sustainability, improving public health, and

enhancing resilience to climate related risks. The strategic intent of the plan links to

the NHS England 10-year plan requirements. Key intended beneficiaries include:

• Patients and service users: Through improved air quality, reduced carbon

emissions, and healthier environments around healthcare facilities, patients

particularly those with respiratory or cardiovascular conditions will experience

better health outcomes.

• Staff and volunteers: A greener, more sustainable working environment

contributes to staff wellbeing, reduces exposure to pollutants, and supports a

culture of environmental responsibility.

• Local communities: By reducing the environmental footprint of healthcare

services and promoting active travel, energy efficiency, and biodiversity, the plan

supports healthier, more equitable communities.

• Vulnerable and marginalised groups: Including those from ethnic minority

backgrounds, low-income households, and people with disabilities who may be

disproportionately affected by environmental degradation and climate change. The

plan aims to address these disparities through inclusive engagement including

staff groups and targeted interventions.

• Future generations: By embedding sustainability into healthcare delivery, the

plan helps safeguard environmental and public health for the long term and build

on the ambition of the 10-year plan.

• Communication and engagement: By ensuring that we engage with all

members of the community including staff group and patients through the

implementation of the Green plan to ensure equal representation through any

service changes or adaptation to infrastructure or estates.

The plan is underpinned by a commitment to equity, inclusion, and accessibility,

ensuring that the benefits of the Green Plan are shared fairly across all population

groups.

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Page 2

Who is intended to benefit from this plan, and in what way?

The Green Plan is intended to benefit a wide range of individuals and groups, both

within the organisation and across the wider community. Key beneficiaries include:

• Patients and service users: By improving environmental conditions such as air

quality, energy efficiency, and access to green spaces, access to healthier foods,

the plan supports better health outcomes particularly for those with respiratory

conditions, cardiovascular disease, Type 2 diabetes, or other vulnerabilities

exacerbated by environmental factors.

• Staff and volunteers: A healthier, more sustainable working environment

contributes to improved wellbeing, reduced exposure to pollutants, and increased

opportunities for active travel and engagement in sustainability initiatives.

• Local communities: The plan promotes environmental justice by addressing

inequalities in exposure to pollution and climate-related risks. It supports healthier

living environments and encourages community participation in sustainability

efforts.

• People from protected characteristic groups: Including ethnic minorities, older

people, disabled individuals, and those from lower socioeconomic backgrounds

who may be disproportionately impacted by environmental degradation. The plan

aims to ensure equitable access to its benefits through inclusive design and

engagement.

• Future generations: By embedding sustainability into healthcare delivery and

infrastructure, the plan helps safeguard environmental and public health for years

to come.

The plan is guided by principles of equity, inclusion, and accessibility, ensuring that

its benefits are distributed fairly and that no group is left behind in the transition to a

more sustainable health and care system

What outcomes are wanted from this plan?

The Green Plan aims to outline the strategic aim on a range of environmental,

health, social, and organisational outcomes that align with the NHS’s commitment to

sustainability and equity. The key desired outcomes include:

• Reduced environmental impact: Lower carbon emissions, improved energy

efficiency, reduced waste, and enhanced biodiversity across healthcare estates

and services.

• Improved public health: By addressing environmental determinants of health

such as air quality, active travel, healthier diets and access to green spaces the

plan supports better physical and mental health outcomes for patients, staff, and

communities.

• Health equity: The plan seeks to reduce health inequalities by ensuring that

vulnerable and marginalised groups, including those from ethnic minority

backgrounds and lower-income communities, are not disproportionately affected

by environmental risks.

• Inclusive engagement: Ensuring that all communities have the opportunity to

contribute to and benefit from sustainability initiatives, with targeted outreach to

underrepresented groups.

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Page 3

• Resilient healthcare services: Building climate resilience into healthcare

infrastructure and operations to ensure continuity of care during extreme weather

events and other environmental disruptions.

• Cultural and behavioural change: Embedding sustainability into everyday

practice, encouraging staff and service users to adopt environmentally responsible

behaviours.

• Compliance and leadership: Meeting national and regional sustainability targets

and positioning the organisation as a leader in sustainable healthcare delivery.

These outcomes are intended to benefit all stakeholders while ensuring that no

group is disadvantaged in the transition to a greener, fairer health and care system.

What factors or forces could contribute or detract from the outcomes?

A range of internal and external factors could influence the success of the Green

Plan and its ability to strategically lead equitable and sustainable outcomes:

Contributing Factors:

• Strong leadership and governance: Clear accountability and senior-level

support will drive implementation and ensure sustainability is embedded across

the organisation.

• Staff engagement and training: Empowering staff with knowledge and tools to

support green initiatives will foster a culture of sustainability and inclusion.

• Community involvement: Inclusive engagement with diverse communities,

including those from ethnic minority backgrounds, will ensure the plan reflects

local needs and priorities.

• Partnership working: Collaboration with local authorities, voluntary sector

organisations, and other NHS bodies will enhance impact and resource sharing.

• Data and monitoring: Robust data collection against national key performance

indicators and analysis will help track progress, identify disparities, and inform

responsive action.

Detracting Factors:

• Resource constraints: Limited funding, staffing, or infrastructure may hinder

implementation or delay progress.

• Lack of inclusive engagement: Failure to involve underrepresented groups

could lead to unequal access to benefits and missed opportunities for co-design.

• Resistance to change: Cultural or behavioural resistance within the organisation

may slow adoption of sustainable practices.

• Digital exclusion: Reliance on digital tools for communication or engagement

may exclude individuals without access or digital literacy.

• Environmental inequalities: Pre-existing disparities in exposure to pollution or

climate risks may be exacerbated if not actively addressed.

To mitigate these risks, the Green Plan includes a commitment to inclusive design,

targeted outreach, and continuous evaluation, ensuring that all communities

especially those most at risk benefit equitably from its outcomes.

Who are the main stakeholders in relation to the plan?

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The Green Plan involves a wide range of stakeholders, each playing a vital role in its

development, implementation, and success. Key stakeholders include:

• Patients and service users: As primary beneficiaries, their health and wellbeing

are directly impacted by improvements in environmental quality and sustainability

within healthcare settings.

• Staff and volunteers: Including clinical, non-clinical, and support staff, who

contribute to and are affected by changes in workplace practices, infrastructure,

and culture related to sustainability.

• Local communities: Particularly those living near healthcare facilities or in areas

vulnerable to environmental risks. Their involvement is essential to ensure the

plan reflects local needs and promotes equitable outcomes.

• People from protected characteristic groups: Including ethnic minorities,

disabled individuals, and older adults, may be disproportionately affected by

environmental challenges and must be considered in all aspects of the plan.

• NHS Cornwall and the Isles of Scilly Integrated Care Board (ICB): As the

strategic lead, the ICB is responsible for aligning the Green Plan with regional

health priorities and ensuring it supports system wide sustainability goals.

• Partner organisations: Including local authorities, voluntary and community

sector organisations, educational institutions, and other NHS bodies whose

collaboration is essential for integrated and impactful delivery.

• Suppliers and contractors: Who influence the environmental footprint of

healthcare services through procurement, transport, and waste management

practices.

• Regulatory and oversight bodies: Such as NHS England, the Care Quality

Commission, and the Environment Agency, which provide guidance, standards,

and accountability.

Engaging these stakeholders meaningfully and inclusively is critical to ensuring the

Green Plan strategically leads equitable, sustainable, and locally relevant outcomes.

Who implements the plan, and who is responsible for the plan?

The implementation of the Green Plan is a shared responsibility across the peninsula

with clear leadership and accountability structures in place to ensure its success.

Implementation is carried out by:

• Provider Operational teams across estates, facilities, procurement, clinical

services, and digital infrastructure, who integrate sustainability practices into day-

to-day activities.

• Staff and volunteers, who contribute through environmentally conscious

behaviours and participation in green initiatives.

• Service leads and managers, who ensure that sustainability goals are embedded

within service delivery and improvement plans.

Responsibility for the plan lies with:

• The Integrated Care Boards through the cluster arrangement, which provides

strategic oversight, ensures alignment with national NHS sustainability targets,

and monitors progress.

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• The Sustainability or Green Plan Lead, who coordinates implementation,

reporting, and stakeholder engagement.

• The Executive Leadership Team, which ensures that sustainability is prioritised at

the highest level and that resources are allocated appropriately.

Clear governance structures, regular reporting, and inclusive engagement

mechanisms are in place to ensure that the Green Plan is implemented effectively

and equitably, with accountability for delivering both environmental and social

outcomes.

Differential impacts

Does this have a positive or negative impact on people from an ethnic minority

background? How will any negative impact be mitigated?

The Green Plan is expected to have a neutral to positive impact on people from

ethnic minority backgrounds. By promoting sustainability, improving air quality, and

reducing environmental hazards, the plan contributes to better public health

outcomes particularly in urban areas where ethnic minority communities may be

disproportionately affected by pollution and climate-related risks. Ethnic minorities in

the UK are more likely to experience health vulnerabilities. Studies show that some

ethnic minority groups have a higher risk of developing multiple long-term conditions

(MLTCs) and experience poorer health compared to the white population.

Additionally, they may face increased risks for conditions such as diabetes and

stroke.

Additionally, the plan supports inclusive engagement and aims to ensure that all

communities, including staff networks, ethnic minorities, are involved in shaping and

benefiting from environmental improvements.

How will any negative impact be mitigated?

While no direct negative impacts are anticipated, there is a risk that ethnic minority

groups may be underrepresented in consultation processes or may face barriers to

accessing green initiatives (for example, due to language, cultural differences, or

socioeconomic factors).

To mitigate this:

• Accessible communication materials can be provided in multiple languages and

formats.

• Partnerships with community leaders and organisations will be established where

possible to build trust and ensure culturally appropriate outreach.

• Monitoring and evaluation will include demographic data to assess participation

and impact across different ethnic groups, allowing for responsive adjustments.

Does this have a positive or negative impact on people who identify as male,

female or intersex? How will any negative impact be mitigated?

The Green Plan is expected to have a neutral to positive impact on people of all

gender identities, including those who identify as male, female, or intersex. The plan

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is designed to improve environmental conditions and public health outcomes, which

benefit all individuals regardless of sex.

However, it is recognised that the protected characteristic of sex can intersect with

other factors such as access to healthcare, employment patterns, and caring

responsibilities which may influence how individuals experience the impacts of

environmental policies.

Potential Negative Impacts and Mitigation:

• Access and engagement: If communication and engagement strategies are not

inclusive, some groups may feel excluded or underrepresented.

• Mitigation: Ensure that all communications and consultations use inclusive

language and imagery and actively seek input from different communities.

• Workplace impacts: Sustainability initiatives may affect working practices (for

example, travel, uniform policies, facilities use) in ways that unintentionally

disadvantage certain sexes.

• Mitigation: Conduct sex sensitive reviews of operational changes and ensure that

facilities (such as toilets, changing areas) are inclusive and accessible to all.

Ensure any new builds and estate management in line with the Green plan ensure

inclusive and accessibility needs are considered.

• Health equity: Environmental risks may disproportionately affect certain groups

due to biological or social factors (such as higher rates of respiratory conditions in

women).

• Mitigation: Monitor health outcomes by sex and ensure targeted interventions

where disparities are identified.

The Green Plan is committed to equality, diversity, and inclusion. Ongoing

monitoring and stakeholder engagement will help ensure that any unintended

impacts are identified early and addressed appropriately.

What is the positive or negative differential impact on people from the

perspective of disability? How will any negative impact be mitigated?

The Green Plan is expected to have a positive impact on people with disabilities,

particularly through improvements in environmental quality, access to green spaces,

and healthier built environments. The plan supports better health outcomes

particularly for those with respiratory conditions, cardiovascular disease, Type 2

diabetes, or other vulnerabilities exacerbated by environmental factors. However, it

is essential to recognise and address potential barriers to ensure full inclusion.

Positive Impacts:

• Improved air quality and reduced pollution can benefit individuals with or at risk of

developing respiratory or cardiovascular conditions.

• Accessible green spaces and active travel routes can support physical and mental

wellbeing for people with a disability or long-term condition.

• Inclusive design of healthcare facilities aligned with sustainability goals can

enhance accessibility and comfort.

Potential Negative Impacts and Mitigation:

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• Physical accessibility: Sustainability upgrades (such as changes to buildings,

transport routes, or energy systems) may unintentionally reduce accessibility if not

designed inclusively.

• Mitigation: All infrastructure changes will be subject to accessibility audits and co-

designed with stakeholders with a range of disabilities and long-term conditions.

• Digital exclusion: Increased reliance on digital tools for engagement or service

delivery may disadvantage individuals with sensory, cognitive, or physical

impairments.

• Mitigation: Provide alternative formats (e.g. Easy Read, audio, large print) and

ensure digital platforms meet accessibility standards.

• Engagement barriers: People with a disability may be underrepresented in

consultation processes.

• Mitigation: Proactive outreach through disability advocacy groups, accessible

venues, and inclusive communication methods will be used to ensure meaningful

participation.

• Transport and mobility: Promotion of active travel must consider the needs of

those who rely on assisted transport or mobility aids.

• Mitigation: Ensure travel planning includes accessible options and does not

disadvantage those unable to walk or cycle.

The Green Plan will be implemented with a commitment to universal design,

inclusive engagement, and continuous monitoring, ensuring that disabled people are

not only protected from negative impacts but actively benefit from sustainability

improvements.

Does this have a positive or negative impact on people who identify as

heterosexual, lesbian, gay, bisexual, pansexual or asexual? How will any

negative impact be mitigated?

The Green Plan is expected to have a neutral to positive impact on individuals of all

sexual orientations, including those who identify as heterosexual, lesbian, gay,

bisexual, pansexual, or asexual (LGBTQ+). The plan focuses on environmental

sustainability and public health, which are universally beneficial and not inherently

linked to sexual orientation.

However, it is important to ensure that the implementation of the plan is inclusive and

does not inadvertently exclude or marginalise LGBTQ+ individuals.

Potential Negative Impacts and Mitigation:

• Inclusive engagement: If consultation and communication processes do not

actively include LGBTQ+ voices, there is a risk that their specific needs or

perspectives may be overlooked.

• Mitigation: Ensure that engagement activities are inclusive, using diverse imagery

and language, and involve LGBTQ+ networks and advocacy groups.

• Workplace culture: Sustainability initiatives may intersect with workplace practices

(e.g. uniform policies, shared facilities, wellbeing programmes) that could impact

LGBTQ+ staff differently.

• Mitigation: Apply an equality lens to all operational changes and ensure that

policies are reviewed for inclusivity and sensitivity to diverse identities.

• Visibility and representation: If LGBTQ+ individuals are not visibly represented in

sustainability campaigns or leadership roles, it may reinforce feelings of exclusion.

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• Mitigation: Promote diverse representation in communications and leadership

opportunities related to the Green Plan.

The Green Plan will be delivered in alignment with the organisation’s commitment

to equality, diversity, and inclusion, ensuring that individuals of all sexual orientations

are respected, represented, and able to benefit fully from its outcomes.

What is the positive or negative differential impact on people from the

perspective of age? How will any negative impact be mitigated?

The Green Plan is expected to have a positive impact across all age groups, with

particular benefits for both younger and older populations. However, differential

impacts may arise due to varying levels of access, mobility, and engagement, which

must be considered and addressed.

Positive Impacts:

• Children and young people: Benefit from improved air quality, reduced exposure

to pollutants, healthier diets and increased access to green spaces, which support

physical and mental development.

• Older adults: Gain from healthier environments, reduced respiratory and

cardiovascular risks, healthier diets and improved access to nature, which can

enhance wellbeing and reduce isolation.

• Future generations: The long-term sustainability goals of the Green Plan help

safeguard environmental and public health for those yet to be born.

Potential Negative Impacts and Mitigation:

• Digital exclusion: Older adults may be less likely to engage with digital platforms

used for communication or consultation.

• Mitigation: Provide non-digital alternatives such as printed materials, and in-

person events.

• Mobility and access: Infrastructure changes (e.g. promotion of active travel or

redesign of facilities) may unintentionally disadvantage those with limited mobility,

including older people.

• Mitigation: Ensure all changes are subject to accessibility reviews and include

age-friendly design principles.

• Engagement barriers: Young people may feel excluded from decision-making

processes, while older adults may be underrepresented due to accessibility or

communication challenges.

• Mitigation: Use targeted outreach to schools, youth groups, and older people’s

organisations to ensure inclusive participation.

The Green Plan will be implemented with a commitment to intergenerational equity,

ensuring that people of all ages are considered, consulted, and able to benefit from

its outcomes. Ongoing monitoring will help identify and address any unintended age-

related disparities.

What is the positive or negative differential impact on people from the

perspective of religion or belief? How will any negative impact be mitigated?

The Green Plan is expected to have a neutral to positive impact on individuals of all

religions and beliefs. Its focus on environmental sustainability and public health

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aligns with many faith-based values around stewardship of the Earth, care for

creation, and community wellbeing.

However, it is important to ensure that the implementation of the plan respects and

accommodates diverse religious practices and beliefs.

Positive Impacts:

• Shared values: Many religious and belief systems promote environmental

responsibility, which may encourage engagement and support for the Green Plan.

• Community cohesion: Inclusive sustainability initiatives can foster collaboration

across faith groups and strengthen community ties.

Potential Negative Impacts and Mitigation:

• Cultural or religious observances: Sustainability-related changes to services,

facilities, or working practices (e.g. energy use, food provision, uniform policies)

may unintentionally conflict with religious customs or dietary requirements.

• Mitigation: Conduct impact assessments for any operational changes and consult

with faith representatives to ensure respectful accommodation.

• Engagement and representation: If religious groups are not actively included in

consultation processes, their perspectives may be overlooked.

• Mitigation: Engage with local faith communities and interfaith networks to ensure

inclusive participation and feedback.

• Facilities and spaces: Changes to estate design or use of space may affect

areas used for prayer or reflection.

• Mitigation: Ensure that spiritual needs are considered in estate planning and that

multi-faith spaces remain accessible and inclusive.

The Green Plan will be implemented with a commitment to respecting religious

diversity, ensuring that individuals of all faiths and beliefs are considered, consulted,

and able to benefit equitably from its outcomes.

What is the positive or negative differential impact on people from the

perspective of marriage and civil partnership? This is particularly relevant for

employment policies. How will any negative impact be mitigated?

The Green Plan is expected to have a neutral impact on individuals based on their

marital or civil partnership status. The plan focuses on environmental sustainability

and public health, which are not directly influenced by whether someone is married

or in a civil partnership.

However, in the context of employment policies and working practices, it is important

to consider how sustainability initiatives may intersect with personal and family

responsibilities, which can be influenced by marital or partnership status.

Potential Negative Impacts and Mitigation:

• Flexible working and travel policies: Changes to commuting expectations (e.g.

promotion of active travel or reduced car use) may affect employees with caring

responsibilities or those who coordinate travel with a partner.

• Mitigation: Ensure that sustainability related changes to travel or working

arrangements are flexible and consider individual circumstances, including family

and partnership commitments.

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• Work-life balance: Sustainability initiatives that alter shift patterns, remote

working, or facility access may impact employees’ ability to balance work with

family or partnership responsibilities.

• Mitigation: Conduct equality impact assessments on any employment related

changes and consult with staff to identify and address unintended consequences.

• Access to benefits or leave: Ensure that any new policies introduced under the

Green Plan (e.g. volunteering days, wellbeing initiatives) are equally accessible to

all staff, regardless of marital or partnership status.

The Green Plan will be implemented in line with the organisation’s commitment

to fair employment practices, ensuring that individuals in marriages or civil

partnerships are not disadvantaged and that workplace policies remain inclusive and

equitable.

Does this have a positive or negative impact on people who identify as trans or

transgender, non-binary, or gender fluid? How will any negative impact be

mitigated?

The Green Plan is expected to have a neutral to positive impact on people who

identify as trans, non-binary, or gender fluid. While the plan focuses on

environmental sustainability and public health, it must be implemented in a way that

is inclusive and respectful of all gender identities to ensure equitable access and

participation.

Potential Positive Impacts:

• Inclusive public health improvements: Better air quality, access to green

spaces, and healthier environments benefit all individuals, including those from

gender-diverse communities.

• Opportunities for visibility and inclusion: Sustainability initiatives can provide

platforms for diverse voices and promote inclusive leadership.

Potential Negative Impacts and Mitigation:

• Facilities and infrastructure: Changes to buildings or estates (e.g. toilets,

changing rooms) may unintentionally reinforce binary gender norms or exclude

non-binary and gender fluid individuals.

• Mitigation: Ensure that all facilities are designed with inclusivity in mind.

• Workplace culture and engagement: If sustainability initiatives do not actively

include trans and non-binary staff, there is a risk of exclusion or invisibility.

• Mitigation: Engage with LGBTQ+ staff networks and ensure inclusive

representation in planning and communications.

• Language and communication: Use of non-inclusive language in plan

documents or promotional materials may alienate individuals.

• Mitigation: Review all materials for inclusive language and imagery and provide

staff training on gender inclusivity.

The Green Plan will be delivered in alignment with the organisation’s commitment

to equality, diversity, and inclusion, ensuring that trans, non-binary, and gender fluid

individuals are respected, represented, and able to benefit fully from its outcomes.

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Does this have a positive or negative impact on people who are pregnant,

people who are breast feeding, or those on maternity leave? How will any

negative impact be mitigated?

The Green Plan is expected to have a neutral to positive impact on people who are

pregnant, breastfeeding, or on maternity leave. Improvements in environmental

quality, such as cleaner air and reduced exposure to pollutants, can contribute to

better health outcomes for both parents and infants. However, it is important to

ensure that sustainability initiatives do not inadvertently create barriers for this group.

Positive Impacts:

• Improved air quality and healthier environments can benefit pregnant

individuals and newborns, reducing risks associated with respiratory and

developmental conditions.

• Access to green spaces and nature-based wellbeing initiatives can support

mental health and recovery during pregnancy and postnatal periods.

Potential Negative Impacts and Mitigation:

• Workplace adjustments: Sustainability related changes to facilities, travel

policies, or working arrangements may unintentionally affect comfort, accessibility,

or flexibility for pregnant or breastfeeding staff.

• Mitigation: Ensure that all changes are reviewed through a health and safety lens

and accommodate the needs of pregnant and breastfeeding individuals, including

access to rest areas and private spaces for feeding.

• Engagement and inclusion: Staff on maternity leave may miss opportunities to

contribute to or benefit from sustainability initiatives.

• Mitigation: Provide flexible engagement options and ensure that communications

and updates are accessible to staff on leave.

• Travel and mobility: Promotion of active travel must consider the physical

limitations or safety concerns for pregnant individuals.

• Mitigation: Offer alternative travel options and ensure risk assessments are in

place for staff affected by pregnancy or postnatal recovery.

The Green Plan will be implemented in line with the organisation’s commitment

to inclusive employment practices and family-friendly policies, ensuring that pregnant

and breastfeeding individuals, as well as those on maternity leave, are supported

and able to benefit equitably from its outcomes.

Are there any other identified groups? How will any negative impact be

mitigated?

In addition to the protected characteristics under the Equality Act 2010, the Green

Plan may have differential impacts on other identified groups, including:

Carers

Individuals with caring responsibilities may be affected by changes to travel, working

arrangements, or access to services.

• Mitigation: Ensure flexible working options and consider the needs of carers in

service design and staff policies.

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People from lower socio-economic backgrounds

Environmental improvements may not be equally accessible to those facing financial

hardship, particularly if sustainability initiatives require personal investment (e.g.

active travel equipment, energy efficient technologies).

• Mitigation: Ensure affordability and accessibility are considered in all initiatives

and provide targeted support where needed.

Rural and remote communities

People living in rural areas may face barriers to accessing green infrastructure,

sustainable transport, or engagement opportunities.

• Mitigation: Tailor initiatives to local contexts, including transport planning and

digital inclusion strategies, and engage with rural stakeholders.

People with limited digital access or literacy

Digital tools used for engagement, education, or service delivery may exclude those

without reliable internet access or digital skills.

• Mitigation: Provide non-digital alternatives and support digital literacy through

training and outreach.

Migrants and asylum seekers

Language barriers and unfamiliarity with local systems may limit access to the

benefits of the Green Plan.

• Mitigation: Offer translated materials, culturally sensitive engagement, and

work with community organisations to reach these groups.

The Green Plan will be implemented with a commitment to inclusive design,

equitable access, and continuous engagement, ensuring that all identified groups are

considered and supported throughout its delivery.

Human rights values

How have the core human rights values of fairness, respect, equality, dignity,

and autonomy been considered in the formulation of this plan, service, or

strategy?

The formulation of the Green Plan has been guided by the core human rights values

of fairness, respect, equality, dignity, and autonomy, ensuring that sustainability

efforts are inclusive, equitable, and responsive to the needs of all individuals and

communities.

Fairness

The Green Plan aims to distribute environmental and health benefits equitably

across all population groups, with particular attention to those who may be

disproportionately affected by climate change and environmental degradation. This

includes targeted engagement and support for vulnerable and marginalised

communities.

Respect

Respect for individual identities, beliefs, and lived experiences is embedded

throughout the plan. Engagement processes have been designed to be inclusive of

diverse voices, including those from protected characteristic groups, and all

communications are developed with cultural sensitivity and inclusive language.

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Equality

The Green Plan aligns with the NHS 10-year plan, Equality Act 2010 and NHS

equality objectives, ensuring that no group is disadvantaged in the transition to

sustainable healthcare. Equality impact assessments are encouraged to be

conducted across all key areas of the plan to identify and mitigate any differential

impacts.

Dignity

All infrastructure, service, and workplace changes proposed under the Green Plan

are reviewed to ensure they uphold the dignity of patients, staff, and service users.

This includes accessible design, inclusive facilities, and respectful treatment of all

individuals regardless of background or identity.

Autonomy

The plan supports individual autonomy by promoting informed choice, enabling

participation in sustainability initiatives, and ensuring that people have access to

clear, accessible information about environmental impacts and opportunities to

contribute to decision making.

The Green Plan is committed to embedding human rights principles into its delivery,

ensuring that sustainability is not only environmentally responsible but also socially

just and inclusive.

Which of the human rights articles does this document impact?

☒ To life

☐ Not to be tortured or treated in an inhuman or degrading way

☐ To liberty and security

☐ To a fair trial

☒ To respect for home and family life, and correspondence

☐ To freedom of thought, conscience, and religion

☐ To freedom of expression

☐ To freedom of assembly and association

☐ To marry and found a family

☒ Not to be discriminated against in relation to the enjoyment of any of the rights

contained in the European Convention

☐ To peaceful enjoyment of possessions

What existing evidence (either presumed or otherwise) do you have for this?

Right to life: Climate change and pollution pose direct threats to life through

extreme weather, poor air quality, and health system strain.

Right to private and family life: Environmental degradation can interfere with

individuals’ well-being, homes, and communities.

Non-discrimination: Climate impacts often exacerbate existing inequalities,

affecting deprived communities more severely

Which of the UN Convention on the Rights of the Child does this document

impact?

Every child has the right to:

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☒ Relax and play (Article 31)

☐ Freedom of expression (Article 13)

☐ Be safe from violence (Article 19)

☐ An education (Article 28)

☐ Protection of identity (Article 8)

☒ Sufficient standard of living (Article 27)

☒ Know their rights (Article 42)

☒ Health and health services (Article 24)

What existing evidence (either presumed or otherwise) do you have for this?

Health and health services

Directly supported: NHS Green Plans aim to reduce pollution, improve air quality,

and mitigate climate-related health risks, especially for children.

Sufficient standard of living

Indirectly supported: Environmental degradation affects housing, nutrition, and

access to clean water—especially in deprived areas. Sustainability efforts help

protect these conditions.

Relax and play

Indirectly supported: Clean, safe outdoor spaces are essential for play. Reducing

pollution and protecting green spaces supports this right.

Know their rights

Supported through engagement: NHS bodies are increasingly involving children in

sustainability planning and education, helping them understand and advocate for

their rights.

How will you ensure that those responsible for implementing the plan are

aware of the human rights implications and equipped to deal with them?

Mandatory training on equality, diversity and human rights. Reference to the human

rights statement and guidance.

Public Sector Value Act 2012

NHS Cornwall and Isles of Scilly is committed and obliged to fulfil the requirements

of the Public Sector Social Value Act 2012. This Act requires the organisations to

consider how services commissioned or procured might improve the economic,

social, and environmental wellbeing of an area.

Please describe how this will support and contribute to the local system, wider

system, and community.

Contribution to the Local System:

• Health and wellbeing: By improving air quality, reducing emissions, and

enhancing access to green spaces, the plan supports better health outcomes for

local residents and reduces pressure on health services.

• Local engagement: The plan promotes inclusive engagement with

communities, ensuring that local voices shape sustainability priorities and benefit

from environmental improvements.

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• Support for local suppliers: Sustainable procurement practices favour local,

ethical, and environmentally responsible suppliers, contributing to the local

economy and job creation.

Contribution to the Wider System:

• Integrated care and sustainability: The Green Plan supports the NHS

Cornwall and Isles of Scilly Integrated Care System (ICS) by embedding

sustainability into service delivery, estate management, and workforce planning.

• Collaboration across sectors: It encourages partnership working with local

authorities, voluntary organisations, and other NHS bodies to deliver joined-up,

system-wide environmental improvements.

• Resilience and preparedness: By addressing climate risks and promoting

sustainable infrastructure, the plan enhances system resilience and supports

emergency preparedness.

Contribution to the Community:

• Equity and inclusion: The plan ensures that environmental benefits are

distributed fairly, with targeted support for vulnerable and marginalised groups.

• Education and awareness: Community-facing initiatives raise awareness of

sustainability and empower individuals to make environmentally conscious

choices.

• Long-term legacy: By investing in sustainable practices today, the Green Plan

helps safeguard the environment and public health for future generations.

In line with the Social Value Act, the Green Plan is not only a commitment to

environmental responsibility but also a strategic tool for delivering measurable social,

economic, and health benefits across Cornwall and the Isles of Scilly.

Describe how the plan contributes towards eliminating discrimination,

harassment, and victimisation.

The Green Plan has been developed in alignment with the principles of the Equality

Act 2010 and the NHS’s commitment to fostering an inclusive, respectful, and safe

environment for all. It actively contributes to eliminating discrimination, harassment,

and victimisation in the following ways:

Inclusive Plan Design

The Green Plan has been formulated through an Equality Impact Assessment

process that considers the needs of individuals across all protected characteristics.

This ensures that no group is disadvantaged and that the plan promotes fairness and

equity in its environmental and operational outcomes.

Respectful Engagement

The plan includes mechanisms for inclusive consultation and engagement, ensuring

that diverse voices particularly those from marginalised or underrepresented

communities are heard and valued. This helps prevent exclusion and fosters a

culture of respect and understanding.

Workplace Equality

Sustainability initiatives within the workplace (e.g. changes to facilities, travel

policies, or wellbeing programmes) are reviewed to ensure they do not inadvertently

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discriminate against any group. Staff are supported through inclusive policies that

uphold dignity and promote equal access to opportunities.

Zero Tolerance for Harassment and Victimisation

The implementation of the Green Plan is underpinned by NHS policies that uphold

zero tolerance for harassment and victimisation. Any changes to services or

environments are assessed to ensure they do not create or reinforce hostile or

unsafe conditions for staff, patients, or service users.

Training and Awareness

The Green Plan promotes awareness of equality and sustainability through staff

training and communications, helping to build a culture where discrimination is

actively challenged and inclusivity is embedded in everyday practice.

Describe how the plan contributes towards advancing equality of opportunity.

The Green Plan actively contributes to advancing equality of opportunity by ensuring

that all individuals regardless of background, identity, or circumstance can access,

participate in, and benefit from sustainability initiatives within the health and care

system.

• Inclusive access to benefits: The plan promotes improvements in air quality,

green spaces, and sustainable transport, which are designed to be accessible to

all, including those from disadvantaged or marginalised groups who may be

disproportionately affected by environmental risks.

• Targeted engagement: The Green Plan includes proactive outreach to

underrepresented communities, ensuring that people from ethnic minority

backgrounds, people with a disability, LGBTQ+ groups, and others have

opportunities to shape and influence sustainability priorities.

• Equitable workplace practices: Employment-related aspects of the plan such

as travel policies, flexible working, and wellbeing initiatives are designed to

accommodate diverse needs, including those of carers, pregnant staff, and

people with disabilities, helping to remove barriers to participation and

progression.

• Education and empowerment: The plan supports awareness raising and

training across the workforce and community, enabling individuals to make

informed choices and contribute to sustainability efforts regardless of their

starting point or level of access to resources.

• Monitoring and improvement: Equality data is used to monitor the impact of

the Green Plan across different groups, allowing for responsive adjustments that

promote fairness and opportunity for all.

By embedding equity into its design and delivery, the Green Plan ensures that

sustainability is not only environmentally responsible but also socially inclusive

creating opportunities for all individuals to thrive in a healthier, fairer future.

Describe how the plan contributes towards promoting good relations between

people with protected characteristics.

The Green Plan contributes to promoting good relations between people with

protected characteristics by fostering an inclusive, collaborative, and respectful

approach to sustainability across the organisation and wider community.

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• Inclusive engagement and co-design: The Green Plan prioritises meaningful

engagement with individuals and groups from all protected characteristics,

ensuring that diverse perspectives are valued and reflected in decision making.

This helps build mutual understanding and respect across communities.

• Shared environmental goals: Sustainability is a unifying theme that

encourages collaboration across different groups. By working together on green

initiatives, individuals from varied backgrounds can build stronger relationships

and a shared sense of purpose.

• Representation and visibility: The plan promotes inclusive representation in

communications, leadership, and participation, helping to challenge stereotypes

and foster positive perceptions of diversity.

• Safe and welcoming environments: Improvements to estates and services are

designed to be accessible and inclusive, supporting dignity and comfort for all

users regardless of identity. This helps reduce barriers and promote positive

interactions.

By embedding equality principles into its design and delivery, the Green Plan

supports a culture where diversity is celebrated, discrimination is challenged, and

positive relationships are nurtured across all parts of the system.

If the differential impacts identified are positive, explain how this plan is

legitimate positive action and will improve outcomes, services and or the

working environment for that group of people.

Where the Green Plan has identified positive differential impacts for specific groups,

these are considered legitimate positive actions under the Equality Act 2010.

Positive action is lawful when it helps to reduce disadvantage, meet different needs,

or increase participation where it is disproportionately low.

Examples of Legitimate Positive Action:

• Improved air quality and access to green spaces disproportionately benefit

people with respiratory conditions, older adults, and children; groups which are

more vulnerable to environmental harm. These improvements help reduce health

inequalities and support better long-term outcomes.

• Inclusive infrastructure design (e.g. accessible buildings, gender-neutral

facilities, quiet spaces) supports disabled people, trans and non-binary

individuals, and those with sensory sensitivities, improving dignity, comfort, and

safety in the workplace and healthcare settings.

• Targeted engagement with underrepresented communities, including ethnic

minority groups, LGBTQ+ individuals, and people from lower socio-economic

backgrounds, ensures their voices are heard in shaping sustainability priorities

and that they benefit equitably from environmental improvements.

• Flexible working arrangements and travel options accommodate carers,

pregnant staff, and those with mobility challenges, helping to remove barriers to

participation and progression in the workplace.

Impact on Outcomes and Services:

These actions contribute to:

• Improved health and wellbeing for vulnerable groups.

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• Greater equity in service access and experience.

• A more inclusive and supportive working environment.

• Enhanced trust and engagement with diverse communities.

By embedding positive action into the Green Plan, the organisation demonstrates its

commitment to advancing equality, reducing disparities, and creating a fairer, more

inclusive health and care system.

Explain what amendments have been made to the plan or mitigating actions

have been taken, and when they were made.

During the development of the Green Plan, several amendments and mitigating

actions were identified and implemented to ensure the plan is inclusive, equitable,

and responsive to the needs of all individuals and communities. These actions were

informed by stakeholder engagement, equality analysis, and feedback from staff and

service users.

If the negative impacts identified have been unable to be mitigated through

amendment to the plan or other mitigating actions, explain what your next

steps are using the following equality impact assessment action plan.

N/A

Equality impact assessment action plan

Issue to be

addressed

Action

required

Responsible

person

Timescale for

completion

Action

taken

Insert issue

Insert action

Who is

responsible?

Insert dates

Insert action

taken

Comments on action plan:

Click or tap here to enter text.

Signed (completing officer): Jess Child

Date: 25 September 2025

Signed (head of department or section): Click or tap here to enter text.

Date: Click or tap to enter a date.

Please ensure that a signed copy of this form with the plan is sent to both the

corporate governance team and equality and diversity lead.

Comments and reviews

Reviewed by

Date

Any comments not captured above

Jayna Chapman

01.10.2025

None.

Tab 2 Item 3.4 - South West Peninsula Green Plan Refresh130 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

2025/26 Annual Plan Progress Report

August 2025

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The report is compiled from updates provided by workstream leads across the organisation. Its purpose is to support assurance

and inform delivery related decision-making. The content moves from a high-level overview to detailed information, as follows:

Section 1 –High-level summary of delivery against NHS Devon’s 2025/26 Annual Plan objectives, including progress and

milestone delivery. A RAG rating indicates the proportion of actions on or off track.

Section 2 –Delivery progress for each individual objective in the reporting month, based on the status of associated projects and

actions. Where no update is available, the status and narrative remains the same as the previous month.

Section 3 –Performance against high-level KPIs, relevant to each objective, taken from the Delivery Management Report (DMR),

aligned with the NHS Oversight Framework and national priorities (further development of this section is planned).

Section 4 –High-level summary of financial benefit tracking for Annual Plan workstreams contributing to ICB CIP delivery.

Section 5 –Shows new and emerging risks identified during the reporting period which are not yet on the corporate, directorate or

programme risk register

Section 6 –Issues requiring further escalation, including those needing resolution at committee or Board level.

Section 7 –Full status updates from leads for each action, project, or programme assigned to them, showing progress against

milestones and any corrective actions being taken. This detail, intended to support Chief Officers in signing off updates, will not

normally be provided to decision-making and/or assurance committees unless specifically requested.

Important note: The content in this document, once approved by Chief Officers, will be used to produce tailored reports to specific

decision-making and/or assurance committees.

Purpose of the Report

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report132 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Section 1: Annual Plan Delivery Summary

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Annual Plan Delivery Summary

Assurance level based on number of on track actions

Objective title

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Develop a Long

-Term, Whole Population Health

Care Strategy

3/3 2/2 1/1

Strengthen Strategic Commissioning to Tackle

Health Inequalities and Promote Prevention

27/33 26/34 28/35

Improve Personalised Care, Access, and

Outcomes Across the System, targeting those with

greater need

19/32 22/33 26/35

Drive Clinical Service Transformation and In

Hospital Productivity

6/8 7/15 6/12

Optimise Workforce, Digital Infrastructure and

Commissioning Support Services, focusing on

delivery at scale

14/18 13/22 14/20

Delivery Statutory Functions and Continue to

Maintain a High

-Quality, Safe and Sustainable

System

19/20 15/20 17/19

High

75% - 100%

Moderate 50%

-74%

Low

0% - 49%

Please note: Some items appear under more

than one objective. This reflects requests from

director leads, who felt it was important that this

work is seen in the context of multiple objectives.

Key Annual Plan Delivery Highlights for August 2025

•Health and Care Strategy design workshops completed; drafting of the strategy document is underway.

•Strategic Commissioning Hub established, with fortnightly meetings in place from 4 August 2025.

•New Models of General Practice progressing well, with a clear timeline in place to meet the August target.

•Weight Management Pathway service reviews completed for specialist weight management.

•Neurodiversity community offer developing, with progress across acute liaison, community, and diagnosis pathways.

•Physical Health Checks for Severe Mental Illness (SMI) progressing well, with anti-psychotic shared care guidelines close to completion.

•Neurodiversity pathways being implemented in line with National Choice Legislation, with positive progress reported to ExCo to support assurance this month.

•Urgent and Emergency Care demand management advancing across ED validation, care coordination, and same day primary care.

•Workforce development progressing, with increased placement capacity and more advanced practitioners. Pilots are underway in UHP

, primary care, and social care, and planning

is in progress for a podiatry AP role in Torbay.

•Organisational change moving forward, with the Chair appointment announced, CEO announcement expected shortly, and preparations underway for Executive and Band 9

consultation.

•Safeguarding requirements back on track, with MARMM implementation progressing. An action plan has been developed, an EQIA completed, and capacity restored.

August status improvement driven mainly by

completed actions, additions from

commissioning plan, removals from de-

prioritisation and progress on mental health

activities

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report134 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Section 2: Objective-Level Overview

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Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Objective 1: Develop a Long-Term, Whole

Population Health Care Strategy

Executive Lead(s)

Chief Strategic Commissioning and Planning Officer

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report136 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective-Level Delivery Summary

1. Develop a Long-Term, Whole Population Health Care Strategy

Programme/Project Action Name

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Strategy Design Phase

Progress August 2025

First design steering group met 15/07 External facilitation has been agreed with Optum

Optum will facilitate a series of workshops throughout July and August that relate to chapters in the strategy structure

Workshops have been booked and invites sent to appropriate stakeholders

All workshops have been successfully facilitated, and outputs are now contributing to the final version of the strategy.

Draft paper will be socialised internally w/c 08/09/2025

Objective-Level Highlights

On Track

Off Track

Not Active

Completed

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report137 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Objective 2: Strengthen Strategic Commissioning

to Tackle Health Inequalities and Promote

Prevention

Executive Lead(s)

Chief Strategic Commissioning and Planning Officer

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report138 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective-Level Delivery Summary

2. Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Programme/Project/Action name

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Out of Hospital (OOH) Programme

Secondary Prevention

Tackle inequalities in access, experience, and outcomes

Embed Population Health Management

Develop Organisational Culture focused on improving Population

Health

Anchor Organisation Strategy

Remote Consultation Procurement

New Models of General Practice

Dental Provision

Pharmacy Services

General Practice Contracting

Joy App Adoption

Local Care Partnership Development

Section 75 Review (Torbay)

Strategic Commissioning (NICE Other)

Commissioning Intentions

Community Hospital Consolidation

Investment Review

Healthcare Associated Infections (HCAI) Monitoring

Antimicrobial Stewardship (AMS) Coordination

Infection Prevention

Outbreak Management

Prepare for ICB's commissioning of section 7a vaccinations

Working with providers to increase vaccination uptake to support

UEC plan

Commissioning Framework

Clinical Waste Procurement

Discharge and Flow

Community Care (TDP)

Community Urgent Care Review

Repatriation of Activity*

Core20+5 Children and Young People (CYP)*

Multi

-agency Safeguarding Hub (MASH) Capacity*

Special Educational Needs & Disabilities (SEND) Improvements*

CYP Crisis Support*

Children’s Services Recommissioning*

Develop Commissioning Hub

Weight Management

On Track

Off Track

Not Active

Completed

*Action belongs to multiple objectives

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report139 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective-Level Highlights

2. Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress August 2025

•

Out of Hospital Programme: Plymouth LCP working on local framework aligned to neighbourhood health

development and wider strategy.

•

Secondary Prevention: Decision to transfer resource to cardiology programme was taken by Exec. Group.

Population Health team will continue to work with internal and external partners to deliver where possible.

•

Tackle inequalities in access, experience, and outcomes: CORE20+5 mapping presented to CORE20+5

group and prioritisation underway

•

Population Health Management: Increase to 72% population coverage for ODD

•

Develop Organisational Culture focused on improving Population Health:

Further work requested with a

view to present to the PH strategy group in October 2025.

•

Anchor Organisation Strategy:Work in progress against Q2 milestone

•

Remote Consultation Procurement: Central contract for AccuRx complete; 3 practices have procured local

systems and will make claims back to the ICB as soon as they have completed all of their governance

paperwork. All ICB work is complete

•

New Models of General Practice. A timeline is in place to meet August target. Cohort 1 Completed, with

minor amendments pending LMC sign-off in September. Cohort 2: Task and finish groups have been

established.

•

Dental Provision: PIN issued on 01/08/25 for a joint, lotted procurement with CIOS ICB. Engagement event

held on 13/08/25 with potential bidders. Debrief on provider feedback conducted by the Collaborative

Commissioning Hub on 29/08/25. ITT documentation is in progress, aiming for mid-September go-live.

•

Pharmacy Services: Workplan implemented to take forward actions from strategic framework Pharmacy

First

•

General Practice Contracting: June Plan submitted on time with strong regional feedback; ongoing efforts

to improve GP compliance and enforce contractual standards.

•

Joy App Adoption: 22 out of 31 PCN’s are now using JOY (71%).

•

Local Care Partnership Development:

Paused to enable future function and form of place to be established

as part of Cluster development. LCPs repurposed to focus on INT development in interim.

•

Section 75 Review (Torbay): This continues to be reviewed through the S75 executive group which meets

monthly, and the current agreement continues until further notice.

•

Strategic Commissioning (NICE Other):Slight slippage on the programme. Plan is to catch up in Q3 and

work should still be complete by March 2026.

•

Commissioning Intentions: The actions have been completed and the maximum CIP realised.

•

Community Hospital Consolidation: Work to date has focussed on understanding current plans

•

Investment Review: Savings have been released from the ending of the Ilfracombe MIU and TSD services

contracts. Review of higher-value contracts underway as part of enhanced contract monitoring

•

Weight Management: Pathway service reviews complete for specialist weight management. Proposals

submitted to Ex Co were approved on 12.09.2025. Now working towards implementation of a WM Single

Point of Access, Expanded Capacity of Tier 3 Services inclusive of weight loss drug prescribing pathways, a

Primary Care Tirzepatide LES. In addition to this also working towards implementation of a Primary Care

Bariatric Follow Up LES, which is being funded via re-

purposed Optimising Referrals LES. Implementation for

these is planned for November 2025. The SPOA will be working to contribute an overall 20% reduction in

waiting times for access to Tier 3 Specialist Weight Management Services over a 12 month pilot period. A

waiting time reduction trajectory and activity plan is being developed for the Tier 3 SWMS, which will be

finalised and added to the specification over the next four weeks.

Progress August 2025

•

Develop Commissioning Hub: Strategic Commissioning Hub established with fortnightly meetings

commenced from 4th August 2025.

•

Healthcare Associated Infections (HCAI) Monitoring: While Devon remains on an upward trajectory,

targeted engagement work is underway with providers to reduce rates in line with agreed thresholds

•

Antimicrobial Stewardship (AMS) Coordination: AMS working group established; system-wide priorities

being set.

•

Infection Prevention: A system-wide C. difficile improvement plan is being co-developed with Trust IPC

leads, incorporating primary care input for a targeted response.

•

Outbreak Management: Devon-

wide MoU for outbreak response has been developed. National guidance on

ICB commissioning for outbreaks has been reviewed and used to identify gaps and inform workplans.

•

Prepare for ICB's commissioning of section 7a vaccinations: Informally advised by national lead that

transfer of commissioning responsibilities to ICBs is being delayed until April 2027. A formal notice is

expected to be circulated by the end of September.

•

Working with providers to increase vaccination uptake to support UEC plan: All plans in place for

vaccination of eligible cohorts for winter vaccinations. Targets for uptake have been shared with the lead for

UEC winter team. Regular review of uptake and mitigating actions where uptake is lower than expected will

be shared with the UEC winter lead.

•

Commissioning Framework: Delayed due to workforce capacity and will be reviewed next reporting cycle.

•

Clinical Waste Procurement: Clinical waste market engagement now live for 3 weeks.

•

Discharge and Flow: Plymouth Intermediate Care Plan in place -

UHP / Livewell off trajectory, but escalation

with remedial action plan in development. Devon -

Hospital Discharge Programme reset workshop completed

to agree principals and support development of plan.

•

Community Care (TDP): Plans in delivery –savings being delivered in line with trajectory

•

Community Urgent Care Review: The case for change was presented to the Commissioning Hub, with a

PID in development to identify resource gaps by the 15th September deadline.

•

Repatriation of Activity*: IS activity remains off target with cost pressures emerging; subcontracts and

repatriation delays are being addressed, while system-wide CRM readiness is progressing toward March

2026.

•

Core20+5 CYP*: Children in care annual report completed demonstrating improved metrics for health

assessment. LA based task and finish groups continue to take forward locally agreed plans and initiatives.

•

Multi-agency Safeguarding Hub (MASH) Capacity*: Devon wide Multi Agency Safeguarding Hub (MASH)

review continues with a delivery date of 31st October 2025. As a result, the entire action is currently pending

review and may be subject to annual plan change log should the milestones for delivery require review.

•

Special Educational Needs & Disabilities (SEND) Improvements*: Although ICB actions on track in line

with this annual plan. SEND as a multiagency programme across Devon and Torbay. Torbay is Not on track

to achieve compliant inspection outcomes due to partnership and NHS constraints. Mitigating actions being

undertaken regarding 'support while waiting' and waiting list recovery. Plymouth preparation positive and

demonstrating good progress.

•

CYP Crisis Support*: Capital bids for Torbay and Plymouth LAs successful, time frames for delivery are

outside of this financial year but joint work is progressing.

•

Children’s Services Recommissioning*: Children's Service Recommissioning: timeline and engagement

plan discussed at August Commissioning Hub Meeting, now progressing to development of a strategic

commissioning intention for 2026/27- 2030

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Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Objective 3: Improve Personalised Care, Access,

and Outcomes Across the System, targeting those

with greater need

Executive Lead(s)

Chief Medical Officer

Chief Nursing Officer

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report141 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective-Level Delivery Summary

3. Improve Personalised Care, Access, & Outcomes , targeting those with greater need

Programme/Project Action Name

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Neighbourhood Health Service Offer

Personalised Care

Monitor and implement statutory and strategic Mental Health objectives

24/7 Mental Health Care

Physical Health Checks for Severe Mental Illness (SMI)

Transitions

Enhance community Mental Health support

Improve UEC Mental Health pathway

Transform Perinatal Mental Health Pathways for Women, Birthing People,

and families

Neurodiversity community offer

Implement Neurodiversity Pathways in Line with National Choice

Legislation

Develop and implement Digital Flag strategy

LeDeR programme

Ensure appropriate inpatient care for LD and Autistic People.

S117 and Individual Patient Placement (IPP).

Enhanced End of Life (EoL) Care Delivery:

Maternity improvements and transformation for the Peninsula

Safe and efficient use of resources in maternity services

Understand workforce and financial implications of MSSP

Develop sustainable perinatal services in Devon

Commission pilot pathways for socially vulnerable women that increase

the number of babies remaining with birth families:

Establish perinatal Mental Health community of practice

Integrated, preventative approach to women's health

Interface with regional clinical networks 

Procurement of All

-Age Continuing Care (AACC)

Core20+5 CYP*

Special Educational Needs & Disabilities (SEND) Improvements*

CYP Crisis Support*

Improve the access to health services for all CYP who need hospital care,

mental health, and community services*

Design and implement an ICB process which consistently addresses

individual commissioning needs for CYP*

Right Care Right Person

On Track

Off Track

Not Active

Completed

*Action belongs to multiple objectives

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report142 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective-Level Highlights

3. Improve Personalised Care, Access, and Outcomes Across the System, targeting those with greater need

Progress August 2025

•

Neighbourhood Health Service Offer: Work is underway to establish proposed INT footprints, informed by LCP

engagement sessions. Vanguard site opportunities are being identified, and joint work with CIOS continues to ensure

alignment with the NHS 10 Year Plan and support shared learning.

•

Personalised Care:

Work is underway to map NHS 10 Year Plan requirements, including the commitment to double

the PHB offer. Personalised care workshop delivered.

•

Monitor and implement statutory and strategic Mental Health objectives: Monthly target reviews with BI and

commissioning teams inform necessary actions and escalation. BAU is part of regional reporting and Q1 reporting

has been completed with oversight meetings in both MH and LDN.

•

24/7 Mental Health Care:

Workstream with DPT PC undertaken as part of the provider workstreams so intending to

remove from commissioning Annual plan as part of the de-prioritisation process.

•

Physical Health Checks for Severe Mental Illness (SMI):Anti-Psychotic Shared care developments - On going

work 1st shared care guidelines near completion finalising provider contribution to the delivery end of the shared care

agreement. Letter to LMC sent and proposal for interim plan with exec for consideration in 2025/2026.

•

Transitions: Whilst this area of work has been considered for de-prioritisation, the of Head of Commissioning ICB

continues to be engaged in a system and regional group to work on transition improvements as part of the MH team

BAU. Transitions will be the focus of work for CHC review of process and care packages for information on

verification.

•

Enhance community mental health support:

With a new lead in the provider inpatient wards (DPT) focusing on the

assertive outreach this has promoted a refocus on the ICB and Lead working together in this area an ICB returns due

in September so a reset of the review of progress in this area is required. Returns received from LSW waiting for

DPTs. Outcomes of review to direct focus. New governance structure for the MH commissioning pathways will

support this work. Met with Clinical Lead for Devon in this area and reigniting engagement with focus on provision

specifically of "risk to others"

•

Improve UEC Mental Health pathway: System-wide mental health commissioning and transformation underway,

with evaluations informing future crisis response, inpatient delivery, and bed base planning

•

Transform Perinatal Mental Health Pathways for Women, Birthing People, and families: Leadership and

direction of work to be led by the Director of Women and Children's. The workplan will be influenced by the recent

safeguarding reviews and maternal death cases. Initial focus will be on ensuring that women or birthing people who

have baby removed are still able to access the support they need. From a MH commissioning perspective, in

addition, work is ongoing to ensure that the current performance within services continues to meet operational

targets

•

Neurodiversity community offer: There are several lines of work attending to this objective in Acute liaison,

community and diagnosis pathways. Roll out of OMMT supporting the skill development in the workforce.

•

Implement Neurodiversity Pathways in Line with National Choice Legislation: Paper proposed to ExCo to

inform on progress and to provide assurance on ICB delivery.

•

LeDeR programme: Exploring integration of LeDeR with PSIRF to enhance system-wide learning, reduce

duplication, and establish robust governance within the ICS

•

Ensure appropriate inpatient care for Learning Disability and Autistic People: There is a continued focus on

people being admitted as close to home as possible, without the need for an out of area placement at additional cost,

reduction in length of stay and potential repatriation.

•

S117 and Individual Patient Placement (IPP): £2.6m overspend driven by Out of Area Acute pressures and high-

cost clients, with mitigations through improved s117 review rates, IPP stability, and targeted quality oversight.

Progress August 2025

•

Enhanced End of Life (EoL) Care Delivery: EoL workstreams progressing within available staff capacity. Key developments

include pilot sites for Gold Standards Framework, upcoming guidance publication for After Death Care, alignment efforts for EOL

medications, and contract review planning for Marie Curie Night Care. Digital group meetings expanded to support E-Teps rollout.

Oversight group to reconvene in September with revised TOR and membership.

•

Maternity improvements and transformation for the Peninsula: Accountability and assurance framework, (including leadership

responsibilities) on track for delivery with appropriate in month progress. Commissioner led working party to be established and

progressing on actions.

•

Safe and efficient use of resources in maternity services: The Q2 target may be revised due to the upcoming launch of the

National Maternity Dashboard (expected Sept/Oct), which aligns with our current local timeline. Any changes will be logged and

taken through the appropriate governance process.

•

Understand workforce and financial implications of Maternity Safety Support Programme (MSSP):

Workforce stocktake due

for completion in August 2025 is now delayed until 31st October 2025 due to team capacity. This has been escalated to CNO.

Financial Implications of MSSP being worked through by providers- systems being set up for September

•

Develop sustainable perinatal services in Devon:

Strategic commissioning intention for maternity transformation included in the

heath and care strategy, with a high-level timeline in development aligned to organisational planning.

•

Commission pilot pathways for socially vulnerable women that increase the number of babies remaining with birth

families: Maternal Mortality Review completed and perinatal care pathways now established within the DCC footprint, supporting

sustainable service development in Devon.

•

Establish perinatal Mental Health community of practice: Strategic commissioning intention developed for maternity

transformation and included in the health and care strategy. High level timeline being worked up in line with organisational pla

nning

timeframes.

•

Integrated, preventative approach to women’s health:

LARC training is underway in Primary Care, with the new contract starting

October 2025. The Specialist Menopause Service expansion remains on track

•

Interface with regional clinical networks: Pro-forma completed to request stand down

•

Procurement of All Age Continuing Care (AACC): CSU compliance checks and evaluation begin w/c 04/08/25; SOP in

development to support tender implementation. POG has approved joint contracting with DPT, and a specialist hospitals

procurement group will be formed to develop the plan.

•

Develop and implement Digital Flag strategy: RADF project gaining momentum with strong stakeholder engagement, growing

recognition, and national visibility—though rollout risks remain around capacity and GP uptake

•

CYP Crisis Support*: Capital bids for Torbay and Plymouth LAs successful, time frames for delivery are outside of this financial

year but joint work is progressing.

•

Core20+5 CYP*:Children in care annual report completed demonstrating improved metrics for health assessment. LA based task

and finish groups continue to take forward locally agreed plans and initiatives.

•

Special Educational Needs & Disabilities (SEND) Improvements*:Although ICB actions on track in line with this annual plan.

SEND as a multiagency programme across Devon and Torbay. Torbay is Not on track to achieve compliant inspection outcomes

due to partnership and NHS constraints. Mitigating actions being undertaken regarding 'support while waiting' and waiting list

recovery. Plymouth preparation positive and demonstrating good progress.

•

Improve the access to health services for all CYP who need hospital care, mental health and community services*: Neuro-

diversity and other CYP pathway recovery programmes have been translated to clear strategic commissioning intentions. ND

workshop planned for early September to confirm commissioning model and agree implementation with providers.

•

Design and implement an ICB process which consistently addresses individual commissioning needs for CYP* Action

remains on track: Q2 delivery depends on process agreement across LA footprints, currently affected by commissioning team

capacity. LAs confirmed for inclusion in IPOC process.

•

Right Care Right Person: The outstanding action from 24/25 of developing a system wide section 136 protocol has been

addressed and there is a clear plan in place to complete this action. The requirements of what should be in place from an NHSE

perspective have been reviewed and a template developed that will be shared with members of the tactical group w/v/ 15th

September.

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report143 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Objective 4: Drive Clinical Service Transformation

and In-Hospital Productivity

Executive Lead(s)

Chief Medical Officer

Chief Strategic Commissioning and Planning Officer

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report144 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective-Level Delivery Summary

4. Drive Clinical Service Transformation and In-Hospital Productivity

Programme/Project/Action Name

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Acute Services Strategy and Transformation

Supporting and driving networked acute care

Eliminating 18

-week community waits

Three

-Year Recovery Plan for 18 Weeks

One Devon Elective Specialty Improvement

Waiting list validation

Elective demand management

Diagnostic delivery

Maximising in

hospital alternatives and admission avoidance

pathways

UEC demand management

Repatriation of Activity*

Improve the access to health services for all CYP who need

hospital care, mental health, and community services*

*Action belongs to multiple objectives

On Track

Off Track

Not Active

Completed

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report145 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective-Level Highlights

4. Drive Clinical Service Transformation and In-Hospital Productivity

Progress August 2025

•

Acute Services Strategy and Transformation: Arrangements to be confirmed

•

Supporting and driving networked acute care: Arrangements for the interface with the

PAPC currently being reviewed.

•

Eliminating 18-week community waits: MSK community service waiting times have

now reduced to 415 waiting over 18 weeks, this is from a baseline position of 2,300 in

March 2025. Sustainable service delivery models are being implemented and maintained

with a strong focus on validation. No resource currently available within the Elective

Commissioning Team to commence improvement work on further services which may flag as

not meeting the 18-week standard: podiatry, diabetes and rehabilitation. Currently being added

to Elective Commissioning Team risk register & COO Directorate risk register.

•

Three-Year Recovery Plan for 18 Weeks: Performance progress around 18-week

standard will be monitored through the Operational Plan delivery mechanism

•

One Devon Elective Specialty Improvement: One Devon Programme continues to

progress with Key improvements delivered in Orthopaedics, Spinal and Ophthalmology

•

Waiting list validation: Programme is live, monitored directly by NHSE. Consider for de-

prioritisation

•

Elective demand management: MSK, Cardiology, ENT, Ophthalmology, and

gynaecology show progress and active implementation, with a few areas awaiting next

steps or clarification. Acute trust demand management group established and meeting

regularly.

•

Diagnostic delivery: System DEXA task and finish group took place on 27th August to

work through shared options to mitigate the continuing fragility of the service. Cornwall

and Isles of Scilly colleagues were also invited however were unable to attend.

•

Demand and capacity work is underway at the ICB to support Royal Devon University

Hospital with mapping a recovery plan for NOUS and Echo due to significant challenges

in performance.

•Exeter CDC and Plymouth CDC preparing bids for site expansion, with positive feedback

from regional colleagues. Exeter’s bid includes Nightingale site and a new hub in North

Devon (pending planning). Business cases due mid-September 2025.

•

Exeter CDC - Underperforming against targets. 13 pathways developed; patient flow

below expectations. Recovery expected to reach 90% in Q3.

•

Torbay CDC - Facing significant performance challenges. Ongoing negotiations to

reprofile targets downward.

•

Plymouth CDC -

Exceeding performance targets. Expanding into ophthalmology following

successful bids for linear lanes in eyecare.

*Action belongs to multiple objectives

Progress August 2025

•

Maximising in-hospital alternatives and admission avoidance pathways:

This was being held in the Locality Planning & Delivery Meetings but will

transition into the Contract Management Meetings when stood up.

Consider

for de-prioritisation

•

UEC demand management: Funding has now been approved to support

delivery of the key workstreams aligned to the ICB’s ED demand

priorities. There is strong representation from acute trusts at the fortnightly

ED Demand Management Oversight Group.

A decision has been made to

extend the current Care Coordination model while partners continue to

develop alternative solutions during Q3 and Q4.

•

Repatriation of Activity*: IS activity remains off target with cost

pressures emerging; subcontracts and repatriation delays are being

addressed, while system-wide CRM readiness is progressing toward

March 2026.

•

Improve the access to health services for all CYP who need hospital

care, mental health and community services*: Neuro-diversity and other

CYP pathway recovery programmes have been translated to clear

strategic commissioning intentions. ND workshop planned for early

September to confirm commissioning model and agree implementation

with providers.

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report146 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Objective 5: Optimise Workforce, Digital

Infrastructure, Estate and Commissioning Support

Services, Focusing on Delivery at Scale and

Financial Sustainability

Executive Lead(s)

Chief Finance Officer

Chief People Officer

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report147 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective-Level Delivery Summary

5. Optimise Workforce, Digital Infrastructure, Estate and Commissioning Support Services

Programme/Project/Action Name

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

TDP: Repatriation of Activity*

Access to technology

Clinical and Care Professional Leadership

Estates transformation

Primary care estates

Devon New Hospital Programme (NHP)

Collaborative working across estates and facilities

NHS App sign

-up

Devon and Cornwall Care Record (DCCR) expansion

Devon and Cornwall Care Record (DCCR) procurement

AI use cases supporting general practice

Increasing placement capacity

Increasing advanced practitioners

Increasing nursing and midwifery apprenticeships

Enabling workforce programmes to support NHS Devon’s strategic priorities

Workforce sustainability

Creating a culture for NHS Devon

System Organisational development

Organisational change

AACC

–Digital Transformation (formerly Transforming Devon workstream)

On Track

Off Track

Not Active

Completed

*Action belongs to multiple objectives

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report148 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective-Level Highlights

5. Optimise Workforce, Digital Infrastructure, Estate and Commissioning Support Services

Progress August 2025

•

Repatriation of Activity*: IS activity remains off target with cost pressures emerging;

subcontracts and repatriation delays are being addressed, while system-wide CRM readiness is

progressing toward March 2026.

•

Access to technology:CCN being signed - development work commenced. First focus on

"About Me" using PRSB standards. Engagement workshop on 2/10/25 with pilot teams being

identified.

•

Clinical and Care Professional Leadership: Pro-forma completed to request work is paused

until clustering has been completed.

•

Estates Transformation: All Devon community property assets have been identified and

allocated to database. On-going review to compile full data from research, reviews, and site

visits.

•

Primary Care Estates: On hold due to restructure; progression is being managed through

interim non-pay contracts. Delivery is being managed but with increased risks surrounding

quality and managing the project pipeline.

•

Devon New Hospitals Programme: .Trusts are working with NHP on reshaping programme

delivery. Current risks associated with the management of the programme are being worked

through with the national NHP team.

•

Collaborative working across estates and facilities: Programme delivery arrangements and

governance established with participating trusts; Outline Business Case stage with NHSE

support is being developed for setting up a WoS. DPT and RCHT not subscribed to the

programme.

•

NHS App sign-up: Limited local action in month to increase adoption rates in specific locations.

Local drop-in sessions completed, and a local 6-

month comms campaign has commenced using

national communication materials. National communications campaign anticipated later in the

year.

•

Devon and Cornwall Care Record (DCCR Expansion): Torbay Council has procured Liquid

Logic as their social care system. Cost of Liquid Logic integration cannot be met by Torbay

Council and are pursuing portal access as an alternative.

Plymouth City Council have yet to sign

the Data Sharing Agreement and this is being pursued within PCC. A technical agreement has

now been reached on launching DCCR portal from PCC OLM Eclipse system.

•

Devon and Cornwall Care Record (DCCR) procurement: The announcement of the abolition

of the CSU is impacting the timely provision of procurement advice and guidance. Despite this

the OBC has been prepared following verbal advice from the CSU, NHSE and independent

research.

•

AI use cases supporting general practice: Events have superseded the project which means

it no longer has to complete as described. Summary of requirements for implementing Ambient

Voice Technology has already been produced and available to practices. Waiting on further

guidance from NHSE.

Progress August 2025

•

Increasing placement capacity: Pilots commenced in UHP, primary care and social care

•

Increasing advanced practitioners: Planning podiatry AP role in Torbay. Planning for acute medicine

roles and hospice services. Summarising scoping numbers for NHSE for Sept 26 starts

•

Increasing nursing and midwifery apprenticeships: Ongoing Engagement: Continued collaboration

with cardiology, Advanced Practice, podiatry, mental health (MH), and occupational therapy (OT)

teams.

•

BT Funding & Partnerships: BT funding has been confirmed. New partnerships are being developed

with private companies such as Amazon and Virgin Media to support pharmacy apprenticeship funding

through the levy.

•

Future Planning: Development of apprenticeship plans for 2027/28 has not yet started; work is

scheduled to begin in September.

•

Enabling workforce programmes to support NHS Devon’s strategic priorities: . PASP future

scenario modelling commenced in August and continuing through September and October, led by

PASP team

•

Workforce Sustainability: Draft plan prepared. Due to agree governance process and dates for local

authority approval. The plan will be shared with Chief People Officers Group in October, then ICB ExCo

in November and aim to release funding by Dec 25.

•

Creating a culture for NHS Devon: Affinity Financial sessions continue and further dates added.

Design of peer support connection sessions underway. Systems thinking development programme to

be focussed on building neighbourhoods in South. Delegates now confirmed. Facilitators confirmed.

Programme to commence 24th September.

•

Unable to make desired progress due to consistently changing messaging and time frames from

national and regional teams re organisational reconfiguration. Concerns escalated re colleagues’ well

being and psychological safety

•

System Organisational Development:Process developed to support strengthening clinical

collaboration and system relationships within cardiology. Participation in Health and Care Strategy

workshops supported the identification of key outcomes that are required to develop the system culture

and leadership, and to deliver the strategy. This will inform the system development plan. CEO

development session that was scheduled for September postponed in order to wait for announcement

of ICB CEO.

•

Organisational Change:

Chair appointment announced 1st September. CEO announcement expected

to follow soon. Preparations underway for Exec and band 9 consultation. Draft timeline for wider staff

consultation has been outlined however lack of clarity around timelines and funding for cost of change

still remain.

•

All-Age Continuing Care (AACC) Digital Transformation: A all milestones currently on track

monitored through the AACC Digital Transformation Oversight Group.DTOG met 05/08/25. Evaluation

and moderation completed. Contract Award Recommendation Report produced and approved at

procurement oversight Group 27 August 2025. Aiming to start contract mobilisation mid Sept 2025

onwards.

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Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Objective 6: Deliver Statutory Functions and

Maintain a High-Quality, Safe, Financially Balanced

and Sustainable System

Executive Lead(s)

Chief Communication and Corporate Affairs Officer

Chief Finance Officer

Chief Nursing Officer

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Objective-Level Delivery Summary

6. Deliver Statutory Functions and Maintain a High-Quality, Safe, Financially Balanced System

Programme/Project/Action Name

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

All

-Age Continuing Care (AACC): Community Deprivation of

Liberty Safeguards

All

-Age Continuing Care (AACC): Safe staffing model

Quality Framework

Establishing Equality Quality Impact Assessment (EQIA) process

System Quality Metrics Dashboard

Patient Safety and Experience

Children’s Wellbeing and Education Bill implementation

Information Sharing to Tackle Violence (ISTV) implementation

Multi

-Agency Safeguarding Hubs (MASH)

Meeting ICB safeguarding requirements and MARMM

implementation

ICS Financial Revenue Plan

ICB Financial Revenue Plan

Research and innovation

Green Plan

Multi

-agency Safeguarding Hubs (MASH) Capacity*

Children’s Services Recommissioning*

Core 20+5 CYP*

Design and implement an ICB process which consistently

addresses individual needs for CYP*

Improve the access to health services for all CYP who need

hospital care, mental health, and community services

*Action belongs to multiple objectives

On Track

Off Track

Not Active

Completed

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report151 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective-Level Highlights

6. Deliver Statutory Functions and Maintain a High-Quality, Safe, Financially Balanced System

Progress August 2025

•

All-Age Continuing Care (AACC): Community Deprivation of Liberty

Safeguards: Recruitment of Band 6 Clinical Practitioner underway. Commences 8

September 2025. Re- design work commenced and will work with partner

organisations during Q3, Oct -

Dec 25 however this may be influenced by the clusters,

to agree an appropriate model and with aim to provide a consistent offer and to

reduce legal costs. Pilot taken place, evidencing it has saved on costs. Next steps to

develop an SLA between the ICB and partner organisations

•

All-Age Continuing Care (AACC): Safe staffing model: Staffing structure and

critical vacancies reviewed. Recruitment approvals obtained (May–June 2025). Two

Band 6 clinical assessors onboarding by end of August. Remaining posts closed 22

July; interviews held in August. Onboarding of six new roles began September 2025.

•

Quality Framework: Quality Management System forming part of health & Care

Strategy. Conference planning will continue when org. change permits. National

Quality Strategy is awaited which will directly inform local work.

•

Establishing Equality Quality Impact Assessment (EQIA) process: Live EQIA in

place for appropriate schemes. NHS Devon policy updated to reflect newly updated

NQB national guidance for QIAs.

•

System Quality Metrics Dashboard:New format of Quality Report implemented

August 25.

•

Patient Safety and Experience:

Working with local authority and police colleagues to

codesign services to deliver Family First Partnership programme.

•

Children’s Wellbeing and Education Bill implementation: Currently working with

local authority and police colleagues to codesign services to deliver Family First

Partnership programme.

•

Information Sharing to Tackle Violence (ISTV) implementation: ICB commitment

maintained. Continuing to support providers to complete DPIA.

*Action belongs to multiple objectives

Progress August 2025

•

Meeting ICB safeguarding requirements and MARMM implementation: NHS

England protocol implementations: Action plan to be developed and EQIA undertaken

and back on track.

Capacity has been restored as of 11/08/2025. Work is underway to

rapidly review and agree next steps in month.

•

ICS Financial Revenue Plan:

Boards have signed off financial plans and established

reporting process across the system. mitigations being identified to negate the impact

of potential slippage

•

ICB Financial Revenue Plan: Boards sign off financial plan identify any mitigations

for potential slippage

•

Research and innovation: Pro-forma completed to request stand down until

clustering is complete.

•

Green Plan: ICS and ICB Green Plan submitted to ExCo (1st July) in readiness for

Board approval in October with CIoS cluster arrangements.

•

Multi-agency Safeguarding Hub (MASH) Capacity*: Devon wide Multi Agency

Safeguarding Hub (MASH) review continues with a delivery date of 31st October

2025. As a result, the entire action is currently pending review and may be subject to

annual plan change log should the milestones for delivery require review.

•

Children’s Services Recommissioning*: Children's Service Recommissioning:

timeline and engagement plan discussed at August Commissioning Hub Meeting, now

progressing to development of a strategic commissioning intention for 2026/27- 2030

•

CYP Crisis Support*: Capital bids for Torbay and Plymouth LA's successful, time

frames for delivery are outside of this financial year but joint work is progressing.

•

Repatriation of Activity*:

IS activity remains off target with cost pressures emerging;

subcontracts and repatriation delays are being addressed, while system-wide CRM

readiness is progressing toward March 2026.

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Summary and additional narrative for

Programme/Project/Actions currently Off-Track

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Objective-Level Delivery Summary

Summary of Programme/Project/Actions Off-Track

Programme/Project/Action name

Aug Narrative / Explanation

Secondary prevention

Decision to transfer resource to cardiology programme was taken by Exec. Group. Population Health

team will continue to work with internal and external partners to deliver where possible.

Develop Organisational Culture focused on

improving Population Health

Further work requested with a view to present to the PH strategy group in October 2025.

Local Care Partnership Development

Paused to enable future function and form of place to be established as part of Cluster development.

LCP's repurposed to focus on INT development in interim.

Strategic Commissioning (NICE Other)

Slight slippage on the programme. Plan is to catch up in Q3 and work should still be complete by

March 2026.

Prepare for ICB's commissioning of section 7a

vaccinations

Informally

advised by national lead that transfer of commissioning responsibilities to ICBs is being

delayed until April 2027. A formal notice is expected to be circulated by the end of September.

Commissioning Framework

Delayed due to workforce capacity and will be reviewed next reporting cycle.

Special Educational Needs & Disabilities (SEND)

Improvements*

Although ICB actions on track in line with this annual plan.

SEND as a multiagency programme

across Devon and Torbay. Torbay is Not on track to achieve compliant inspection outcomes due to

partnership and NHS constraints. Mitigating actions being undertaken regarding 'support while

waiting' and waiting list recovery.

Plymouth preparation positive and demonstrating good progress.

24/7 Mental Health Care

Workstream with DPT PC undertaken as part of the provider workstreams so intending to remove

from commissioning Annual plan as part of the de

-prioritisation process.

Understand workforce financial implications of

MSSP

Workforce stocktake due for completion in August 2025 is now delayed until 31st October 2025 due to

team capacity. This has been escalated to CNO.

Financial Implications of MSSP being worked through by providers

- systems being set up for

September

Right Care Right Person

The outstanding action from 24/25 of developing a system wide section 136 protocol has been

addressed and there is a clear plan in place to complete this action. The requirements of what should

be in place from an NHSE perspective have been reviewed and a template developed that will be

shared with members of the tactical group w/c15th September.

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Objective-Level Delivery Summary

Summary of Programme/Project/Actions Off-Track

Programme/Project/Action name

Aug Narrative / Explanation

Interface with regional clinical networks 

Pro

-forma being completed to recommend to ExCo that the work is paused.

Acute Services Strategy and Transformation

Arrangements to be confirmed

Supporting and driving networked acute care

Arrangements for the interface with the PAPC currently being reviewed.

Eliminating 18

-week community waits

MSK community service waiting times have now reduced to 415 waiting over 18 weeks, this is from a baseline position

of 2,300 in March 2025. Sustainable service delivery models are being implemented and maintained with a strong

focus on validation.

No resource currently available within the Elective Commissioning Team to commence improvement work on further

services which may flag as not meeting the 18

-week standard: podiatry, diabetes and rehabilitation. Currently being

added to Elective Commissioning Team risk register & COO Directorate risk register.

Three

-Year Recovery Plan for 18 Weeks

Performance progress around 18

-week standard will be monitored through the Operational Plan delivery mechanism

Waiting list validation

Programme is live, monitored directly by NHSE. Consider for de

-prioritisation

Maximising in

-hospital alternatives and

admission avoidance pathways

This was being held in the Locality Planning & Delivery Meetings but will transition into the Contract Management

Meetings when stood up.

Consider for de-prioritisation

Clinical and Care Professional Leadership

Pro

-forma being completed to request to ExCo that the work is paused until clustering has been completed.

Primary care estates

OOn hold due to restructure; progression is being managed through interim non

-pay contracts. Delivery is being

managed but with increased risks surrounding quality and managing the project pipeline

Devon New Hospital Programme (NHP)

Trusts are working with NHP on reshaping programme delivery

. Current risks associated with the management of the

programme are being worked through with the national NHP team.

Devon and Cornwall Care Record (DCCR)

procurement

The announcement of the abolition of the CSU is impacting the timely provision of procurement advice and guidance.

Despite this the OBC has been prepared following verbal advice from the CSU, NHSE and independent research.

Creating a culture for NHS Devon

Affinity Financial sessions continue, and further dates added. Design of peer support connection sessions underway.

Systems thinking development programme to be focussed on building neighbourhoods in South. Delegates now

confirmed. Facilitators confirmed. Programme to commence 24th September.

Unable to make desired progress due to consistently changing messaging and time frames from national and regional

teams re organisational reconfiguration. Concerns escalated re colleagues well being and psychological safety

Organisational change

Chair appointment announced 1st September. CEO announcement expected to follow soon. Preparations underway for

Exec and band 9 consultation. Draft timeline for wider staff consultation has been outlined however lack of clarity

around timelines and funding for cost of change still remain.

Quality Framework

Quality Management System forming part of health & Care Strategy.

Conference planning will continue when org.

change permits.

National Quality Strategy is awaited which will directly inform local work.

Research and innovation

Pro

-forma is being completed to request the work is paused until clustering is complete.

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Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Section 3: Impact tracking via Delivery

Management Report (DMR)

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Note: This revised dashboard is still under development. All available targets/plans have been included as applicable. Where targets or technical guidance were undefined a best practice approach or national

data sources have been applied.

2. Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

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3. Improve Personalised Care, Access, and Outcomes Across the System, targeting those

with greater need

data sources have been applied.

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4a. Drive Clinical Service Transformation and In-Hospital Productivity

data sources have been applied.

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4b. Drive Clinical Service Transformation and In-Hospital Productivity

data sources have been applied.

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5. Optimise Workforce, Digital Infrastructure, Estate and Commissioning Support

Services, Focusing on Delivery at Scale and Financial Sustainability

data sources have been applied.

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6. Deliver Statutory Functions and Maintain a High-Quality, Safe, Financially Balanced

and Sustainable System

data sources have been applied.

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Section 4: CIP Delivery

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CIP Performance as at Month 5 (Aug)

CIP Performance as at month 5

Recurrent

/ Non

Recurrent

Plan

Savings

Delivery

£000

Actual

Savings

Delivery

£000

Variance

Favourabl

(Adverse)

£000

Plan

Savings

Delivery

£000

Actual

Savings

Delivery

£000

Variance

Favourable/

(Adverse)

£000

Acute - System provider embedded

efficiency

Fully Developed R 14,400 14,400 0 34,556 34,556 0

Community - System provider

embedded efficiency

Fully Developed R 3,135 3,135 0 7,523 7,523 0

Mental Health - System provider

embedded efficiency

Fully Developed R 2,510 2,510 0 6,026 6,026 0

20,045 20,045 0 48,105 48,105 0

Acute - Repatriation of Independent

sector activity

Plans In Progress R 835 0(835) 2,000 2,000 0

Acute - Independent sector activity Plans In Progress N/R 1,040 0 (1,040) 2,500 2,500 0

Prescribing - Medicines

management Plans In Progress R 1,431 3,140 1,709 7,441 7,441 0

Continuing healthcare Plans In Progress R 600 903 303 3,000 3,000 0

Intersystem Contracts and IS

efficiency/convergence

Fully Developed R 1,605 2,991 1,386 3,861 3,861 0

Primary & Community Care Plans In Progress R 0 0 0 2,500 2,500 0

SDF Review Fully Developed N/R 1,360 3,265 1,905 3,265 3,265 0

SDF Stretch Fully Developed N/R 0 2,000 2,000 2,393 2,393 0

Strategic Placements and AACC

Digitisation

Plans In Progress R 0 0 0 1,234 1,234 0

Running cost reductions

Opportunity N/R 0 0 0 4,500 4,500 0

In year allocations and investment

review

Plans In Progress R & N/R 0 1,918 1,918 4,568 4,568 0

Primary care

Plans In Progress N/R 0 0 0 7,000 7,000 0

Other Flexibilities Plans In Progress R & N/R 1,114 1,114 0 4,459 4,459 0

System Risk Share & Unidentified

Stretch

Plans In Progress N/A 0 0 0 7,061 7,061 0

Total 28,030 35,376 7,346 103,887 103,887 0

Forecast

Month 5

Scheme

Plan Status

Risk RAG

Status

Year to date

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Section 5: Risks

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Risks

Emerging risks highlighted not yet on corporate or directorate risk registers

Objective

Programme /

Project / Action

name

Risk Lead

July

Status

Corrective

Action

Risk description

Number of times

featured in report

Risk Register and

Risk ID

Objective 4

Elective Demand

Management

Emma Herd

•No internal referral data feed from TSDFT, data quality issues with

RDUH data. One Devon Improvement Programme Risk Register.

Risk ID TBC

•Awaiting reconciliation exercise between national clock stop data

position and local referral data (Glen Burley letter)

Original plans proposed a <5% growth in total referrals, superseded

by NHSE demand management letter mandating 0.2% growth.

One Devon Improvement

Programme Risk Register.

Risk ID TBC

Objective 5

Creating a culture for

NHS Devon

Katy Kerley

Risk capture form being completed, it is anticipated the mitigated

score will be 15 and may become a corporate risk.

IF NHS Devon cannot find alternative means of resource within the

OD team, then it will be unable to fully deliver the current OD

programme

Organisational

Development risk register,

risk number 1.2

Not yet on corporate risk

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Risks

Risks highlighted on previous reporting cycle and not yet on corporate or directorate risk registers

Objective

Programme /

Project/ Action

name

Risk Lead

Status

Corrective Action

Risk description

Number of

times

featured in

report

Risk Register and Risk ID

Objective 4

Eliminating 18

-week

community waits

Karen Barry

Elective Care Waits

IF: The Devon System fails to deliver the 25/26

Operating Plan capacity, productivity and

performance required THEN: We will fail to

meet the national performance standards for

18 weeks and 52 weeks waiters RESULTING

IN: Potential patient safety issues and reduced

clinical outcomes.

Corporate risk register

–TBC

Also added as escalation

Multiple

(TDP) Repatriation of

Activity

Sean Beeken /

Emma Herd

None

There is a risk that if NHSE do not agree with

the ICB set IAPs for IS partners, then inflated

indicative activity plans will need to be provided

to ISPs leading to the requirement for financial

clawback from acute providers and reduction in

CIP.

TBC

Objective 2

Dental Provision

Paul Green

None

Collaborative Commissioning Hub Risk

- Urgent Dental

Care delivery

National baseline data taken for

2023/24 does not account for continued

decline in UDC delivery in Devon. Owing to

trend in performance continuing in 2024/25,

Devon's starting position to meet its 24,269

additional (81,705 including baseline) target for

2025/26 has become more challenged,

meaning we must first arrest a further decline

before making progress on baseline and

additional targets. Urgent dental care is an

area of work that has seen year on year

decline in the previous decade.

TBC

Objective 5

Organisational

Change

Sam Tribble

National instruction is to

achieve cost per head of

population of £19 by April 26.

Road map to achieve this is

unclear.

Discussions underway between Sam Tribble

and Governance team re inclusion of new risks

on corporate risk register. Significant risk

regarding funding of cost of change.

TBC

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Risks

Risks highlighted on previous reporting cycle and now on corporate or directorate risk registers

Objective

Programme /

Project / Action

name

Risk Lead

Status

Corrective Action

Risk description

Risk Register and Risk ID

Objective 4

Pharmacy Services

Paul Green

None

Existing risk COR0012 relating to capacity during

the transitional phase of Evolving the ICB. POD

team currently operating at 60% of structure.

Dedicated role to deliver Pharmacy First funding

expires end October 2025.

There is a growing provider side risk of

inadequate workforce capacity to deliver target.

This cannot be quantified by ICB at this time.

COR0012

ICB capacity risk escalated to Exec portfolio

holder August 2025. Shared with

Commissioning Hub August 2025.

Objective 5

Enabling

workforce

programmes

to support

NHS Devon’s

strategic

priorities

Mark Sowden

None

IF providers do not

provide workforce data

responsively and on time

THEN the PASP

modelling will be

inaccurate RESULTING

IN an incomplete picture

for decision making

18/09/25 update:

SLT of CPO directorate

confirmed that this isn't a risk to the workforce

team's delivery and will therefore not appear in a

risk register. It has been raised with the PASP

group as a risk to PASP

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Section 5: Escalations

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Escalations

New escalations in this reporting period

Objective

Programme/Project/

Action name

Escalation

Has the matter been

escalated to the SRO?

Solutions considered

so far

Where does the issue

need to be escalated

(ExCo, SLG etc)?

Is there a

recommendation of

proposed solution to

put forward?

Objective 4

Eliminating 18

week community

waits

Elective Care Waits

IF: The Devon System fails to

deliver the 25/26 Operating

Plan capacity, productivity and

performance required THEN:

We will fail to meet the national

performance standards for 18

weeks and 52 weeks waiters

RESULTING IN: Potential

patient safety issues and

reduced clinical outcomes.

Corporate Risk Register: Risk

ID: TBC

Yes

Exco

Identify and agree ICB actions

and whether resource needs to

be identified to support this area .

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Section 6: Action-Level Delivery Updates

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Section 6: Action-Level Delivery Updates

Objective 1: Develop a Long-Term, Whole Population Health Care

Strategy

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Objective 1: Develop a Long-Term, Whole Population Health Care Strategy

Progress against milestones (1 of 1)

Ref

Programme/

Project/

Action Name

Programme/Project/

Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective actions

AP3

Strategy Design

Phase

In the design phase, the focus shifts

to developing solutions based on the

insights gathered during the

discover phase. This phase will

bring together expertise from across

the system to solve the strategic

challenges identified within the

discover phase, define the key

strategy delivery elements, and set

the design parameters and specific

elements of the strategy. This stage

is often iterative, with multiple

rounds of design, feedback, and

refinement.

1. Agree design principles

2. Develop Engagement Plan

3. Component leads to develop strategy

design via Design Steering Group /

Strategic Development Workshops

4. Draft Strategy paper

5. Socialise outline Strategy with key

stakeholders

6. Finalise Strategy / Discover Report and

sign

-off

7. Governance points on critical path

8. Engagement (list)

- LCP chairs / ICP

board / team meetings / staff briefing

Evaluation framework

First design steering group met 15/07 External

facilitation has been agreed with Optum

Optum will facilitate a series of workshops throughout

July and August that relate to chapters in the strategy

structure

Workshops have been booked and invites sent to

appropriate stakeholders

All workshops have been successfully facilitated, and

outputs are now contributing to the final version of the

strategy.

Draft paper will be socialised internally w/c 08/09/2025

None

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Section 6: Action-Level Delivery Updates

Objective 2: Strengthen Strategic Commissioning to Tackle Health

Inequalities and Promote Prevention

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Objective 2: Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress against milestones (1 of 9)

Ref

Programme/

Project/ Action

Name

Programme/Project/Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective actions

AP5*

Core20+5 CYP

Core20+5: To improve the delivery of priority health

services consistently across Devon for children and

young people living with long term conditions, and

reduce the level of health inequalities experienced, by

March 2026.

Implementation plan developed

Children in care annual report completed demonstrating improved

metrics for health assessment.

LA based task and finish groups continue to take forward locally agreed

plans and initiatives.

None

AP30*

Multi

-agency

Safeguarding Hubs

(MASH) Capacity

To commission sufficient capacity as set out in the

Working Together to Safeguard Children 2023

guidance, within the multi

-agency safeguarding hubs

(MASH), to ensure delivery of all front door

safeguarding statutory duties and improve the delivery

of safeguarding practice, by March 2026.

Implementation plan within

resource available agreed

Devon wide Multi Agency Safeguarding Hub (MASH) review continues

with a delivery date of 31st October 2025.

As a result, the entire action is currently pending review and may be

subject to annual plan change log should the milestones for delivery

require review.

Online portal for DCC Now operational.

None required at this time, as there

are plans and mitigations in place to

ensure effective recovery in year

post review.

AP31*

Special Educational

Needs & Disabilities

(SEND) Improvements

To lead the health system delivery of Special

Educational Needs & Disabilities (SEND) health

improvements as a statutory responsibility of the ICB,

through effective commissioning and leadership across

all three Local Areas, with full implementation by March

2027.

1. Lead delivery of improvement

in local areas, as identified in

each area's SEND

improvement plan

2. Ensure any opportunities for

whole Devon improvement are

realised

Torbay SEND Published

- Improvement plan co-produced across the

Torbay partnership and submitted to Ofsted and CQC. Reviewed at

ExCo 2/09/25, prior to submission for assurance.

Prep for inspection in Plymouth stepped up this month with check and

challenge meetings completed with the DFE and NHSE for all priorities.

Devon inspection prep also underway.

Director quality assurance of all submission documents completed.

Although ICB actions on track in line

with this annual plan.

SEND as a multiagency programme

across Devon and Torbay. Torbay is

Not on track to achieve compliant

inspection outcomes due to

partnership and NHS constraints.

Mitigating actions being undertaken

regarding 'support while waiting' and

waiting list recovery.

Plymouth preparation positive and

demonstrating good progress.

AP32*

CYP Crisis Support

To develop the model of crisis support for children and

young people (CYP) with emotional wellbeing and

mental health, in conjunction with the South West

Provider Collaborative's redesign of inpatient support

and pathways by March 2027.

Pathways and model developed

and agreed with stakeholders,

including South West Provider

Collaborative

This actions as described are off track and are being redeveloped as

part of wider work to ensure that UEC pathways are inclusive of children

and young people and mental health as this will achieve a greater

strategic and sustainable change.

Capital bids for Torbay and Plymouth LA's successful, time frames for

delivery are outside of this financial year but joint work is progressing.

None

AP33*

Children’s Services

Recommissioning

To plan for the effective recommissioning of Children's

Services to enable improved and more consistent

delivery across the Devon footprint by March 2029.

Commence needs assessment

and stakeholder engagement

Children's Service Recommissioning: timeline and engagement plan

discussed at August Commissioning Hub Meeting, now progressing to

development of a strategic commissioning intention for 2026/27

-2030

Provider finance and commissioning returns deadline has been

breached and this will be escalated via Exec.

None

*Action belongs to multiple objectives

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report175 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective 2: Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress against milestones (2 of 9)

Ref

Programme/

Project/

Action Name

Programme/Project/Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective actions

AP4

Out of Hospital

Programme (OOH)

Complete the design phase of the OOH

programme by the end of Q1, to define

the community model for delivery, with

a strong focus on mitigating demand on

the UEC system.

Implementation phase

Plymouth LCP have agreed to and have been working towards

designing a local framework in response to the out of hospital

model. This is being worked up in conjunction with

neighbourhood health development aligned to the wider health

and care strategy design work. This work will form a part of the

final health and care strategy. There is ongoing work to

incorporate learning from Cornwall and Ilse of Scilly ICB as we

prepare for the ICB cluster arrangements. The system is

hosting a workshop in July 2025 to bring together a wide

range of stakeholders to support the continued development of

out of hospital services and personalised care.

Continued development within the neighbourhoods' section of

the health and care strategy.

None

AP6

Secondary

Prevention

Increase Secondary Prevention to

improve outcomes in Population Health

by developing system wide plans for

prevention of CVD, Diabetes,

Respiratory, and Falls and Frailty

Ongoing delivery of the CVD

plan, complete development of

Falls & Frailty Plan, establish a

Respiratory Working Group, and

draft a Diabetes Plan by end of

Q2.

SBAR in progress on diabetes given lack of capacity to

support programme delivery.

Decision to transfer

resource to cardiology

programme was taken by

Exec. Group.

Population Health team will

continue to work with

internal and external

partners to deliver where

possible.

AP7

Tackle inequalities

in access,

experience, and

outcomes

Implement NHSE Inclusion

Framework

Implement mechanisms to

demonstrate progress on Core20+5

Framework

Ongoing delivery of Inclusion

Health Framework, agree

evaluation framework for

Population Health, and establish

a regular reporting mechanism to

feed into the Core 20+5

governance group to update on

activity and drive progress.

IHF action plan now being delivered through working group

CORE20+5 mapping presented to CORE20+5 group and

prioritisation underway

Agreement to undertake EQIA audit to improve quality of

EQIAs and maximise opportunities for reduction of inequalities

None

AP8

Embed Population

Health Management

Embed Population Health Management

(PHM) approach

Commission system wide

infrastructure to support use of One

Devon Dataset (ODD)

Increase Primary Care sign up to ODD

Establish segmentation and risk

stratification processes (aligned

to neighbourhood teams) and

begin proactive engagement

Increase to 72% population coverage for ODD

None

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report176 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective 2: Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress against milestones (3 of 9)

Ref

Programme/

Project/

Action Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against

milestone

Status

Corrective

actions

AP9

Develop

Organisational

Culture focusing on

improving

Population Health

•

Agree and implement Population Health governance

and reporting framework

•

Implement Digital Inclusion Framework (DIF)

•

Implement Population Health Charter and supporting

resources

•

Create a set of Devon Personas

1. Governance Groups (x4) commenced and agree a

plan for Digital Inclusion Framework (DIF) and

launch Charter with all partners.

Launch SHINE and ongoing delivery of the Digital

Inclusion Framework (DIF)

- Groups commenced and PH measurement

framework agreed.

Digital Framework agreed and now being implemented.

Charter and SHINE

- presented on 11th August to PH

strategy group. Further work was requested by the

group. An amended paper will be presented to the group

in October 2025.

Charter completed

and implementation

paused due to org.

change

- Off track in

Q1.

Q2: presented to PH

Strategy Group to

agree way forward.

Further work

requested with a view

to presenting to the

PH strategy group in

October 2025.

AP10

Anchor Organisation

Strategy

Implement Anchor Organisation Strategy by March 2026

Health system engagement on the Anchor Strategy and

action plan

–secure collective commitment and map

existing Anchor activity in NHS and finalise the

framework for measurement and evaluation

Q2: Work in progress against Q2 milestone

None

AP12

Remote Consultation

Procurement

Procurement complete and contract in place for primary

care remote consultation solution by end of June 2025.

Put a new process in place to allow GP practices that

have decided to purchase their own system from the

approved list to reclaim equivalent funding

Central ICB contract of Accrux complete. Central

contract of eConsult not due to expire until 2026. 3

practices have procured local systems and will make

claims back to the ICB as soon as they have completed

all of their governance paperwork. All ICB work is

complete.

None

AP13

New Models of

General Practice

The ICB will build resilience and invest in new models of

general practice to achieve same day and 2

-week targets,

demonstrated on a quarterly basis using GPAD and:

Halve historic LES funding deficits

Increase Practice resilience (agreed as per headline

submission)

Increase Practice ratings of Good and/or Outstanding

(Agreed as per headline submission)

- Invest in and implement viable PCN / PCN+ new delivery

models

- Undertake comprehensive LES review (20 total) by March

2026

1. PCN Acute Care Services (new models): complete 2nd

evaluation to share with ExCo by end August 2025.

2. LES review: Cohort 1 complete by end July.

3. Cohort 2 complete by end October.

4. Cohort 3 complete by end February 2026.

5. Cohort 4 by end October 2025 (note: cohort 4 is being

managed outside of Primary Care Team).

1. PCN Acute Care Services

- timeline to achieve

August target in place with all partners advised on what

information is needed by when, and meetings that need

to review prior to submission. On agenda for ExCo in

September 2025.

2. Cohort 1

completed pending small amendments for

LMC to sign off in September.

Cohort 2 task and finish groups established.

None

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report177 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP14

Dental Provision

ICB will improve dental provision in Devon by achieving a

10% increase in NHS dental activity by Q4 25/26 by:

Supporting 10 (wte) Golden Hellos under the national

incentive scheme

Increasing activity by 10%

- Delivering 24,269 urgent episodes of care above baseline

(Q4)

- will be backloaded trajectory with 0 from Q1

Evaluating and implementing in feasible new patient

premium

Running a procurement process for at least 2 new dental

practices in Devon

•

- Golden Hellos - 3

applications supported

•

- By the end of Q2, 15% of

target is delivered (3,640)

•

- New dental practice

procurement process live

Golden hellos

- 3 applications supported

Procurement process for new dental practices

- Prior Information Notice (PIN) issued to

the market 01/08/25 detailing a joint, lotted procurement approach with CIOS ICB for

dental practices and related services.

Engagement event held with potential bidders on 13/08/25 with Collaborative

Commissioning Hub debrief on provider feedback on event questionnaire held 29/08/25.

ITT documentation being drawn up currently, targeting mid

-September go-live date for

procurement process.

None

AP15

Pharmacy

Services

ICB will extend the provision of locally commissioned

pharmacy services by 40% from the baseline by Q4 25/26

by:

Increasing contractor resilience

Growing nationally commissioned clinical pharmacy

services by 40% from baseline

Pharmacy First clinical pathway consultations (Baseline

3,205)

Oral contraceptive service consultations (Baseline 768)

Hypertension case finding service blood pressure check

consultations (Baseline 5,224)

Launching strategic framework for community pharmacy

•

Pharmacy First Q2 - 11,530

local target 19,494 revised

national target

•Oral contraceptive service Q2

-2121

•

Hypertension service Q2 -

5,827

•

Workplan implemented to

take forward actions from

strategic framework

Q2 update:

Workplan implemented to take forward actions from strategic framework

Pharmacy First (clinical pathways) July :6120

August:

September:

Oral contraceptive service Q2

- July:1552

August:

September:

Hypertension service Q2

- July:5685

August:

September:

None

AP16

General Practice

Contracting

Put in place action plans to improve general practice

contract oversight, commissioning, and transformation and

tackle unwanted variation in 2025/26.

Finalised plans in June 2025

June Plan submitted to NHS England on 30/06/25 (in line with national timeline). Awaiting

formal feedback, but expectation is that plan will be ranked green across all areas.

Regional feedback received 13/08/25 with a number of strengths identified.

Annual review of GP Practice annual eDec submissions complete and submitted to PC

SLT for oversight, further action to identify areas to improve compliance across Devon.

Continue to gain greater assurance through Contract Review Meetings where GP

contractors have been identified as requiring Contract Review.

Continue to work with CQC and ICB Safeguarding leads to enact contractual sanctions

where practices have been identified.

None

AP17

Joy App

Adoption

Joy App Adoption

Achieve 100% adoption of the Joy App by social prescribers

across all PCNs.

60% coverage on Joy App

22 out of 31 PCN’s are now using JOY (71%).

None

Objective 2: Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress against milestones (4 of 9)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report178 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme

/ Project/

Action

Name

Programme/Project/Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective actions

AP18

Local Care

Partnership

Development

Local Care Partnership Development of

LCPs across Devon (maturity of

arrangements and response to local

population need).

Agree ICB ambition for delivery

against operating model

Maturity work paused with focus of Devon's LCP's

repurposed to drive INT development.

Work on future place arrangements (function and form)

progressed as part of cluster development.

Paused to enable future function

and form of place to be

established as part of Cluster

development. LCP's repurposed

to focus on INT development in

interim.

AP19

Section 75

Review (Torbay)

Review Adult Social Care arrangements

(those subject to Section 75 partnership

agreement) in Torbay to strengthen

support for hospital discharge, reablement,

and independent living.

Undertake a review of the Section 75

agreement

Confirm outcome of review and

decision

–September 2025

This continues to be reviewed through the S75 executive

group which meets monthly, and the current agreement

continues until further notice.

None

AP20

Strategic

Commissioning

(NICE Other)

Review HCD spend across secondary

care providers to identify where Devon

spends more than SW median for its

population and review practice with

secondary care clinicians.

The

agreed refocus of this project is to

address variation in secondary biologic

sequencing in gastro, rheum, derm,

neurology and ophthalmology

- with

associated variation in cost.

Q2. Rheumatology was completed

last year and will be refreshed in Q2.

National guidance was issued at end

May for Ophthalmology (had been

expected in April) and meetings are

being arranged in Q2 to agree

sequencing ahead of biosimilars

becoming available in November

2025;

Q2. British Gastro Society guidelines

have been anticipated for some time

and have just been published and will

be reviewed with gastro teams in Q2

Q1. Overarching briefing document prepared in 2024/25 is

being updated. This was due by the end of June and has

slipped by a few weeks, but this doesn't delay the remainder

of the programme.

Q2. Meeting arranged for ophthalmology (up to £7m

recurrent savings). Request issued to clinical teams not to

change practice until system agreement reached. Initial

gastro review to be completed by end of September.

Slight slippage on the

programme. Plan is to catch up

in Q3 and work should still be

complete by March 2026.

AP21

Commissioning

Intentions

Implement targeted decommissioning of

selected GPwER and Independent Sector

Community Diagnostic services to

streamline provision and reduce

duplication. Negotiate and apply an

additional efficiency factor across all

contracts

- 4% for Non-VCSE providers

and 2% for VCSE partners

- to drive

system wide financial sustainability.

Price reductions have been negotiated for 25/26 where

possible (e.g. neurodiversity ASD price reduced by over

10%).

GPwSI headache service has been decommissioned.

No further actions planned against this action during 25/26.

The actions have been completed and the maximum CIP

realised.

None

Objective 2: Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress against milestones (5 of 9)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report179 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against

milestone

Status

Corrective

actions

AP22

Community Hospital

Consolidation

Community Hospital Consolidation (TDP)

Q3. Stock take, local engagement

Q4. mapping current activity / trust

level plans

Work to date has focussed on

understanding current plans

None

AP23

Investment Review

Undertake a comprehensive review of all contracts and

influenceable commissioning spend across the ICB to identify

opportunities for financial optimisation and improved

outcomes. This will involve assessing the values and impact

of services through benchmarking, quality impact

assessments (QIA) and system wide consequence analysis,

to inform decisions on service continuation, revision, or

decommissioning.

End Q2

- Completed reviews

undertaken for the following contracts:

•

GPwER contracts

•

Low-value (<£250k) contracts

•

Enteral feeds contract

•

Higher value contracts to explore

efficiency opportunities.

-Home Oxygen Service (HOS) VAT

exemption claim Now submitted to HMRC

for SW Region. Claim costed

- Year 1 -

£1,359,320 / recurrent

£373,830 Expected

outcome by m6 (following HMRC

clarification questions in m5)

Review of higher-value contracts - work

underway as part of enhanced contract

monitoring

- proposed scope work for

system partner CRMs underway and agreed

within ICB

low-value (<£250k) contracts -

Continuation of agreed Notice processes for

contracts expiring Q2 2025/26.

Ilfracombe MIU contract ending Sept 2025 -

£71k savings released

DSE

- TSD service ending w/c 19.11.25 -

£55k savings released

None

AP24

Healthcare Associated

Infections (HCAI)

Monitoring

Improved patient safety by ensuring that the system is

resilient and able to respond to, manage and mitigate HCAI

with the Devon System.

Trusts to adopt SW IPC strategy into

their IPC action plans and report on

their progress at each IPC Committee

meeting and completion of impact

assessment (EQIA)

Discussed and reviewed, no significant

change in month:

Monitoring of HCAIs continues, with a clear

baseline now established.

While Devon remains on an upward

trajectory, targeted engagement work is

underway with providers to reduce rates in

line with agreed thresholds.

None

Objective 2: Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress against milestones (6 of 9)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report180 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project /Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP25

Antimicrobial Stewardship

(AMS) Coordination

Update our approach to outbreak planning in line with the

Model ICB by identifying opportunities to commission

services at scale with system partners, improving

vaccination uptake for preventable diseases, and

supporting enhanced antimicrobial effectiveness.

Continued development and refocus of the

Peninsula Anti

-microbial Resistance

Group, (supporting the Devon/CIOS future

close working).

Discussed and reviewed, no significant change in month:

The Anti

-Microbial Resistance Working Group has met in July to

agree the terms of reference and set system

-wide priorities.

None

AP26

Infection Prevention

Update our approach to outbreak planning in line with the

Model ICB by identifying opportunities to commission

services at scale with system partners, improving uptake

of vaccinations for preventable diseases, and

strengthening collaborative and system leadership.

-create projects with partners focusing

on infection management, prevention, and

control

We are working collaboratively with Trust IPC leads to develop a

system

-wide C. difficile improvement plan.

A survey has been circulated to primary care colleagues to ensure

their input is reflected, making the plan relevant across the whole

health and care system. Further discussions with IPC Leads, with a

view to a more targeted Primary Care response.

Tuberculosis project changes are being considered as part of

implementing relevant GIRFT recommendations and as part of

strengthening services. Business case is under development with

engagement from stakeholders and clinical teams across the

system. Meeting planned for September to confirm priorities.

None

AP27

Outbreak Management

Improved patient safety by ensuring that the system is

resilient and able to respond to manage, mitigate

infection outbreaks within the Devon System.

Collaboration with partner agencies to

implement NHSE guidelines

Devon

-wide Memorandum of Understanding (MoU) for outbreak

response has been developed. Two stakeholder meetings have

been held to agree and finalise the document, with an output of

identified and agreed system gaps & challenges, to inform planning

work.

National guidance on ICB commissioning for outbreaks has been

reviewed and used to identify gaps and inform workplans.

Avian Flu swabbing: pathway has been implemented within Torbay

and Plymouth, further work required to ensure appropriate

engagement with the Community Teams in RDUH to ensure a full

Devon coverage, including North and East.

None

AP28

Prepare for ICB's

commissioning of section

7a vaccinations

Prepare for ICB's commissioning of section 7a

vaccinations by April 2026, achieve higher vaccination

rates.

Develop a detailed plan for ICB

commissioning transition and launch

campaigns to increase routine 0

-5s

vaccination uptake

Verbally advised by national lead that transfer of commissioning

responsibilities to ICBs is being delayed until April 2027. A formal

notice is expected to be circulated by the end of September.

Annual COVER published end of August, shows 0

-5s vaccination

uptake is improving in Devon with 4 out of 14 vaccinations at >95%,

9 out of 14 vaccinations at 90

-94.9% and 1 vaccination at <90%

(vaccination now changed in national schedule). This reflects a

stronger position than the regional or national position.

Once confirmed, work to

the new timescale for

transfer of responsibility

Objective 2: Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress against milestones (7 of 9)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report181 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action

Name

Programme/Project/

Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP29

Working with

providers to

increase

vaccination

uptake to support

UEC plan

Take a lead in planning prevention work

with providers to increase vaccination

uptake to support the UEC plan by

reducing avoidable hospital attendances

and admissions. Support system wide

UEC Winter Plan

Develop a detailed plan for

increasing flu uptake in Trust

FLHW by 5% and to reduce ED

respiratory attendance and

admissions

All plans in place for vaccination of eligible cohorts for winter vaccinations.

Focus is on 2

-3s, CEV and FLHW.

Targets for uptake have been shared with the lead for UEC winter team.

Regular review of uptake and mitigating actions where uptake is lower than

expected will be shared with the UEC winter lead.

None

AP34

Commissioning

Framework

Develop a framework for

commissioning/decommissioning linked to

delivery of the 2025/26 operational plan

Develop framework and process

for decommissioning linked to op

plan delivery

Draft framework developed and next step will be to take to August Exco for

approval and adoption

- This has been delayed due to workforce capacity

Delayed due to

workforce capacity

and will be

reviewed next

reporting cycle.

AP35

Clinical Waste

Procurement

CIP clinical waste procurement for

general practice and community

pharmacy in Devon

Engage with GP practices outside

the ICB contract arrangement

regarding moving to a single

provider model

Clinical waste market engagement live from 01/08/25 for 3 weeks. Market

engagement complete with 6 responses received. 2 responses indicated that

they could complete a 'weight based' methodology. CSU completing follow

up calls.

Finalise and develop FMT envelope for Devon

complete by end September

2025.

Finalise ITT questions, supporting documentation and final specification

complete by end September 2025.

Data collection to analyse existing supplier models/pay mechs

- completed.

Further evidence being sought to scope benefits of managing agent.

None

AP78

Community

Urgent Care

Review

Undertake a review of community urgent

care provision with a focus on

modernising Devon’s Type 3 community

urgent care services (MIUs, UTCs, and

WICs), to address longstanding

operational inefficiencies, inconsistent

standards, and escalating workforce and

financial pressures.

Approve the Case for Change

–

15/07/2025

The case for change was presented to the Commissioning Hub on Monday

1st September. A request was made to identify the resource requirements

needed to drive the programme of work forward. Caroline Stead is engaging

with the relevant teams to develop a Project Initiation Document (PID), which

will highlight any resource gaps. The deadline for completion is 15th

September.

None

Objective 2: Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress against milestones (8 of 9)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report182 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programm

e/ Project/

Action

Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against milestone

Status

Correctiv

e actions

AP80*

TDP:

Repatriation

of Activity

Oversee sufficient capacity within NHS providers to

enable IS providers to move back to provision at

originally contracted levels fulfilling the patient

choice requirements for commissioners.

Through reduction in IS IAPs support the facilitation

of c.£17m financial recovery for the system. Plans

for IS providers are indicative only and do Not affect

patient choice.

Aggregate system IAP reduction at a speciality level

Cardiology 100%, Ophthalmology 75%, General

Sx Urology & Gastro 70%, Spinal 75% and

Orthopaedics 30%

A medium and long term strategic plan will also be

in place to support the outcomes based strategic

commissioning of a sustainable Devonshire NHS

service.

This will be facilitated through the maximisation of

system assets and improved productivity at the

base acute sites.

The initiative will Not impact on any patients right to

choose as per the NHS Choice Framework and the

Health and Care Act 2022

Ongoing pathway work to

ensure SPOA for choice and

informed choice discussions.

All IS IAPs agreed and in place with QEIA supporting,

showing neutral impact.

Letter issued to all acute providers reiterating the need for

subcontracts to be in place for any IPT/MA activity as there

remains challenges with acute providers sending IPTs

across outside of the agreed contract.

July IS cost is significantly off target. This was expected in

part due to the reality of the repatriation scheme not being

fully online until September due to delays in agreeing IAPs,

however close monitoring is required as there is a risk of

significant cost pressure.

Changes to DRSS patient scrips has been deemed as not

viable at present time due to the significant variance in

waiting times in some specialities, the only changes

therefore have been made to cataract scripts.

The first shadow CRM was postponed for August due to

high volume of annual leave across the system but the next

is planned for September. Work is continuing in the

background to phase tasks in order to have everything in

place by the end of March 26 for formal CRMs to be in

place for all acute providers.

None

Objective 2: Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress against milestones (9 of 9)

* Action belongs to multiple objectives

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report183 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme

/ Project/

Action

Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against milestone

Status

Correctiv

e actions

AP128

Discharge and

Flow

Intermediate Care Plan developed and in place for each

LA footprint, covering discharges from each Devon Acute

Hospital

Q2. Undertake Demand &

Capacity Analysis and pathway

design

Q3. Develop Intermediate Care

model with agreed roles /

responsibilities

(provider/commissioner)

Q4. Embed delivery (commission

capacity and oversee provider

delivery plans).

Plymouth Intermediate Care Plan in place

- UHP / Livewell off

trajectory, but escalation with remedial action plan in development.

Devon

Hospital Discharge Programme reset workshop completed

to agree principals and support development of plan.

None

AP130

Community

Care (TDP)

Delivery of Community CIP (£2.5m in year)

Q1. Undertake modelling and

identify opportunity, agree route to

cash

Q2. Agree delivery plan

Q3. Monitor delivery

Q4 Monitor Delivery

Plans in delivery

- savings being delivered in line with trajectory

None

AP127

Develop

Commissioning

Hub

Development of Strategic Commissioning Hub to deliver

the Commissioning Plan and oversee the production of

Strategic Commissioning Intentions following the approval

of the Health & Care Strategy.

Establish Commissioning Hub by end of

Q2.

Strategic Commissioning Hub established with fortnightly meetings

commenced from 04Aug25.

AP129

Weight

Management

Develop and implement weight loss drug prescribing

pathways in line with the NICE TAs ensuring prescribing is

in line with the NHSE eligibility cohorts.

Develop and implement a 0

-2 year follow up pathway for

people who have had NHS or privately funded bariatric

surgery via the specialist bariatric services at UHP and

MPH.

Commission a 2 year lifelong follow up service for people

who have had NHS or privately funded bariatric surgery

via a general practice LES.

1. Executive Committee finance

sign

-off (12.08.25)

Pathway service reviews complete for specialist weight

management. Proposals submitted to Ex Co were approved on

12.09.2025. Now working towards implementation of a WM Single

Point of Access, Expanded Capacity of Tier 3 Services inclusive of

weight loss drug prescribing pathways, a Primary Care Tirzepatide

LES. In addition to this also working towards implementation of a

Primary Care Bariatric Follow Up LES, which is being funded via re-

purposed Optimising Referrals LES. Implementation for these is

planned for November 2025. The SPOA will be working to contribute

an overall 20% reduction in waiting times for access to Tier 3

Specialist Weight Management Services over a 12 month pilot

period. A waiting time reduction trajectory and activity plan is being

developed for the Tier 3 SWMS, which will be finalised and added to

the specification over the next four weeks.

Objective 2: Strengthen Strategic Commissioning to Tackle Health Inequalities and Promote Prevention

Progress against milestones (9 of 9)

* Action belongs to multiple objectives

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report184 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Section 6: Action-Level Delivery Updates

Objective 3: Improve Personalised Care, Access, and Outcomes Across

the System, targeting those with greater need

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report185 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those

with greater need

Progress against milestones (1 of 11)

* Action belongs to multiple objectives

Ref

Programme/

Project/ Action

Name

Programme/Project/Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective actions

AP5*

Core 20+5 CYP

To improve the delivery of priority health

services consistently across Devon for children

and young people living with long term

conditions, and reduce the level of health

inequalities experienced, by March 2026.

Implementation plan

developed

Children in care annual report completed demonstrating improved

metrics for health assessment.

LA based task and finish groups continue to take forward locally

agreed plans and initiatives

None

AP31*

Special

Educational

Needs &

Disabilities

(SEND)

Improvements

To lead the health system delivery of Special

Educational Needs & Disabilities (SEND)

health improvements as a statutory

responsibility of the ICB, through effective

commissioning and leadership across all three

Local Areas, with full implementation by March

2027.

1. Lead delivery of

improvement in local

areas, as identified in each

area's SEND improvement

plan

2. Ensure any

opportunities for whole

Devon improvement are

realised

Torbay SEND Published

- Improvement plan co-produced across

the Torbay partnership and submitted to Ofsted and CQC.

Reviewed at ExCo 2/09/25, prior to submission for assurance.

Prep for inspection in Plymouth stepped up this month with check

and challenge meetings completed with the DFE and NHSE for all

priorities.

Devon inspection prep also underway.

Director quality assurance of all submission documents

completed.

Although ICB actions on track in line with

this annual plan.

SEND as a multiagency programme

across Devon and Torbay. Torbay is Not

on track to achieve compliant inspection

outcomes due to partnership and NHS

constraints.

Mitigating actions being undertaken

regarding 'support while waiting' and

waiting list recovery.

Plymouth preparation positive and

demonstrating good progress.

AP32*

CYP Crisis

Support

To develop the model of crisis support for

children and young people (CYP) with

emotional wellbeing and mental health, in

conjunction with the South West Provider

Collaborative's redesign of inpatient support

and pathways by March 2027.

Pathways and model

developed and agreed

with stakeholders,

including South West

Provider Collaborative

This actions as described are off track and are being redeveloped

as part of wider work to ensure that UEC pathways are inclusive

of children and young people and mental health as this will

achieve a greater strategic and sustainable change.

Capital bids for Torbay and Plymouth LA's successful, time frames

for delivery are outside of this financial year but joint work is

progressing.

None

AP54*

Improve the

access to health

services for all

CYP who need

hospital care,

mental health,

and community

services

To improve the access to health services for all

Children & Young People (CYP) who need

hospital care, mental health, and community

services including all those on health waiting

lists, through improved delivery against current

contracts, and effective commissioning of

additional and enhanced capacity where this is

required by March 2026.

Implementation plan within

resource available agreed

Neuro

-diversity and other CYP pathway recovery programmes

have been translated to clear strategic commissioning intentions.

ND workshop planned for early September to confirm

commissioning model and agree implementation with providers.

None

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report186 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

* Action belongs to multiple objectives

Ref

Programme/

Project/ Action

Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP55*

Design and

implement an ICB

process which

consistently

addresses

individual

commissioning

needs for CYP

To design and implement an ICB process which consistently

addresses individual commissioning needs for CYP, where their

needs fall outside of core commissioned services, by March

2026.

Process designed on

how to address individual

commissioning needs

This action remains on track currently but Q2 delivery is

contingent on process being fully agreed across each LA

footprint which is being impacted by capacity within the

individual commissioning team.

Agreement to include LAs in IPOC process.

None

AP36

Neighbourhood

Health Service Offer

Deliver a core neighbourhood health service offer, with delivery

tailored to local needs and assets and response to national

guidance.

Agree neighbourhood

health service offer

blueprint

Establishment of proposed INT geography underway

individual LCP engagement sessions underway to progress

agreement.

Identification of vanguard site opportunities.

Joint work with Cornwall (via INT conference and place /

locality director engagement) to ensure alignment of

development and shared learning.

Mapping of INT roadmap against NHS 10 year plan.

Waiting feedback from NNHIP applications (supporting place

level engagement in national programme).

Review/update of roadmap to reflect ambitions set out in the

Health & Care strategy and emerging commissioning

intentions.

None

AP37

Personalised Care

Implement risk stratified, personalised care across integrated

teams, prioritising high need groups e.g., frailty, dementia, and

end of life care.

Process design and

development and review

and agreed phased

implementation plan.

Mapping against NHS 10 year plan (doubling of PHB offer).

Personalised care workshop delivered (22/7)

- reviewing

progress to develop work programme actions and further

training offer.

None

AP38

Monitor and

Implement

Statutory and

Strategic Mental

Health objectives

Monitor and implement mandatory and statutory requirements

and long term plan

objectives

Including Access to Talking Therapies, Reliable recovery,

reliable Improvement, Completed course of treatment, Out of

Area Placements, Access to perinatal MH, IPS Length of stay

LOS.

Consider separation of performance/core business. Health

inequalities out and target/BAU work to be removed.

•Evaluate monitoring

quality assurance

report

•

Consider outcomes

in year

Review of achievement of targets with BI and commissioning

team each month. Necessary actions will be determined and

escalated if required. BAU is part of our regional reporting

and Quarter 1 reporting has complete with oversight meeting

in both MH and LDN.

None

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those with

greater need

Progress against milestones (2 of 11)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report187 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/ Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP41

24/7 Mental Health

Care

24/7 MH Care

Provider Collaborative

Signature Move

Consider de

-prioritisation given

reframing to providers. (ICS).

Agreed by System Leadership

group regarding provider ICB split.

Conduct a comprehensive

needs analysis aligned to 24/7

access to care by engaging

key stakeholders and

analysing relevant data, EQIA.

And gap analysis.

Develop a commissioning

policy for the effective delivery

of 24/7 care

Workstream with DPT PC undertaken as part of the provider workstreams so

removing from commissioning Annual plan as part of the de

-prioritisation requests.

AP42

Physical Health

Checks for Severe

Mental Illness

(SMI)

Physical health monitoring for

individuals with Severe Mental

Illness (SMI) and Eating Disorders.

Reduce inequalities in Mental

Health care by increasing the rate

of annual physical health checks so

that people with severe mental

illness (SMI) are receiving a full

annual health check with at least

64% receiving one by March 2026

ensuring appropriate follow

up care

for all those who need it

Implementation of the LES/shared

care recommendations

Three current workstreams under this objective:

SMI PHC Current performance is 5960 people have received SMI PHC against local

target of 5979 (

-0.32%) Whilst target was not achieved, this is not at present of

statistical significance. Proposed activity for September Comms approach through GP

Bulletin.

ED PHC Contracting agreed 2 Month extension to current Ed contract across

Plymouth. Commissioning team discussing plus 1 direct award to give specification

time for development. Population needs for both ED and disordered eating requires

potential procurement Clinically informed pathway to be developed to support

onwards contracting.

Anti

-Psychotic Shared care developments -

On going work 1st shared care guidelines

near completion finalising provider contribution to the delivery end of the shared care

agreement. Letter to LMC sent and proposal for interim plan with exec for

consideration in 2025/2026. Attendance at negotiations meeting October and

November. Data Audit returned to establish demand across the system. Cohort E

proposals for on going care for those hat do not meet the requirements of the Shared

Care Agreement.

None

AP43

Transitions

-prioritisation re: resource

Conduct mapping exercise

Evaluate programme

N.B. Whilst this are of work has being considered for de

-prioritisation, the of Head of

Commissioning ICB continues to be engaged in a system and regional group to work

on transition. improvements as part of the MH team BAU.

Transitions will be the focus of work for CHC review of process and care packages for

information on verification.

-prioritisation

and future system

focus and appetite

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those with

greater need

Progress against milestones (3 of 11)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report188 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/ Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP44

Enhance

Community Mental

Health Support

Intensive community support

National Guidance to enhance

community Mental Health response

Full review of operational procedures and

growth and undertake EQIA to consider

impact of recommendation within Devon

With a new lead in the provider inpatient wards (DPT) focusing on the

assertive outreach this has promoted a refocus on the ICB and Lead working

together in this area an ICB returns due in September so a reset of the review

of progress in this area is required.

Returns received from LSW waiting for DPTs. Outcomes of review to direct

focus. New governance structure for the MH commissioning pathways will

support this work. Met with Clinical Lead for Devon in this area and reigniting

engagement with focus on provision specifically of "risk to others"

Reset on work in

progress with

providers.

AP45

Improve UEC

Mental Health

Pathway

Devon ICB will work with system

partners to improve the service

users' journey through the UEC

Mental health pathway, to reduce

inappropriate demand and delays

in ED and improve outcomes for

services users.

Complete recommendations

2. Full review of operational procedures

and growth and undertake EQIA to

consider impact of recommendation

within Devon

Activity: Finalised commissioning principles to support LSW capital bid and

associated revenue.

Tactical group Terms of Reference been developed and agreed will incorporate

MH Crisis and Inpatient Delivery.

Evaluation of MHRV underway and triangulation with MH Desk expansion we

still do not have the agreement of the revenue for this provision.

System evaluation will support on going decision for the vehicle.

Opel Action Cards and UEC Action cards are being review in provider

operational space.

Discovery Work on the Informal patent admission trends across the system

being undertaken.

Inpatient transformation program being brought back into the ICB with

commissioning intentions in future years to understand bed base and usage.

AP46

Transform

Perinatal Mental

Health Pathway for

Women, Birthing

People, and

families

Perinatal Mental Health and

transform Emotional and Mental

Health pathways of care for

Women, Birthing People, babies

and partners during pregnancy and

the first year after childbirth that:

In year focus on Mothers and

Birthing people that have had

removal of a baby

Is integrated with social care led

vulnerable pregnancy pathways

and early help offers.

1. Review current service provision and

undertake scoping exercise to

consider gap analysis undertake

EQIA, and stakeholder engagement.

2. To be reviewed by Maternity CYP and

Women’s Health

Activity: To work with the Director of Women and Children's to agree

roles/responsibilities and focus for a joined up, integrated LMNS, perinatal and

maternal MH forum to improve outcomes for birthing people and women.

Achieved: Lead identified from within MH commissioning team to work in this

space. Leadership and direction of work to be led by the Director of Women

and Children's. The workplan will be influenced by the recent safeguarding

reviews and maternal death cases. initial focus will be on ensuring that women

or birthing people who have baby removed are still able to access the support

they need. From a MH commissioning perspective, in addition, work is ongoing

to ensure that the current performance within services continues to meet

operational targets. The mental Health Commissioning Team are associate

commissioners the lead will be held in Women's and Children's.

Impact: a holistic pathway of support will be available to women or birthing

people learning from recent incidents.

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those with

greater need

Progress against milestones (4 of 11)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report189 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/ Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP47

Neurodiversity

Community Offer

Community provision for autistic

people who are experiencing a mental

health need. this is to support the end

to end pathway for new capacity in

Learning Disability and Neurodiversity

mental health developments, ensuring

that the offer from providers meets the

identified MH needs of our population.

Complete gap analysis, data

collection, and EQIA, analyse

data collection, and produce

stakeholder engagement events

for pathway development.

Hold system workshops,

coproduce neurodiversity

system pathway, and establish

coproduction forum, LDN

Groups, and Local Authority

Focus in Month on Autism Liaison Nurse Function. ICB benchmark returns

received x3, Cornwall and Isles of Scilly and UHP have commissioned inhouse

Acute Laison service creating inequalities in offer.

Impact: Limited consistency offer on commissioned service Acute Hospitals,

limited allocations/capacity of Acute Laison Nurse for Torbay and RDUH.

Ongoing discussions re: Governance arrangements within RDUH & TSDFH with

nurses employed through DPT. Provider recognises issues and working through

risk register and Team Register.

Completion on mapping exercise with providers to establish need and potential

to redirect existing resources to areas of greatest need.

Wider LDN community offer: Started additional scoping work and stakeholders to

be identified. Inform 26/27 commissioning intentions.

Right To Choose: Contracts supporting the provision of Psychoeducation as part

of the treatment pathway ensuring advice guidance and signposting available to

all those receiving diagnosis work.

Service specification work being undertaken with providers on ASc/ADHD impact

criteria for appropriateness of referrals. Workshop held 08.09.2026

Plymouth Community Development for Step Down provision on going with PCC.

There are several

lines of work

attending to this

objective in Acute

liaison, community

and diagnosis

pathways. Ro out of

OMMT supporting

the skill

development in the

workforce.

AP48

Implement

Neurodiversity

Pathways in line

with National

Choice Legislation

Neurodiversity (inc. Right to Choose

and delivery pathway)

- Implement

national legislation through the right

choice.

Significant pathway, requires pathway

review and consider shift to primary

care.

Develop dashboard to inform

trajectories and referral routes

from primary care, standardise

contract reporting and

governance oversight, and

undertake and complete EQIA.

Dashboard roll out and first

information from the DRSS

referral route, trajectories on

patterns of referral routes,

convergent rates, and

neurodiverse profile

Activity: CRM's, September meeting planned with providers (8/09/25) regarding

complexity definition and Paeds RTC queries.

FAQ's Written, signed off and published on ICB website.

T&F meeting as per request from Commissioning Hub Steering Group, Outcome

to move forward on SPOA model vis DRSS posts.

IAP's ongoing.

Impact: Changes to Annual review principles agreed sent to contracting. 1 new

accredited provider, start date 1/9.

Risk: Realisation of potential £10m financial risk Commissioning Hub Steering

Group. (financial risk recognised however this is held corporately, whereas the

Governance, process oversight and assurance in is place).

VCP panel agreed post to support SPOA model. Waiting for recruitment DRSS.

Update given to LMC October negotiations on position. Threshold criteria

proposed to manage flow and impact.

Concerns. Legislation and value of diagnosis in the community.

Financial Forecasting:

Collect and monitor RTC Devon contracted activity.

Paper proposed to ExCo to inform on progress and to provide assurance on ICB

delivery.

None

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those with

greater need

Progress against milestones (5 of 11)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report190 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/ Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP49

Develop and

Implement Digital

Flag Strategy

Reasonable adjustment digital flag

linked to electronic roll out across the

system.

Digital development ICB led and

developed across the system. Part of

the Health Inequalities agenda.

Continued implementation

across health care providers and

progress report

Activity and achievement: Met with NHSE Project Manager

- positive feedback on

progress received

Patient and service provider literature development commenced.

Monthly check in meeting with Cornish peers set up.

Project introduced to Darin Halifax, Head of Voluntary Community and Social

Enterprise. Invitation to present at VCSE monthly assembly membership 6,000 with

1,800 active attendees

Continued support to GP practices with recording flags.

Impact: Continued increase in the number of organisations acknowledging the need

and importance of RADF.

Risk: Capacity, appetite (kick back from some GP practices as it isn’t mandatory

(yet)) and better roll out and support tools from National Team

None

AP51

Ensure appropriate

inpatient care for

Learning Disability

and Autistic People

South

-West Regional Future beds -

This is in the Mental Health In

Patient

Unit (One in Devon and one in Bristol

for the seven ICBs of SW).

Appropriate inpatient care for LD and

Autistic People.

Opening July: Move to regional

oversight quality measures. BSU

oversight. Health Inequalities strategy.

Devon: Regional overview and

monitoring of provision and

implementation review

Bristol: Preparation of workforce

working towards and quarterly

update on mobilisation

Activity: The South West Regional Front Door panel has considered 14 referrals to

The Brook and Kingfisher (when open). Panel has recommended 2 referrals for

admission to The Brook.

Consistent bed day rate has been approved for both services (The Brook and

Kingfisher)

Achieved: First two patients to be admitted to Brook by 15/09/25.

There is a continued focus on people being admitted as close to home as possible,

without the need for an out of area placement at additional cost, reduction in length

of stay and potential repatriation.

None

AP52

S117 and Individual

Patient Placement

(IPP)

Delegation of financial responsibilities.

Financial risk/growth, currently ICB

business.

Full review of operational

procedures and growth and

undertake EQIA to consider impact

of recommendation within Devon

Reported position is £2.6m overspent. This is largely a result of the continued spike in Out

of Area Acute clients & three high

-cost clients (<20k/week) but offset by favourable IPP

ABI/S117 variances.

The current outturn position for month 4:

Budget = 43,929,930

Forecast = 46,577,483

Variance =

-2,634,553

IPP reviews remain stable at 74%. LDAN & OPMH patients out of area received safe and

wellbeing reviews every 8 weeks. For the ABI cohort Devon ICB continue to improve

tracking of the cohort and working with NHS providers to allocated key workers.

Over the past 3 months there has been an increase in s117 eligible patients from 458 to

477. There has been a 31% increase of in date s117 reviews since March 2025 currently

at 56%

Safe & wellbeing checks continue to out of area hospitals, concerns on quality raised in

one unit linked to communication issues, patient safety and over restrictive practice.

Plan

-All areas of concern shared with ICB SRO and meetings set up to ensure

improvements are made.

None

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those with

greater need

Progress against milestones (6 of 11)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report191 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

* Action belongs to multiple objectives

Ref

Programme/

Project/

Action Name

Programme/Project/ Action

Description

Q2 Milestones

Update on progress against milestone

Status

Correc

tive

action

AP53

Enhanced

End of Life

(EoL) Care

Delivery

Enhance end of life care with early

identification, advanced care planning,

and coordinated support

Procure new service

elements (note that

some procurement

activity will extend into

2026/27)

August Update: The EOL work has been prioritised within the staff resources available for the following

workstreams:

Gold Standards framework

–Guidance and comms complete –possible pilot sites have been identified across

Devon.

After Death Care

–Guidance to be signed off by end of September then published to F&R website.

End of life medications

–Need to prioritise alignment of PMAR across Devon –working group to be set up and

clinical advisor has been identified.

Marie Curie Night care contract

–

Options appraisal has been completed and working through EQIA for working

group review at the beginning of September. There is a commissioning review of Hospice contract/ grant

agreements required which will need to incorporate the Marie Curie contract and therefore the timescales for

reviewing this contract may move to align with the wider review. The plan and timeline will be confirmed in next

month's update.

-Teps – Meetings have been widened and renamed to “Devon & Cornwall Neighbourhoods Digital Group” for

weekly meetings to monitor usage and also look at wider DCCR development. TSD now live. Revised Go live

date for RDUH end of September. SWAST live and usage tracked weekly.

The EOL Oversight group will meet in September. The TOR and membership are being reviewed.

None

AP56

Maternity

Improvement

s and

Transformati

on for the

Peninsula

Establish the leadership and

governance framework needed to drive,

deliver, and assure maternity

improvement and transformation for the

Peninsula

Revised accountability

and assured framework

developed and

leadership

responsibilities clariid

and agreed

August Update:

Maternity improvements and transformation for the Peninsula:

Accountability and assurance framework, (including leadership responsibilities on track for delivery with

appropriate in month progress.

Commissioner led working party to be established and progressing on actions.

None

AP57

Safe and

efficient use

of resources

in maternity

services

Lead and drive priority improvements at

system level that will achieve patient

safety requirements and efficient use of

resources

Data review and

assurance process in

place (have we met out

safety ambitions and

are current

interventions making a

difference?)

August Update:

Safe and efficient use of resources in maternity services:

Q2 target will be subject to a change as the launch of a National Maternity Dashboard is due for imminent launch,

(September/October).

It is expected at this time that the National timescales for roll out will meet our previously defined local target date.

However should this change, then the Objective Change log will be updated appropriately and change will be

taken through the appropriate Governance route.

None

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those with

greater need

Progress against milestones (7 of 11)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report192 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

* Action belongs to multiple objectives

Ref

Programme/

Project/ Action

Name

Programme/Project/

Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective actions

AP58

Understand

workforce and

financial

implications of

Maternity Safety

Support

Programme (MSSP)

Quantify where Maternity

Safety Support Programme

(MSSP) and other

improvement agendas have

workforce and financial

implications. Prioritise and

agree case for change within

the context of current financial

pressures

Workplace plans costed and

capital costs scoped

2. Financial commitments fed into

systems financial planning for

affordability 2025/26 and

opportunities for 2026/27

August Update:

Birthrate Plus Report for Torbay is essential to the completion of this action, the report

is still outstanding at this time.

Workforce stocktake due for completion in August 2025 is now delayed until 31st

October 2025 due to team capacity. This has been escalated to CNO.

Financial Implications of MSSP being worked through by providers

systems being set

up for September

Delay in respect to third

party company that handles

the Birthrate Plus reports,

leading to delays in ICB

taking forward actions.

Torbay have in place a

Maternity & Neonatal

Improvement Advisor who

has been supporting the

collation of information

through their workforce

review.

AP59

Develop

sustainable

perinatal services

in Devon

Establish the work

programme needed to

develop sustainable future

perinatal services in Devon, in

conjunction with PASP.

In conjunction with PAST, LMNS to

provide clinical and commissioning

perinatal expertise

August Update:

Strategic commissioning intention developed for maternity transformation and included

in the health and care strategy. High level time line being worked up in line with

organisational planning timeframes.

None

AP60

Commission pilot

pathways for

socially vulnerable

women

Commission pilot pathways

for socially vulnerable women

that increase the number of

babies that remain safely with

their birth families by March

2026.

Pilot pathways developed

August Update: Develop sustainable perinatal services in Devon:

Maternal Mortality Review process completed.

Pathways now in place within the DCC footprint.

None

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those with greater

need

Progress against milestones (8 of 11)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report193 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action

Name

Programme/Project/ Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective actions

AP61

Establish

perinatal

Mental Health

community of

practice

Establish perinatal Mental Health

community of practice to ensure a

cohesive mental health and emotional

support pathway of care for women,

birthing people, and their families.

1. Community of practice established

Collaborative vision agreed and

gap analysis completed

August Update:

Mortality and Morbidity review has commenced to capture the

mental health and social complexity root causes in the perinatal

period.

This will help to inform strategic commissioning intentions for

perinatal mental health.

Pending outcome and

recommendations a maternal

death review which was late

concluding, as a result,

impacted on Q1.

AP60 & AP61 will be reviewed

in light of the findings of the

review above: to ensure

appropriate reframing of the

objectives in line with the

Maternal Mortality Review

recommendations.

AP62

Integrated and

preventative

approach to

women’s

health

Develop a more integrated,

preventative approach to women's

health, through effective coordination

of women's health initiatives across

Devon ICS.

Services which could be developed to

work in a health hub model identified

and engagement commenced

August Update:

Integrated, preventative approach to women's health

LARC (Long Acting Reversible Contraception) training is

currently being rolled out across Primary Care.

New contract for LARC services commences October 2025,

Pharmacy first services to be on line from October 2025

including emergency contraception.

Expansion of the Specialist Menopause Service is on track for

delivery in year.

None

AP63

Interface with

Regional

Clinical

Networks

Develop alignment between ICB/ICS

objectives and regional clinical

networks 

Review network workplans and

identify contributions to ICS plans

Ensure ICB network places are

complementary

Pro

-forma completed to request stand down

Consider for de

-prioritisation

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those with

greater need

Progress against milestones (9 of 11)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report194 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action Name

Programme/ Project /

Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP103

Procurement of All-

Age Continuing

Care (AACC)

Undertake market development

procurement to ensure that the ICB

has legally compliant contracts for

complex care, live

-in care, trusted

assessor services. Explore

opportunity for joint procurement with

DPT for specialist hospitals to ensure

quality and value for money with

volume discounts.

1. Identify the contracts that cannot be

extended under SAW

2. Work with CSU, contracting and

AACC Ops to identify the contracting

lots and procurement approach.

3. Develop lot specifications, engage

with market

4. Develop tender documentation and

pricing approach

5. Launch tender

6. Evaluate bids

7. Award contracts

8. Mobilise contracts

1. Completed: Contracts identified and POG signed off SAW

extension whilst procurement underway.

2. Completed: Market development procurement lots: complex care,

live

in care and trusted assessor. Specialist hospitals to be a separate

procurement, exploring joint procurement with DPT, proposal paper

written and going to POG 23/07/25 for endorsement.

3. Completed.

4. Completed.

5. Market development procurement launched 04/06/25, closing date

13/07/25.

6. CSU to complete compliance checks during w/c 04/08/25 and

evaluation to begin w/c 04/08/25. Operational SOP to support the

implementation of the tender is being developed. POG signed off the

joint contracting approach for specialist hospitals with DPT. Specialist

hospitals procurement group to be established to develop the plan.

Evaluation ongoing August

-Sept 2025.

None

AP123

LeDeR Programme

The LeDeR

Programme drives

transformational improvements in

care quality by using learning from

mortality reviews to reduce avoidable

deaths and address health

inequalities for people with learning

disabilities and autistic people. It

aligns to the strategic commissioning

plan by providing evidence to

commission targeted, equitable

services that reduce avoidable harm

and variation within PLUS5

populations, embedding

improvement into system planning

and prevention strategies

Improve Timeliness and Quality of

Reviews

- Strengthen LeDeR

workforce capacity, systems, oversight

and streamlining processes to ensure

that reviews are completed in a timely,

high

-quality and person-centred

manner in line with national KPIs and

objectives within the LeDeR policy.

Integrate LeDer data into planning and

commissioning

- Ensure themes and

findings from LeDeR reviews directly

inform service planning commissioning

decision and health inequalities action

plans access the system . DAWN: QA

with reviewers. Take to gov Part A.

CHRIS: Data analysis.

Activity: To explore and make recommendations on a new process to

align LeDeR with PSIRF and recognise the need to focus on the

learning and the collaboration of services within the ICS.

QALIA b, new standing agenda item and Task and Finish group to be

established with remit to develop an options paper outlying the

integration of LeDeR and PSIRF and to set out the governance

process to ensure effective oversight and how it aligns to PSiRF,

consider whether these functions can be widened to incorporate the

completion of LeDeR reviews in the future. National LeDeR team

shared the 'Dorset Model' which places an emphasis on ICS'

completing the reviews, with ICB oversight, sign off , sharing and

embedding the learning within local systems.

Impact: To reduce duplication and strengthen patient safety learning

across partners.

Risk: TRO12 remains with backlog reviews and limited ring fenced

SDF funds cease 31st March 2026 , (Audit Committee for Corporate

risk identification).

None

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those with

greater need

Progress against milestones (10 of 11)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report195 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action Name

Programme/ Project /

Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP142

Right Care Right

Person

This programme of work was in the

responsibility of the Provider

Collaborative and we have brought

the responsibility back into the ICB

commissioning team.

The tactical developments underway

with Terms of Reference agreed and

liaison with the head of

commissioning and the police lead.

With changes to the directorate

ownership the Strategic groups is yet

to be set up. Commissioning lead

has written TORS next strategic

reset to be arranged.

S136 protocol reviewed for the

purposes of the role out of the policy.

Q2 Tactical Group coordination and

first meeting

Activity: To ensure that TOR for the operational/tactical and strategic

groups are drafted; to ensure that there is a clear plan for progression

of RCRP agenda.

Achieved: TOR have been drafted with police co

chair and fellow ICB

CIOS commissioners.

These have been reviewed and can be circulated to members of the

tactical group for review/comment with formal sign off scheduled for

October meeting. The strategic TOR will be shared for comment,

noting that as yet the strategic group has not been commenced/stood

up.

The outstanding action from 24/25 of developing a system wide

section 136 protocol has been addressed and there is a clear plan in

place to complete this action.

The requirements of what should be in place from an NHSE

perspective have been reviewed and a template developed that will

be shared with members of the tactical group w/v/ 15th September.

The ask being that providers RAG rate themselves and RAG rate the

system against the criterion. The outputs from this will form the basis

of the RCRP operational workplan.

Impact: there will be clarity on the purpose of the tactical partnership

group and a benchmarked position to inform next steps.

Strategic RCRP

partnership group is

not yet convened.

Objective 3: Improve Personalised Care, Access, and Outcomes across the system targeting those with

greater need

Progress against milestones (11 of 11)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report196 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Section 6: Action-Level Delivery Updates

Objective 4: Drive Clinical Service Transformation and In-Hospital

Productivity

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report197 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action Name

Programme/Project/

Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP54*

Improve the

access to health

services for all

CYP who need

hospital care,

mental health, and

community

services

To improve the access to health services

for all CYP who need hospital care, mental

health, and community services including

all those on health waiting lists, through

improved delivery against current

contracts, and effective commissioning of

additional and enhanced capacity where

this is required by March 2026.

Implementation plan within resource

available agreed

August Update

Neuro

-diversity and other CYP pathway recovery programmes have been

translated to clear strategic commissioning intentions.

ND workshop planned for early September to confirm commissioning model

and agree implementation with providers.

None

AP80*

TDP: Repatriation

of Activity

(TDP) Repatriation of Activity: Oversee

sufficient capacity within NHS providers to

enable IS providers to move back to provision

at originally contracted levels fulfilling the

patient choice requirements for

commissioners.

Through reduction in IS IAPs support the

facilitation of c.£17m financial recovery for the

system. Plans for IS providers are indicative

only and do Not affect patient choice.

Aggregate system IAP reduction at a

speciality level is

-Cardiology 100%,

Ophthalmology 75%, General Sx Urology &

Gastro 70%, Spinal 75% and Orthopaedics

30%

A medium and long term strategic plan will

also be in place to support the outcomes

based strategic commissioning of a

sustainable Devonshire NHS service.

This will be facilitated through the

maximisation of system assets and improved

productivity at the base acute sites.

The initiative will Not impact on any patients

right to choose as per the NHS Choice

Framework and the Health and Care Act 2022

1. IAP agreements with IS providers by 1st

July.

2. Ongoing pathway work to ensure SPOA

for choice and informed choice discussions.

3. Agree additional elective activity volumes

(aiming HVLC activity) to be commissioned

from NHS providers

4. Ongoing assurance processes from NHS

providers regarding capacity and

performance.

5. Quarterly IS CRMs with additional monthly

(TBC)

6. Ongoing oversight and review of DRSS

patient facilitation to ensure robust and fair

patient choice is maintained.

6) Monitor delivery levels, waiting times

against GIRFT productivity measures for all

additional activity (Focus on cardiology,

ophthalmology, spinal, orthopaedics)

All IS IAPs agreed and in place with QEIA supporting, showing neutral impact.

Letter issued to all acute providers reiterating the need for subcontracts to be in

place for any IPT/MA activity as there remains challenges with acute providers

sending IPTs across outside of the agreed contract.

July IS cost is significantly off target. This was expected in part due to the reality

of the repatriation scheme not being fully online until September due to delays in

agreeing IAPs, however close monitoring is required as there is a risk of

significant cost pressure.

Changes to DRSS patient scrips has been deemed as not viable at present time

due to the significant variance in waiting times in some specialities, the only

changes therefore have been made to cataract scripts.

The first shadow CRM was postponed for August due to high volume of annual

leave across the system but the next is planned for September. Work is

continuing in the background to phase tasks in order to have everything in place

by the end of March 26 for formal CRMs to be in place for all acute providers.

None

* Action belongs to multiple objectives

Objective 4: Drive Clinical Service Transformation and In-Hospital Productivity

Progress against milestones (1 of 5)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report198 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/

Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP64

Acute Services

Strategy and

Transformation

Provide leadership in the

development, consultation, and

commissioning of new models of

acute care

—including major

service changes

—

by supporting

the

development and sign-

off of

the Case for Change, in line with

our strategic commissioning

responsibilities.

Develop and approve Clinical Services

Strategy

Develop and approve case for change

relating to acute service transformation

Arrangements to be confirmed.

None

AP70

Eliminating 18

week community

waits

Establish a recovery plan and

programme to eliminate waits of

over 18 weeks for community

services and how front

-end

pathways are streamlined and

consistent to support in hospital

activities.

1. Design and delivery a recovery plan for

all services with waiting lists

Pathways/service review for key

community priority areas as flagged

through monthly NHSE reporting

MSK community service waiting times have now

reduced to 415 waiting over 18 weeks, this is from a

baseline position of 2,300 in March 2025.

Sustainable service delivery models are being

implemented and maintained with a strong focus on

validation.

MSK

Community

recovery is on

track.

AP71

Three Year

Recovery Plan for

18 Weeks

Develop a three

-year recovery

plan to return to and meet the 18

week standard for elective

services. This will commence with

high volume specialties initially

(Orthopaedics).

Produce demand and capacity plan to

understand gap in capacity

2. Validate plan with providers and monitor

productivity delivery realised and plan to

create additional capacity

Performance progress around 18 week standard will

be monitored through the Operational Plan delivery

mechanism.

Consider for de-

prioritisation

Objective 4: Drive Clinical Service Transformation and In-Hospital Productivity

Progress against milestones (2 of 5)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report199 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP73

One Devon

Elective

Specialty

Improvement

For a set of prioritised elective specialties (One

Devon Elective Specialty Improvement):

-deliver further faster metrics in line with national

GIRFT benchmarks

-Maximise all capacity by working cross provider,

and ensuring adoption of best practice and

innovative delivery models (e.g. Group clinics,

targeted ‘waiting well’ health optimisation

approaches)

-implement best practice referral and community

pathways and surgical pathways

Hold grip around

deliverables at provider

level and facilitate

pathway redesign work

and supporting policy

requirements with

clinical teams and

primary care

One Devon Programme continues to progress. Key improvements include:

Orthopaedics:

continuation of surgical pathway for best practice for hip and knee surgery

- further benchmarks such as numbers per clinic and numbers of patients per list continue to

hold position

reduction in percentage of activity in Ortho lost to trauma

Spinal:

Recovery plan for scoliosis on track to deliver by end of September.

Ophthalmology:

increase market share to 70% for cataracts.

holding position on HVLC waiting times.

overall reduction in glaucoma backlog and recovery plans provided by UHP, RDUH and

TSD.

None

AP74

Waiting List

Validation

For all specialties

Deliver best practice waiting list validation

- System leadership and grip of national validation

sprint roll out.

Programme is live, monitored directly by NHSE.

Consider for

prioritisation

AP75

Elective

Demand

Management

Demand Management:

For all elective care specialties:

- Implement a 'No acceptance of Consultant referral

without application of commissioning policy and

CRG ensuring secondary care as standard'

discipline

For further specialties that specifically have a

referral rate higher than peer comparators:

CRG review

Development and implementation of system

standard best practice (national referral pathways)

Commence/finalise

implementation and

reviews (30/09/2025)

•Cardiology

- GP Cardiologist NHSE workstream (Oxford model) –commissioning

community cardiology pathway/service model for lower complexity cardiology patients.

Successful EoI for NHSE programme. Awaiting notification of next steps

•ENT

- Nurse-led ENT clinics and Tinnitus self-management app –successful EoI

•ENT

–Consultant to Consultant referral auditing progress

•Gynaecology

- Physio first POP pathway (Uro-gynae) live at UHP, reducing community

physio waits at RDUH/TSD with subsequent roll out of POP pathway (target end November)

•Gynaecology

–

Consultant to Consultant referral audit completed, action plan to be agreed

with gynae clinical leads in One Devon sept meeting(05/09/25)

•MSK

Living Options Devon holistic support offer currently being rolled out with ESP teams

in all Trusts. EoI submitted (11/8) to support Community Assessment Day delivery and

Living Options offer at point of referral

•MSK

- New system-

wide hip and knee CRGs drafted, pathway redesign group commenced

•Ophthalmology

–ICB neighbourhood scheme proposed to avoid unnecessary referrals to

secondary care by up to 50%. Validating assumptions with provider data and teams

presently. Clarifying if funding stream from previous NHSE bid is retained within the RDUH

and requesting direction to this. This is a very high

volume specialty, will provide significant

overall reduction

•Collective acute trust demand management system leads Group stood up and meeting 4

weekly

Objective 4: Drive Clinical Service Transformation and In-Hospital Productivity

Progress against milestones (3 of 5)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report200 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/Action

Description

Q2 Milestones

Update on progress against milestone

Status

Correct

ive

actions

AP76

Diagnostic

Delivery

To enable delivery of the in year operational

plan a programme of work will be

implemented to maximise the delivery of

diagnostic procedures. This will be done

through:

- The full implementation of CDCs in all

localities and expanding on direct to test and

one stop pathways.

- Ensuring best practice operating models are

in place.

Diagnostic demand management, with a

focus on key challenged modalities.

A wider strategic delivery plan will be drawn

up to support the commissioning of

sustainable diagnostic services, taking into

account access, all age delivery and reduction

in health inequalities in line with the Health

Care Strategy.

1. Achievement of monthly CDC

trajectory plans

2. UHP CDC online by 31st

March 26

3. All CDC sites to host a

minimum of 3 pathways by

March 26 for TSD & RDUH and

August 26 for UHP.

4. Develop and implement a

demand management and

productivity plan for DEXA and

Ultrasound. (Sept 2025)

The initial system DEXA task and finish group took place on 27th August to work through

shared options to mitigate the continuing fragility of the service. Cornwall and Isles of Scilly

colleagues were also invited however were unable to attend.

Demand and capacity work is underway at the ICB to support Royal Devon University Hospital

with mapping a recovery plan for NOUS and Echo due to significant challenges in

performance. There will be a wider D&C piece with PenRad in these specialities also.

NOUS data request from University Hospital Plymouth remains outstanding and escalated

through Tier 2.

Deep dive into triage and productivity has commenced.

Both Exeter CDC and Plymouth CDC are working on submitting bids for site expansion, pre

meet with regional colleagues have indicated a positive view , business case are due to be

submitted mid September 25. Exeter expansion includes the Nightingale site and an additional

hub site in North Devon (pending planning).

Exeter CDC is under performing against targets, operations teams have developed 13

pathways in the CDC and patient flow has not met expected levels, recovery is anticipate

-ed

to reach 90% in Q3.

Torbay CDC performance has been significantly challenged, and negotiations are continuing

with regional colleagues to reprofile down.

Plymouth CDC is exceeding performance targets and developing services in ophthalmology

following successful pathway bids for linear lanes in eyecare.

None

AP77

Maximising In

Hospital

alternatives and

admission

avoidance

pathways

Ensuring maximised in hospital alternatives

and pathways / avoidance of hospital capacity

when Not required consistently for Devon

including SDEC, Frailty, UTC, MIU, Virtual

Wards, LoS, and Discharge. This includes the

daily monitoring of service activity via ICB

operational pressures dashboard, discussion

at daily system tactical calls and through

performance management meetings between

providers and commissioners.

Performance and assurance through the

locality planning and delivery group as well as

the tactical Management group?

Propose de

prioritisation as agreed work was

with providers. Any out of hospital work,

should be picked up in new action below.

1. For areas lists as delivery

phase, ICB will monitor. For

development areas (LoS and

Discharge): review and refine

current discharge improvement

plans with localities, create

further in hospital LoS

efficiencies by working with

providers to review

interventions for patients over

an agreed LoS and alternative

management

2. For areas listed as delivery

phase, ICB will monitor.

Commence implementation of

development areas

This was being held in the Locality Planning & Delivery Meetings but will transition into the

Contract Management Meetings when stood up.

Consider

for de

prioritisat

ion

Objective 4: Drive Clinical Service Transformation and In-Hospital Productivity

Progress against milestones (4 of 5)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report201 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/Action

Description

Q2 Milestones

Update on progress against

milestone

Status

Corrective

actions

AP79

UEC demand

management

Develop additional services /

interventions to reduce demand on

Emergency Department including:

Increasing enhanced clinical

validation of emergency outcomes in

NHS 111

Effective navigation to ED

alternatives from SWAST call stack

Increasing access to same day

primary care

Improved access to respiratory

services in the community

Commence implementation

Funding has now been approved to support

delivery of the key workstreams aligned to the

ICB’s ED demand priorities. There is strong

representation from acute trusts at the

fortnightly ED Demand Management Oversight

Group.

A decision has been made to extend the current

Care Coordination model while partners

continue to develop alternative solutions during

Q3 and Q4. This decision followed a workshop

where partners shared their existing models,

outlining both strengths and limitations. It was

recognised that each partner is operating at a

different stage of maturity.

None

AP121

Supporting and

driving networked

acute care

Involvement via PAPC Executive

Group and PAPC Committee in

Common to drive networked and

consolidated models of care for fragile

and duplicated services and to identify

ICB approval where required.

(Ref 11.10

- Clinical Service Change

and Transformation)

Arrangements for the interface with the PAPC

currently being reviewed.

Consider for de

prioritisation

* Action belongs to multiple objectives

Objective 4: Drive Clinical Service Transformation and In-Hospital Productivity

Progress against milestones (5 of 5)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report202 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Section 6: Action-Level Delivery Updates

Objective 5: Optimise Workforce, Digital Infrastructure, Estate and

Commissioning Support Services, Focusing on Delivery at Scale and

Financial Sustainability

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report203 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against

milestone

Status

Corrective

actions

AP80*

TDP: Repatriation of

Activity

Oversee sufficient capacity within NHS providers to enable IS

providers to move back to provision at originally contracted

levels fulfilling the patient choice requirements for

commissioners.

Through reduction in IS IAPs support the facilitation of c.£17m

financial recovery for the system. Plans for IS providers are

indicative only and do Not affect patient choice.

Aggregate system IAP reduction at a speciality level is

Cardiology 100%, Ophthalmology 75%, General Sx Urology &

Gastro 70%, Spinal 75% and Orthopaedics 30%

A medium and long term strategic plan will also be in place to

support the outcomes based strategic commissioning of a

sustainable Devonshire NHS service.

This will be facilitated through the maximisation of system

assets and improved productivity at the base acute sites.

The initiative will Not impact on any patients right to choose as

per the NHS Choice Framework and the Health and Care Act

2022

1. IAP agreements with IS providers by 1st

July.

2. Ongoing pathway work to ensure SPOA

for choice and informed choice discussions.

3. Agree additional elective activity volumes

(aiming HVLC activity) to be commissioned

from NHS providers

4. Ongoing assurance processes from NHS

providers regarding capacity and

performance.

5. Quarterly IS CRMs with additional

monthly (TBC)

6. Ongoing oversight and review of DRSS

patient facilitation to ensure robust and fair

patient choice is maintained.

6) Monitor delivery levels, waiting times

against GIRFT productivity measures for all

additional activity (Focus on cardiology,

ophthalmology, spinal, orthopaedics)

All IS IAPs agreed and in place with QEIA

supporting, showing neutral impact.

Letter issued to all acute providers reiterating the

need for subcontracts to be in place for any IPT/MA

activity as there remains challenges with acute

providers sending IPTs across outside of the agreed

contract.

July IS cost is significantly off target. This was

expected in part due to the reality of the repatriation

scheme not being fully online until September due to

delays in agreeing IAPs, however close monitoring is

required as there is a risk of significant cost

pressure.

Changes to DRSS patient scrips has been deemed

as not viable at present time due to the significant

variance in waiting times in some specialities, the

only changes therefore have been made to cataract

scripts.

The first shadow CRM was postponed for August

due to high volume of annual leave across the

system but the next is planned for September. Work

is continuing in the background to phase tasks in

order to have everything in place by the end of

March 26 for formal CRMs to be in place for all acute

providers.

None

Objective 5: Optimise Workforce, Digital Infrastructure, Estates, and Commissioning Support Services,

Focusing on Delivery at Scale and Financial Sustainability

Progress against milestones (1 of 7)

* Action belongs to multiple objectives

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report204 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action Name

Programme/Project/Action

Description

Q2 Milestones

Update on progress against

milestone

Status

Corrective

actions

AP82

Access to

Technology

By end of March 2026, we will have explored

opportunities to develop an approach with

partners to enable access to technology for

personalised care at home for patients with

long term conditions and end of life via

Integrated Care Plans and electronic

Treatment Escalation.

Assess different technology solutions, engagement,

and identify barriers

August update: CCN being signed

development work commenced. First focus on

"About Me" using PRSB standards. Engagement

workshop on 2/10/25 with pilot teams being

identified.

None

AP83

Clinical and Care

Professional

Leadership

Framework

Update Clinical & Care Professional

Leadership framework and develop updated

implementation plan, with any actions agreed

for 2025/26 to take place.

(Defer until we have merged with CIoS or

we will have to do the work twice)

Prepare updated framework

Socialise framework with stakeholders

Pro

-forma completed to request stand down

Consider for de

prioritisation

AP84

Estates

Transformation

In 25/26 we shall drive transformation and

deliver savings across the estates portfolio

and programme through minimising wastage

and undertaking long term strategic planning

to enable future decisions to be made over

our core assets. 

Use outputs from Q1 milestones to collate assets

database for use by all providers and NHSPS

Estates Managers. Includes development of

PowerPoint visual guides for each asset

1. All Devon community property assets have

been identified and allocated to database. On

going review to compile full data from research,

reviews, and site visits.

None

AP85

Primary Care

Estates

As PCN funding becomes available we shall

then plan and manage a primary care estates

delivery programme which shall seek to

commence delivery over a 15 year schedule.

Recruit to Primary Care Estates Manager role

Reset primary care estates deliver programme

in accordance with NHSE PCN guidance

following a change in government

1. On hold due to restructure (interim

arrangements are in place for parts of essential

work only)

2. Awaiting NHSE national funding

announcements for primary care estates

3. Progression is being managed through interim

non pay contracts.

Delivery is being managed

but with increased risks

surrounding quality and

managing the project

pipeline.

Objective 5: Optimise Workforce, Digital Infrastructure, Estates, and Commissioning

Support Services, Focusing on Delivery at Scale and Financial Sustainability

Progress against milestones (2 of 7)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report205 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action Name

Programme/Project/Action

Description

Q2 Milestones

Update on progress against

milestone

Status

Corrective

actions

AP86

Devon New Hospital

Programme (NHP)

The NHP requires considerable investment of time

and strategy to ensure its effective delivery.

Review scope of NHP programme for

each trust in light of recent funding

announcements

Assess risks associated with changed in

NHP delivery and revise each trust

programme in accordance with new

funding timescales.

1. Trusts are working with NHP on reshaping programme

delivery

2. Current risks associated with the management of the

programme are being worked through with the national

NHP team.

3. The programme has recently been shared with PASP

and further work has been committed to by the group for

the 5 highest risks.

4. On hold due to NHS restructure.

The pace of NHP

support in

programme delivery

does not match the

pace of needing to

resolve risks

surrounding

infrastructure and

backlog

maintenance

AP87

Collaborative

working across

Estates and

Facilities

In 2025/26 Estates and facilities shall implement

new ways of collaborative working. We shall run a

series of workshops to identify areas for

collaboration for service mergers and agree a plan

for further system integration.

Establish a series of workshops with various

strands of Estates and Facilities departments

A substantial programme board and governance has been

established. All committed trusts are working through

outline business case stage and NHSE are supporting in

the application process for setting up a WoS. Target

business case submission is Oct 2025. Separate work is

being undertaken to establish a Wholly Owed Subsidiary

(WoS) for Cornwall Partnership Foundation Trust (CFT)

under separate governance arrangements. As it stands

DPT and RCHT have not subscribed to the programme.

None

AP88

NHS App Sign

-up

Number of eligible citizens connected to the NHS

App increased to 60%

Consider Deprioritisation as current performance is

at 58% and on target to hit 60%. The activity to

increase uptake is primarily communication and

engagement. The NHS App is the national priority

for the delivery of digital services to the public and

there is a commitment to its continued

development.

National Target for Board consideration.

56%

Limited local action in month to increase adoption rates in

specific locations.

The last proactive local drop

-in sessions at libraries have

completed and a local six month NHS App comms

campaign has commenced using national communication

material. A national communications campaign is

anticipated later in the year.

None

Objective 5: Optimise Workforce, Digital Infrastructure, Estates, and Commissioning

Support Services, Focusing on Delivery at Scale and Financial Sustainability

Progress against milestones (3 of 7)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report206 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP89

Devon and

Cornwall Care

Record

(DCCR)

expansion

Remaining core health and care organisations connected to

the Devon and Cornwall Care Record (DCCR) by March

2028

1a. TSDFT connected to DCCR

1b Care Home pilots connected to

DCCR

2a. Torbay Council and

4. 2b. 90% of GP practices connected to

DCCR

3a. Plymouth City Council

6. 3b. 98% of GP practices connected to

DCCR

7. 4. All core organisations connected to

DCCR

1a. TSDFT went live as a consumer of data on 31 July 25. Complete.

1b. 60 care homes connected in Devon

- pilot concept proven Complete.

2a. Torbay Council has procured Liquid Logic as their social care system. Cost of Liquid Logic integration cannot be met by

Torbay Council and are pursuing portal access as an alternative. Dependency on Torbay Council Liquid Logic

implementation. On track.

2b. 93% of GP practices connected. Complete.

3a. Plymouth City Council have yet to sign the DSA and this is being pursued within PCC. A technical agreement has now

been reached on launching DCCR portal from PCC OLM Eclipse system. Work in progress.

3b. Work on

-going to sign up remaining GP practices. Work in progress.

4. See above.

None

AP90

Devon and

Cornwall Care

Record

(DCCR)

Procurement

To prepare the business case for the re

procurement of the

Devon and Cornwall Care Record ( DCCR )and subject to

approval to procure and implement the DCCR. The DCCR

is the Devon's and Cornwall's provision of a shared care

record, the provision of which is a national requirement.

1. Business case completed Apr 25, ICB

Devon decision on business case (OBC):

contract extension, full procurement or stop

2. Procurement completed July 2025

1. Draft OBC prepared. Engagement completed with NHSE on contract length. CSU have been supporting with procurement

advice but recent organisational news has disrupted timeliness of advice / service. Cornwall are engaged through their CDIO

/ CIO. Extraordinary DCCR Programme Board held to consider and endorse proposed re

-procurement approach. Briefing

paper prepared in advance of OBC progressing through governance. On track.

2. There are many current uncertainties in the NHS that have delayed progress (Announcement of CSU abolishment, clarity

on governance arrangements, approach to Single Patient Record, clarity on contract length). Off track.

3. There is a dependency on Milestones 1 and 2. Off track.

4. There is a dependency on Milestones 1, 2 and 3. On track.

2. The

announcement of

the abolition of the

CSU is impacting

the timely provision

of procurement

advice and

guidance. Despite

this the OBC has

been prepared

following verbal

advice from the

CSU, NHSE and

independent

research.

3. See above

AP91

AI use cases

supporting

General

Practice

Conduct an AI assessment to explore appropriate use

cases for supporting General Practice, ensuring alignment

with governance standards. (This Objective overlaps with 2,

Primary Care Outcomes).

Potential low risk Deprioritisation opportunity. There is a

national AI team that are preparing AI guidance and advice,

the first of which is already published. A national Notice of

09/06/25 indicates a vendor approval, sign

off compliance,

DPA governance approval and assurance role for ICBs;

further detail is required to understand the implications and

resource requirements. Adoption of AI technology and

national involvement is moving quickly which is superseding

this activity.

Explore possible solutions and test them

via the NHS England Regional Primary

Care Lab

Events have superseded the project which means it no longer has to complete as described.

Summary of requirements for implementing Ambient Voice Technology has already been produced and available to

practices.

Waiting on further guidance from NHSE.

None

AP92

Increasing

placement

capacity

Increase placement capacity across the system by 20%

with the range of placement experiences increasing by 30%

and reducing under

-utilisation by 30%.

1. Collate placement baseline in secondary

care COMPLETE

2. Placement baseline data across primary

and secondary care, and placement

demand baseline from educational

establishments COMPLETE

3. Analysis of supply and demand data

from providers and education partners,

design and pilot new learner models to

1. COMPLETE

2. COMPLETE

3. WTE known in all trusts and compared with learner numbers

- now know figures for underutilisation. Will progress from

start of academic year when education providers return

4. COMPLETE. Dashboard in place with 1 year of data. Not yet live with providers inputting quarterly.

5. Pilots commenced in UHP, primary care and social care

None

Objective 5: Optimise Workforce, Digital Infrastructure, Estates, and Commissioning Support Services,

Focusing on Delivery at Scale and Financial Sustainability

Progress against milestones (4 of 7)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report207 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programm

e/ Project/

Action

Name

Programme/Project/ Action

Description

Q2 Milestones

Update on progress against milestone

Stat

Corrective

actions

AP93

Increasing

Nursing

and

Midwifery

apprentice

ships

Increase Nursing and Midwifery

Apprenticeships by 20%.

1. Apprenticeship provider plans across health and social care in place for

25/26 academic starts, build apprenticeship system dashboard assuring use

of supply, and 20% increase from baseline target. COMPLETE

2. Review of at

-risk professional groups and commence plans for 2026/27

(MH/LDA/ODP, Podiatry, OT, and Orthotics), review educational pathways to

meet system need, and pilot dashboard with providers

3. System wide levy agreement signed off and embedded int BAU,

engagement with private sector to increase levy funds if needed, and system

dashboard operating.

2. Ongoing engagement with cardiology, Advanced Practice,

podiatry, MH, OT

4. BT funding confirmed, partnerships being developed with

other private companies for levy income e.g. Amazon and

Virgin media to fund pharmacy apprenticeships

5. Develop apprenticeship plans for 27/28 not started, due to

commence September.

None

AP94

Increasing

Advanced

Practitione

Increase Advanced Practitioners by

10% and by end of 2025/26, 100%

compliance with Advanced Practice

Matrix.

Workshop 2 to design posts and job plans and workforce planning for

Advanced Practice posts 2026/27

Planning podiatry AP role in Torbay

Planning for acute medicine roles and hospice services

Summarising scoping numbers for NHSE for Sept 26 starts

None

AP95

Enabling

Workforce

Programm

es to

support

NHS

Devon’s

strategic

priorities

Design and deliver workforce

programmes to enable new care

models and transformation delivery

to support NHS Devon's strategic

priorities, including Transforming

Devon Plan, Healthcare strategy

and Integrated Neighbourhood

Teams.

PASP modelling of workforce data to future scenarios

1. PASP baseline for maternity, UEC and paeds completed

and built into Power BI dashboard. COMPLETED

2. PASP future scenario modelling commenced in August and

continuing through September and October, led by PASP team

3. Have obtained baseline CYP Autism data from providers. BI

dashboard produced. Final data validation exercise to be

carried out.

4. Review of delivery of the support from third party Strategic

Workforce Intelligence Forecasting Tool (SWIFT) is underway

5. Workforce team participation in Health and Care strategy

workshops has completed

None

AP96

Workforce

Sustainabil

ity

Design future workforce, talent

attraction, and development models

to enable optimum service delivery

and workforce sustainability

Commence development of future workforce plan aligned to INT and TDP

models and continue development of system career hub model

1. Draft plan prepared. Due to agree governance process and

dates for local authority approval. The plan will be shared with

Chief People Officers Group in October, then ICB ExCo in

November and aim to release funding by Dec 25.

2.3 &4. Not started

None

Objective 5: Optimise Workforce, Digital Infrastructure, Estates, and Commissioning Support

Services, Focusing on Delivery at Scale and Financial Sustainability

Progress against milestones (5 of 7)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report208 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/

Action Description

Milestones

Update on progress against milestone

Status

Corrective actions

AP97

Creating a

culture for NHS

Devon

Create a culture for NHS Devon

staff to grow and develop,

nurturing talent and developing

leadership skills at all levels,

maximising the opportunities for

NHS Devon to be a well

-run,

effective and efficient

organisation in pursuit of our

aims and objectives.

Design and begin

implementation of

a development

plan for a

'clustered' ICB

Board, Executive

Team and Senior

Leadership Team

1. Further Skylite sessions paused until timescales of organisational change has been confirmed.

Recorded Skylite sessions are now available on the Intranet. Phase 2 support session dates

(including workshops to support completing job applications, CVs, generating social media profiles

and routes to the job market) to commence late October/Early November to align with current

restructure timelines. Will continue to flex these dates to align with the timelines as they adapt.

Affinity Financial sessions continue and further dates added. Design of peer support connection

sessions underway. These sessions will be face to face, maximum group size 16 and initially

offered to nursing and quality with a potential to offer to rest of the organisation following feedback

and adaption. Opportunity offered to all staff to express interest in coaching sessions.

2 & 3. To commence when clustering arrangements and new structure are in place

4. Systems thinking development programme to be focussed on building neighbourhoods in South.

Delegates now confirmed. Facilitators confirmed. Programme to commence 24th September.

Unable to make desired

progress due to consistently

changing messaging and

time frames from national

and regional teams re

organisational

reconfiguration. Concerns

escalated re colleagues well

being and psychological

safety

AP98

Organisational

Development

Develop and deliver a

comprehensive organisations

development (OD) plan for the

Devon System in preparation for

the successful delivery of the

NHS 10 year plan and a single

operating model for Devon

System wide

CEO

development

1. Process developed to support strengthening clinical collaboration and system relationships within

cardiology. Key executive stakeholders within RDUH and TSD met and positive encouragement to

proceed with one to one meetings from mid September.

Participation in Health and Care Strategy workshops supported the identification of key outcomes

that are required to develop the system culture and leadership, and to deliver the strategy. This will

inform the system development plan.

2. CEO development session that was scheduled for September postponed in order to wait for

announcement of ICB CEO.

None

AP99

Organisational

Change

Design and implementation of

new ICB to deliver the running

cost target of £19 per head of

population

Consult and

implement Chief

Executive and

Chair roles

1. High level structure designed and remains subject to change through check and challenge

processes

2. Chair appointment announced 1st September. CEO announcement expected to follow soon.

3. Preparations underway for Exec and band 9 consultation.

4. Draft timeline for wider staff consultation has been outlined however lack of clarity around

timelines and funding for cost of change still remain.

Staff briefings continue with all staff with all staff briefed on postponement of wider staff consultation

the lack of clarity on timelines still remains and has been communicated to staff

Support package in place and timing of delivery of wellbeing and financial sessions under review

National instruction is to

achieve cost per head of

population of £19 by April

26. Road map to achieve

this is unclear.

Objective 5: Optimise Workforce, Digital Infrastructure, Estates, and Commissioning

Support Services, Focusing on Delivery at Scale and Financial Sustainability

Progress against milestones (6 of 7)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report209 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action

Name

Programme/Project/

Action Description

Q2 Milestones

Update on progress against

milestone

Status

Corrective

actions

AP102

All

-Age

Continuing Care

(AACC): Digital

Transformation

(formerly

Transforming

Devon

workstream)

Implement new digital case

management system, with brokerage

capability, to enable workforce

efficiency

1 Procurement Launched 21 June 2025.

2 Procurement Closed to bidders 12 pm 21 July 2025

3 Procurement Compliance checks 21/22 July 2025

4 Procurement evaluation Moderation 12

- 18 August 2025

5 Contract award recommendation and approved at

Procurement Oversight Group 31 August 2025

6 Contract award and procurement processes and compliance

completed 30 September 2025

7 Pre

- Mobilisation of contract 1 October 2025 to 31 January

2026.

8 Phased Go Lives commence February 2026

4 Procurement Bids subject to individual evaluation against

weighted questions and service specification 23 July 2025

-8

August 2025

All milestones currently on track monitored

through the AACC Digital Transformation

Oversight Group. DTOG will meet on 05/08/25.

Evaluation and moderation completed by

18/08/25.

Contract Award Recommendation Report

produced and approved at procurement oversight

Group 27 August 2025.

Contract award letter to be sent w/c 1 Sept 2025.

Aiming to start contract mobilisation mid Sept

2025 onwards.

None

Objective 5: Optimise Workforce, Digital Infrastructure, Estates, and Commissioning

Support Services, Focusing on Delivery at Scale and Financial Sustainability

Progress against milestones (7 of 7)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report210 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Proud to be part of One Devon: NHS and CARE working with communities and local organisations to improve people’s lives

Section 6: Action-Level Delivery Updates

Objective 6: Deliver Statutory Functions and Maintain a High-Quality,

Safe, Financially Balanced and Sustainable System

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report211 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action

Name

Programme/Project/Action

Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP100

All

-Age

Continuing Care

(AACC):

Community

Deprivation of

Liberty

Safeguards

Deliver action plan for the application of

Community Deprivation of Liberty Safeguards

to enable the identification those individuals

being deprived of their liberty and progress

applications to the Court of Protection.

Develop policy, SOP, and deliver staff training

(31/12/2025)

1. Recruitment of Band 6 Clinical Practitioner underway.

Commences 8 September 2025.

- purposing an associate practitioner role to develop a

para legal role to support progression of legal work. to

commenced Sept 2025.

3. Policy and SOP have been drafted with a view to

complete 31/12/25

4. Re

- design work commenced and will work with partner

organisations during Q3, Oct

Dec 25 however this may be

influenced by the clusters, to agree an appropriate model

and with aim to provide a consistent offer and to reduce

legal costs. Pilot taken place, evidencing it has saved on

costs. Next steps to develop an SLA between the ICB and

partner organisations ( e.g. DPT, Livewell and TSDFT).

5.For advocacy service to be agreed as a commissioned

service. Proposal drafted.

None

AP101

All

-Age

Continuing Care

(AACC): Safe

Staffing Model

Recruitment to AACC business critical roles

as described within the safe staffing model. If

the NHS Devon AACC service does not have

the appropriate staffing resources, essential

and statutory areas of work may be

compromised. This could result in poor

patient experience, patient safety issues,

deterioration and in and risk to patient health,

increased scrutiny from NHSE, financial and

legal consequences and reputational

damage.

The ICB is considering the consolidation of

the Torbay and South Devon service into the

NHS Devon service to enable a single AACC

service offer for Devon. The consideration of

this is also within the context of the COIS

clustering proposals.

2. The ICB Exec to commission a deep dive report

into the CHC service at TSD to understand income vs

expenditure.

3. TSD and ICB Exec to consider the deep dive report

and the opportunity for the CHC service at TSDFT to

be repatriated to the ICB to create one Devon AACC

team.

All Age Continuing Care Safer Staffing model:

1. Deep dive completed on staffing structure and

outstanding business critical vacancies. Vacancy panel

approvals sought May and June 2025 to recruit to the

remaining business critical posts. Onboarding for two new

band 6 clinical sessors in progress

- complete end August

2025. Closing date for remaining posts 22 July 2025.

Shortlisting and interviews August 2025. Onboarding of 6

new posts commenced Sept 2025.

None

Objective 6: Deliver Statutory Functions and Maintain a High-Quality, Safe, Financially

Balanced, and Sustainable System

Progress against milestones (1 of 6)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report212 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/ Action

Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective actions

AP104

Quality Framework

Deliver a 'working draft' framework for

consultation and collaboration of a

NHS

Devon/CIOS

5 year Quality Framework (strategy) inclusive of

Total Quality Management principles enabling an

engagement programme to coproduce a Quality

Strategy to be launched in 2026/27.

Deliver an NHS Devon Quality of Care

conference to celebrate and inspire improving

care quality across Devon, sharing the draft

framework for system strategy co

-production

Engagement and

collaboration events/activities

to develop final strategy,

conference planning for Q3

event, ongoing

implementation of QI hub,

and updates to QPEC

Quality Framework published June 2025.

Quality Conference planning meetings commencing 23.07.25

decision re focus/timeline in light of significant organisational change.

Sep 25 Update: Quality Management System forming part of health &

Care Strategy.

Conference planning will continue when org. change permits.

National Quality Strategy is awaited which will directly inform local

work.

Specific quality and statutory in reach to the development of the NHS

Devon Health and Care Strategy

Consideration is currently

being given to the most

appropriate time for the

conference given the previous

timescales. As a result of the

further changes announced

the timing of the Conference

rather than the principle of is

being considered.

All other milestones on track.

AP105

Establishing

Equality Quality

Impact

Assessment

(EQIA) Process

NHS Devon will have robust and evidenced

impact assessments through the EQIA process

Maintain mandatory ICB staff

EQIA training and

monitor/report coverage and

quality of EQIAs undertaken

Discussed and reviewed, no significant change in month:

Training sessions have continued for NHS Devon staff with 312 staff

now trained out of 470.

Significant promotion of the training sessions has continued through

both Staff briefing and communications. Reporting to ExCo alongside

risk reporting agreed. Live EQIA in place for appropriate schemes.

NHS Devon policy updated to reflect newly updated NQB national

guidance for QIAs.

None

AP106

System Quality

Metrics Dashboard

Implementation of system quality metrics

dashboard incorporating QEWS, Model Health,

Learning from Patient Safety Events (LfPSE) and

other national data sources for 'Watch and

escalation' and respond to identification of risks

from the dashboard

Implement dashboard

through System Quality

Group and reporting to

Quality & Patient Experience

Committee (QPEC)

Quality Metrics within Delivery Management Workstream prioritised;

incl. development of real

-time patient experience data (ICB and

provider).

Further work to develop wider ICB quality 'watch metrics' dashboard

in Q2 and Q3

- will be aligned to recently published NHSE

Performance Assessment Framework (published July 2025). Further

update with regards to progress to be given next month.

New style quality report to be deployed for September 2025 reporting

cycle.

Sep 25 Update: New format of Quality Report implemented August

25.

Further improvements in train for Oct 25 Quality Report.

Quality metrics dev. as per plan, with addition of CRM process.

None

Objective 6: Deliver Statutory Functions and Maintain a High-Quality, Safe, Financially

Balanced, and Sustainable System

Progress against milestones (2 of 6)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report213 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective

actions

AP107

Patient Safety

and Experience

Maintain and improve standards of patient safety, experience and

outcomes throughout the Devon system via:

BAU delivery of LfPSE/PSIRF

Increasing primary care adoption (100% GP practice coverage

target)

Independent/VCSE sector support/development

Patient safety partners development

Delivery of plan progress

update reported to QPEC, and

implement Patient Experience

Network in Devon System

(Inclusive of CYP participation)

Discussed and reviewed, no significant change in month:

Working action plan reporting regularly to QAM and QPEC.

Primary Care engagement and PSIRPs approval continuing

to improve.

None

AP108

Children’s

Wellbeing and

Education Bill

Implementation

Work with Safeguarding partners to implement the Children's

Wellbeing and Education bill, ensuring health resources to meet

requirements for an integrated front door, Lead Practitioners, and

multiagency child protection services

Develop plan with Women and

Children Commissioners and

complete EQIA

Children’s Wellbeing and Education Bill implementation:

Working with local authority and police colleagues to

codesign services to deliver Family First Partnership

programme. Progressing well with local authorities. Plans in

place to recruit additional support for Torbay and Plymouth.

None

AP109

Information

Sharing to Tackle

Violence (ISTV)

Implementation

Support ED providers to implement ISTV (Information Sharing to

Tackle Violence) that will enable NHS Devon to meet Serious

Violence duties

Review data sharing

arrangements to ensure

implementation

Information Sharing to Tackle Violence (ISTV)

implementation: ICB continues to support providers to

complete Data Protection Impact Assessments (DPIAs) in

order to support sharing of information in line with legislative

requirements.

Follow up emails sent to providers. Will escalate to

CNO/CMO if progress not achieved by end of Q2

None

AP110

Multi

-Agency

Safeguarding

Hubs (MASH)

Commission sufficient capacity within the multi

-agency

Safeguarding Hubs to ensure delivery of all front door

safeguarding statutory duties by September 2025.

Review provider recruitment to

MASH posts

Multi

-Agency Safeguarding Hub: Capacity issues being

monitored through the Partnership Front Door Steering

Group, any issues will continue to be escalated both to CNO

and the Safeguarding Children's Partnership.

Increased demand within MASH has identified the need for a

more comprehensive review of MASH model.

None

Objective 6: Deliver Statutory Functions and Maintain a High-Quality, Safe, Financially

Balanced, and Sustainable System

Progress against milestones (3 of 6)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report214 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective actions

AP111

Meeting

Safeguarding

requirements

and MARMM

implementation

The National Safeguarding Steering Group has updated a suite of

protocols that outline ICB responsibilities in relation to:

Child protection - Information system

Female Genital Mutilation (FGM).

Child death review process

Domestic abuse and sexual violence

Modern Slavery and human trafficking

Domestic homicide reviews

MARMM Implementation

Support TDSAP and health providers to implement MARMM

(Multiagency risk management meetings) across Torbay and

Devon.

•

Implement plan to ensure

compliance with protocols

•

Evaluate MARMM test of

change

NHS England protocol implementations: Action

plan to be developed and EQIA undertaken and

back on track.

Multi

-Agency Risk Management Meeting

(MARMM). MARMM test of change implemented.

Further roll out being considered by Torbay and

Devon Safeguarding Adult Partnership.

Capacity has been

restored as of 11/08/2025.

Work is underway to

rapidly review and agree

next steps in month.

AP112

ICS Financial

Revenue Plan

Deliver ICS financial revenue plan for 25/26 including delivery of

CIP targets and any additional financial criteria related to NoF4

exit.

•

Boards sign off financial plan

and establish robust reporting

metrics across the system

•

identify any mitigations for

potential slippage

Boards sign off financial plan and establish robust

reporting metrics across the system

Identity any mitigations for potential slippage

None

AP113

ICB Financial

Revenue Plan

Deliver ICB financial revenue plan for 25/26 including delivery of

the CIP targets and any additional financial criteria related to NoF4

exit.

•

Boards sign off financial plan

•

Identify any mitigations for

potential slippage

Boards sign off financial plan

Identify any mitigations for potential slippage

None

Objective 6: Deliver Statutory Functions and Maintain a High-Quality, Safe, Financially

Balanced, and Sustainable System

Progress against milestones (4 of 6)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report215 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Ref

Programme/

Project/

Action

Name

Programme/Project/Action

Description

Q2 Milestones

Update on progress against

milestone

Status

Corrective

actions

AP115

Research and

Innovation

Produce Devon ICS Research and Innovation

Strategy

Prepare and socialise draft strategy

Publish strategy

Pro

-forma completed to request stand down

Consider for de

prioritisation

AP116

Green Plan

Complete ICS Green Plan which will set out aims,

objectives and delivery plans for carbon reduction

for the system and works in parallel with the ICS

Estates Infrastructure Strategy.

Submit Green Plan

1. Closed

- Engagement with strategic

sustainability group complete. Guidance and

governance routes shared.

2. ICS and ICB Green Plan submitted to

ExCo (1st July) in readiness for Board

approval in October with CIoS cluster

arrangements.

3. Awaiting sign off and publication

4. Next system wide sustainability meeting

None

Objective 6: Deliver Statutory Functions and Maintain a High-Quality, Safe, Financially

Balanced, and Sustainable System

Progress against milestones (5 of 6)

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report216 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Objective 6: Deliver Statutory Functions and Maintain a High-Quality, Safe, Financially Balanced, and

Sustainable System

Progress against milestones (6 of 6)

* Action belongs to multiple objectives

Ref

Programme/

Project/ Action

Name

Programme/Project/Action Description

Q2 Milestones

Update on progress against milestone

Status

Corrective actions

AP5*

Core 20+5 CYP

To improve the delivery of priority health

services consistently across Devon for

children and young people living with long

term conditions, and reduce the level of health

inequalities experienced, by March 2026.

Implementation plan developed

August Update

Children in care annual report completed demonstrating

improved metrics for health assessment.

LA based task and finish groups continue to take forward

locally agreed plans and initiatives

None

AP32*

CYP Crisis Support

To develop the model of crisis support for

children and young people (CYP) with

emotional wellbeing and mental health, in

conjunction with the South West Provider

Collaborative's redesign of inpatient support

and pathways by March 2027.

Pathways and model developed and

agreed with stakeholders, including

South West Provider Collaborative

August Update:

This actions as described are off track and are being

redeveloped as part of wider work to ensure that UEC

pathways are inclusive of children and young people and

mental health as this will achieve a greater strategic and

sustainable change.

Capital bids for Torbay and Plymouth LA's successful,

time frames for delivery are outside of this financial year

but joint work is progressing.

None

AP54*

Improve the access

to health services for

all CYP who need

hospital care, mental

health, and

community services

To improve the access to health services for

all Children & Young People (CYP) who need

hospital care, mental health, and community

services including all those on health waiting

lists, through improved delivery against

current contracts, and effective commissioning

of additional and enhanced capacity where

this is required by March 2026.

Implementation plan within resource

available agreed

August Update

Neuro

-diversity and other CYP pathway recovery

programmes have been translated to clear strategic

commissioning intentions.

ND workshop planned for early September to confirm

commissioning model and agree implementation with

providers.

None

AP55*

Design and

implement an ICB

process which

consistently

addresses individual

commissioning

needs for CYP

To design and implement an ICB process

which consistently addresses individual

commissioning needs for CYP, where their

needs fall outside of core commissioned

services, by March 2026.

Process designed on how to address

individual commissioning needs

August Update

This action remains on track currently but Q2 delivery is

contingent on process being fully agreed across each LA

footprint which is being impacted by capacity within the

individual commissioning team.

Agreement to include LAs in IPOC process

None

Tab 3 Item 4.3a - NHS Devon Annual Plan Progress Report217 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25



lives

NHS Devon

Quality Report

Executive Leads:

Penny Smith, NHS Devon ICB Chief Nursing Officer (CNO)

Peter Collins, NHS Devon ICB Chief Medical Officer (CMO)

October 2025 –reporting on July and August 2025 data, unless

otherwise stated within the report

Tab 4 Item 4.3b - NHS Devon Quality Report218 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

The Primary Care Strategy has three main aims:

•Developing a supportive, learning environment and just culture in primary care, with sharing across

the system so that the services can continually improve,

•Ensuring that the safety and wellbeing of patients and staff is central, and that our approach to

managing safety is systematic and based on safety science and systems thinking,

•Involving patients in the identification and co-design of primary care patient safety ambitions,

opportunities and improvements.

Recognises the pressures in primary care, the implementation of the strategy is flexible, with General

Practices (GPs) being the priority for implementation, starting with registration of Learn from Patient

Safety Events (LfPSE), which is now within their NHS contracts.

The progress toward this aim is monitored by tracking the number of GPs confirmed as registered on

LfPSE and the monthly count of reported patient safety concerns.

Relevant groups/

committees

Regular updates go to the Quality Assurance Meeting and Senior

Leadership Team for Primary Care.

Quality & Patient Experience Committee (QPEC).

Current performance

GP registered to LfPSE progress:

---]73%

What the data shows

The percentage of confirmed GPs registered with LfPSE

continues to increase.

The GP reporting to LfPSE has a fluctuating trend, the

percentage of reported patient safety concerns varies month to

month, however since March 2025 there has been a consistent

increase in the number of patient safety events being reported.

There has been a significant increase in reporting by community

pharmacies between May 2024 and January 2025, peaking in

January 2025.

Risks and

mitigation

Although there is currently no associated risk recorded on NHS

Devon’s risk register, the requirement for GPs to be registered

on LfPSE as part of the NHS contract should be monitored to

ensure compliance.

Next Steps &

Escalation

The Patient Safety Team continue to supporting GPs to register and report patient safety incidents and concerns to the national Learn from Patient Safety Events (LfPSE) system.

Reported patient safety concerns related to medication and prescribing (identified as one of the top three types of concerns) continue to be shared with the Medicines Optimisation

Team at NHS Devon to support learning and improvement.

October 2025Exec Lead CNO

Patient Safety: Primary Care Learning from Patient Safety Events

(LfPSE)

Tab 4 Item 4.3b - NHS Devon Quality Report219 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

The main providers within NHS Devon have started to review their data and engage with stakeholders

to prepare for the submission of their revised year two Patient Safety Incident Response Plan (PSIRP).

A refreshed summary of all local priorities will be compiled once all PSIRPs have been submitted.

Serious Incidents that were open at the time of an organisations transferring to PSIRF were to remain

open and be investigated under the previous framework.

Relevant groups/

committees

Regular updates go to the Quality Assurance Meeting and

discussed within provider meetings which the ICB are invited to

attend.

Contracting colleagues are updated monthly with received,

reviewed and approved PSIRF policies from independent

providers.

Quality & Patient Experience Committee (QPEC).

Current performance

Independent Providers PSIRF policy Submission Progress:

--------------] 51%

The Patient Safety Panel reviewed three Providers’ PSIRF policies and plans in September. One policy,

from Axminster Minor Injuries Unit, was approved. The remaining two are nearly ready for approval

but require some final amendments. A further two policies have been submitted and are scheduled

for review next month.

What the data shows

The data show a continuous downward trend of open serious

incidents which is expected.

There are currently 13 serious incidents across Devon that

remain open. This is a reduction from 15 last month.

Risks and mitigation

A proportion of Independent Providers have not engaged with

NHS Devon or provided a copy of a policy and plan that aligns to

PSIRF principles.

Next Steps &

Escalation

The Patient Safety Team will continue to collaborate with Independent Providers, assisting them in developing a policy and plan that aligns with PSIRF.

The Contracting Team is supporting the Patient Safety Team by reaching out to Independent Providers who have not yet submitted or engaged with NHS Devon regarding a PSIRF

policy. Relevant information will also be provided ahead of each Provider’s contract review meeting.

Additionally, the Patient Safety Team has received several PSIRF policies from domiciliary care providers, which are being reviewed in proportionate detail.

October 2025Exec Lead CNO

Patient Safety: Patient Safety Incident Response Plans

& Serious Incident Closure

Tab 4 Item 4.3b - NHS Devon Quality Report220 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

National Patient Safety Incident Investigations (PSII) are specific types of investigations outlined in the

Patient Safety Incident Response Framework (PSIRF). These incidents must be formally recorded as

PSIIs and investigated at the local level. In many cases, an independent investigation team from the

Healthcare Safety Investigation Branch (HSSIB) will also conduct or support the investigation.

In addition to the PSII being recorded, all patient safety events are to be recorded onto the national

reporting system, Learn from Patient Safety Events (LfPSE).

Relevant groups/

committees

Regular updates go to the Quality Assurance Meeting and

discussed within provider meetings which the ICB are invited to

attend.

Quality & Patient Experience Committee (QPEC).

Current performance

Reported PSII April 2024 –09 September 2025

Reported patient safety events on LfPSE April 2024 –August 2025

What the data shows

Never Events and deaths considered more likely than not to

have resulted from problems in care are the two most

frequently reported national Patient Safety Incident

Investigations (PSIIs).

TSDFT and UHP are the highest reporters of Never Events and

continue to collaborate on shared learning and the

implementation of NatSSIPs (National Safety Standards for

Invasive Procedures).

The trend in reporting to LfPSE continues to rise steadily,

reflecting the increasing number of organisations registering and

engaging with the system. While there was a dip in reporting in

June 2025, this appears to have been due to the LfPSE system

itself rather than a reduction in Provider submissions, as

assurance has been received that Providers’ reporting activity

has remained consistent.

Risks and

mitigation

While there is no associated risk currently recorded on NHS

Devon’s risk register, PSII cases are monitored by the Patient

Safety Team. If a trend or recurring theme is identified, further

information is requested from the Provider. This includes details

on actions taken, how learning is being shared, and the progress

in implementing NatSSIPs and LocSSIPs

Next Steps &

Escalation

The Patient Safety Team will continue to monitor themes and trends and share learning with all organisations in Devon and Cornwall.

October 2025Exec Lead CNO

Patient Safety: Patient Safety Incident Investigations (PSII)

& LfPSE reporting

Tab 4 Item 4.3b - NHS Devon Quality Report221 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

Never Events were previously classified under the 2015 Serious Incident Framework and had their own specific

criteria and framework. They continue to be recognised and reported under the Patient Safety Incident Response

Framework as a national priority.

Never Events are largely preventable patient safety incident that should not occur if proper procedures are

followed, therefore the higher the number reported are a concern.

Never Event Framework Consultation

The consultation on the new Never Event Framework has now been published, acknowledging the need for further

engagement with stakeholders. In the meantime, the current framework remains in place. However, organisations

may complete proportionate learning responses instead of undertaking a full Patient Safety Incident Investigation

(PSII).

Relevant groups/

committees

Regular updates go to the ICB Quality Assurance Meeting and discussed

within Provider meetings which the ICB are invited to attend.

NHS England also monitor never events and provide quarterly reports.

Quality & Patient Experience Committee (QPEC).

Current performance

What the data shows

The data shows us that we had a significant number of reported never

events between the end of 2024 and September 2025.

The data also illustrated that the highest reported never event is wrong

site surgery.

During July 2 never events were reported:

RDUHT –Retained foreign object

RDUHT –Administration of medication by the wrong route

During September 3 never events were reported:

UHPNT –Retained foreign object

UHPNT - Administration of medication by the wrong route

RDUHT –Wrong implant/prosthesis

Risks and mitigation

Nationally UHP and TSDFT are currently high reporters of never

events. Both Trusts are working together on learning from never events,

including peer to peer supervision.

UHP are undertaking a thematic review of Never Events reported since

April 2024, using the Systems Engineering Initiative for Patient Safety

(SEIPs) methodology. Learning will be shared via a Never Event Summit

in November 2025.

Next Steps & Escalation

The Patient Safety Team will maintain ongoing monitoring of emerging themes and trends related to patient safety across Devon. Insights and learning from investigations will be shared proactively with all

relevant healthcare organisations to support continuous improvement.

In addition, the Quality Improvement and Patient Safety Team regularly engages with the Acute Providers through scheduled meetings to discuss safety concerns, best practices, and opportunities for

improvement.

The Patient Safety Team to review and refresh the previous never event report, specifically to understand the learning from wrong site surgeries and ensure this is shared across all Trusts and for all Trusts

to provide updates on their implementation on of NatSSIPs.

October 2025Exec Lead CNOPatient Safety: Never Events

Tab 4 Item 4.3b - NHS Devon Quality Report222 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

Patient safety alerts are official safety communications issued within the NHS in England to quickly

share urgent information about risks to patient safety. They are centrally coordinated and tracked.

Organisations must acknowledge receipt and provide assurance that required actions are completed.

Relevant groups/

committees

Regular updates go to the ICB Quality Assurance Meeting.

NHS England also receive monthly updates provided by the Trusts

and NHS Devon to monitor outstanding patient safety alerts.

Quality & Patient Experience Committee (QPEC).

Current performance

New patient safety alerts received that require action:

NatPSA/2025/005/NHSPS

Harm from delayed administration of rasburicase for tumour lysis syndrome.

Outstanding patient safety alerts:

What the data shows

Across the South West, there are 13 open alerts, 8 of which are in

Devon, and 5 specifically at RDUHT. 3 of the open alerts are < 30

days post implementation deadline.

Risks and mitigation

The two alerts that have been outstanding the longest are

recorded on each provider's risk register, where they are being

managed.

Next Steps & Escalation

The Patient Safety Team provides monthly updates on outstanding alerts to NHS England.

As the number of outstanding alerts has increased, additional monitoring will be implemented. This will include confirming that all outstanding alerts are recorded and actively

managed on the providers’ risk registers, ensuring that the Providers’ Board and Executive Lead are informed, and reviewing outstanding alerts during NHS Devon and providers’

monthly quality and improvement meetings.

October 2025

Exec Lead CNO

Patient Safety: Patient Safety Alerts (PSAs)

Tab 4 Item 4.3b - NHS Devon Quality Report223 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

Informal concerns received, logged and processed by the ICB, by month.

Relevant

groups/

Committees

Quality & Patient Experience Committee (QPEC)

Current performance

What the data shows

There has been 15% decrease in contact over the last month, though

special cause variation remains.

Main themes for the last two months (July, August):

Main topics for the last two months (July, August):

Audiology: During July and August the team received 73 contacts in

relation to one provider. Improved communication with commissioners

and dynamic information on the NHS Devon website has been

implemented to signpost the public to appropriate services.

Dental: Ongoing dental access contacts with 74 received in the last

two months.

Phlebotomy services in primary care

A campaign was run by a patient group to reinstate a specific

pharmacy.

Weight loss Injections: The team have started to see an increase in

contact from patients regarding weight loss injections following the

recent media coverage.

Risks and

mitigation

There is an ongoing risk to patient experience regarding dental access

across Devon which is frequently shared with primary care commissioning

colleagues.

Signposting of inappropriate complaints to appropriate providers has been

implemented and contributed to the reduction of inappropriate complaints

and concerns.

Next Steps &

Escalation

Audiology: Completion of Patient Experience Standard Operating Procedure (SOP) to ensure all providers are aware of the correct processes to follow & to direct members of the public.

Dynamic management of the Devon ICB website is in place for correct signposting for enquiries and complaints.

Dental access: Continue to work with commissioning colleagues and receive updated position statements to support responses to patients.

October 2025Exec Lead CNOPatient Experience: Informal Concerns

Theme

Number

received

Main topic

Access to service

436

Themes mainly relate to the change of

audiology services in East Devon and

a specific pharmacy.

Communication

115

Themes relating to pharmacy services,

GP experiences and referral pathways.

Attitude & Behaviour

Behaviours, attitudes and lack of

support across a number of disciplines.

Tab 4 Item 4.3b - NHS Devon Quality Report224 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

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Metric

Fornal complaints received, logged and processed by the ICB (or Collaborative

Commissioning Hub), by month.

Relevant

groups/

committees

Quality & Patient Experience Committee (QPEC)

Current performance

What the data shows

Top 3 themes for the last two months (July, August):

There has been a 33% decrease in formal complaints since July

2025, though special cause variation remains.

As of the 10th September 2025, there are currently 78 open

formal complaints. 30 of which are related to the closure of a

social enterprise for routine and specialist audiology. These

continue to be worked on with the support of commissioning

colleagues.

Risks and mitigation

The number of complaints fluctuates, increasing when there is

significant change in communities for example.

Team capacity also impacts managing the complaints process.

The team have weekly meetings with senior management to

discuss workload planning and are putting processes in place to

support specialist areas to manage their responses in a timely

way.

Steps &

Escalatio

There is a trend in the increase in number of cases where the client is escalating the status from an informal concern to a formal complaint. Actions are being

developed to improve processes, and these are being managed through a dynamic action plan.

The team continue to use weekly huddles to risk assess outstanding formal complaints and escalate any concerns to the ICB senior leadership team.

Exec Lead CNOPatient Experience: Formal Complaints

Theme

Number

received

Main topic

Access to service

Themes mainly relate audiology

services in East Devon,

Leatside

Pharmacy and access to

weightloss

injections.

Communication

Themes relating to

audiology/pharmacy services and

referral pathways.

Commissioning

Access to

weightloss injections and

audiology services.

October 2025

Tab 4 Item 4.3b - NHS Devon Quality Report225 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

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Metric

This metric tracks the number of Primary Care contacts received by month into the ICB Patient

Experience Team.

Relevant groups/

committees

Quality & Patient Experience Committee (QPEC)

Current performance

What the data shows

There has been a 28% decrease in dentistry contacts over

the last month and a 7% decrease in General Practice

contacts. This can be associated with Patient Experience

following process and sign posting to appropriate providers.

Following an 94% increase in pharmacy contacts in July

due to the specific pharmacy campaign, these decreased

by 20% in August.

The main theme across the 3 specialities mentioned above

remains access to services.

Risks and

mitigation

Signposting of inappropriate contacts back to Primary

Care providers has been implemented and contributed to

the reduction of inappropriate complaints and concerns.

This has also been supported by practices updating their

website contact details.

Next Steps &

Escalation

Completion of Patient Experience SOP to ensure all providers are aware of the correct processes to follow and direct members of the public.

Intelligent planning of management of escalating quality and concerns that may result in multiple complaints.

Dynamic management of the Devon ICB website for correct signposting for enquiries and complaints.

Actions are being developed to improve processes, and these are being managed by a dynamic action plan to manage work and capacity.

October 2025Exec Lead CNOPatient Experience: Primary Care Contacts

Tab 4 Item 4.3b - NHS Devon Quality Report226 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

This metric tracks the number of Primary Care Formal Complaint Responses received by the

Patient Experience team.

Relevant

groups/

committees

Quality & Patient Experience Committee (QPEC)

Current performance

What the data shows

There was a 59% increase in formal complaint responses

received by the Collaborative Commissioning Hub (CCH)

in July 2025 which has remained static in August 2025.

The top 3 themes for the last two months (July,

August):

Risks and

mitigation

It was identified that the quality of complaint responses

from the Collaborative Commissioning Hub were not in



Experience Lead has met with the manager of CCH to

discuss this and agree a plan of action.

Next Steps &

Escalation

There is on-going liaison with the CCH to drive further improvement.

Actions are being developed to improve processes (including executive sign off), and these are being managed by a dynamic action plan to support work and capacity.

October 2025Exec Lead CNOPatient Experience: Primary Care Formal Complaints

Theme

Number

receive

Main topic

Access to service

Themes mainly relate to

dental access, and pharmacy

services.

Procedure & Process

Themes relating to dental

services and the referral

pathways.

Communication

Communication with GP

practices.

Tab 4 Item 4.3b - NHS Devon Quality Report227 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

The Summary Hospital-level Mortality Indicator (SHMI) reports on mortality at trust level

across the NHS in England using a standard and transparent methodology. It is produced

and published monthly as an Accredited Official Statistic by NHS Digital.

The SHMI is the ratio between the actual number of patients who die following

hospitalisation at the trust and the number that would be expected to die on the basis of

average England figures, given the characteristics of the patients treated there.

A SHMI score of 1.00 represents expected deaths balancing with observed deaths.

Data: May 2024- April 2025

Relevant groups/

committees

Data is reported to the Devon Morbidity & Mortality Group

that report into the Regional Mortality Group.

Current performance

What the data

shows

Torbay & South Devon (TSD) and Royal Devon University

Healthcare (RDUH) are both below this marker.

University Hospitals Plymouth (UHP) has a SHMI score

above 1.00, meaning more deaths observed in comparison

to what was expected in the twelve-month period.

Risks and mitigation

UHP have provided some assurances in regard to coding

being a factor and have implemented actions such as

clinical reviews and a live Trust App to monitor mortality

per directorate.

A Rapid Quality Review (RQR) was undertaken 19 August

2025, where it was agreed to move into the Quality

Improvement Group (QIG) process (National Quality

Board). A QIG took place 18 September 25, chaired by the

ICB Chief Medical Officer (CMO) with a further QIG

planned for 7 October 2025.

UHP have developed an action plan which will be

monitored through the group for improvement; a requisite

to exiting from the process.

Next Steps &

Escalation

UHP's latest SHMI position and mitigation was discussed at the September 2025 Devon Morbidity & Mortality Group and formed part of the escalation to the

Regional Mortality Group 11 September 2025.

October 2025Exec Lead CMO

Clinical Effectiveness: Summary Hospital-Level Mortality Indicator

(SHMI)

RDUH

Tab 4 Item 4.3b - NHS Devon Quality Report228 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

The IFR process is a statutory duty through which the ICB considers requests to fund, for an

individual, an episode of healthcare that currently falls outside commissioned services, or

where a patient does not meet the clinical criteria set out in ICB commissioning policy but is

considered by the referring clinician to demonstrate exceptionality.

EEA/S2 applications are also considered to confirm with the NHSE European Healthcare team

whether treatment being requested would be routinely commissioned by NHS Devon,

available to the patient in their specific circumstances, how soon the treatment could be

delivered within the NHS and whether this is a medically justified timeframe.

Relevant groups/

committees

Individual Funding Request (IFR) Panel

Current performance

Applications received via the IFR process (July and August 2025) –status as at 03/09/25

Applications considered by the IFR panel (July and August 2025)

What the data shows

Effective triage processes support identification of requests

not appropriate for IFR, most commonly for individual

cases, and requires liaison with internal and external

colleagues. Of the 3 cases identified as not for IFR, 2 were



Individual Patient Placements (IPP).

In July and August, the IFR panel considered 41 requests

and 1 EEA/S2 application. There is consistency in the

number and type of requests being submitted and

considered by the panel. The majority are for low priority

treatments, with the highest proportion of these for benign

skin lesions and breast procedures.

Risks and mitigation

Risks:

Challenges with confirming that the ICB is the

responsible commissioner for certain individual requests

due to lack of clarity in the NHSE Prescribed

Specialised Services Manual.

Mitigations:

Support from ICB colleagues, e.g. commissioning,

medicines optimisation and clinical effectiveness teams.

Seeking clarity directly via the NHSE IFR panel on

queries re commissioning remit

Next Steps &

Escalation

s.

During the reporting period this has included:

Raising concerns with relevant commissioning colleagues regarding the reported inability of specialist weight management services to make reasonable

adjustments to support people with learning disabilities in accessing services.

Highlighting a regular area of policy query relating to the definition of premature ovarian failure via the clinical effectiveness team to support clarification

of this aspect of the Assisted Conception policy for the benefit of clinicians and IFR panel members.

October 2025Exec Lead CMOClinical Effectiveness: Individual Funding Request (IFR) Panel

Application type

Proceeding to

IFR panel

Further info

pending

(from clinician)

Not for IFR

(e.g. meets policy,

NHSE commissioned)

Total

Individual 6 1 3 10

Exceptional 3 1 0 4

Low Priority 31 17 048

EEA/S2 - - - 1

Application type Requests for Total

Individual Semaglutide (weight loss) / Knee-Ankle-Foot Orthosis /

Eltrombopag (severe aplastic anaemia) / Dissociative

Identity Disorder treatment

Exceptional Fertility treatment 1

Low Priority Benign skin lesions (16) / Breast procedures (12) / Body

sculpturing (3) / Varicose veins (2) / Birthmarks/ facial (1) /

Scar revision (1) / Ear procedures (1)

EEA/S2 Laparoscopic inguinal hernia repair 1

Tab 4 Item 4.3b - NHS Devon Quality Report229 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

The NHS is legally obliged to fund and resource medicines and treatments recommended by

the National Institute for Health & Clinical Effectiveness (NICE) Technology Appraisal (TA)

guidance and Highly Specialised Technologies (HST) guidance, making them available within

three months of publication (or 30 days if recommended through a fast-track appraisal

process).

The NICE Planning Advisory Group (NPAG) provides a forum for the ICB to fulfil its statutory

responsibilities in respect of mandatory TAs and HSTs.

Relevant groups/

committees

NICE Planning Advisory Group (NPAG)

Current performance

TAs and HSTs due to be added to the Devon Formulary during July and August 2025 in

line with ICB statutory commissioning responsibilities

* The last couple of years has seen the publication of NICE TAs with extended multi-year

implementation periods with more complex implementation and roll out plans (e.g. TA1026

Tirzepatide for overweight and obesity & TA943 Hybrid closed loop systems for type 1 diabetes)

NPAG identification of issues relating to specific TAs:

Of the TAs above that were ICB commissioning responsibility, a potential impediment to the

delivery of TA1057 Relugolixestradiolnorethisterone for symptoms of endometriosis is

providers ability to give timely access to DXA scans which are required for initiation and

monitoring of this drug.

What the data

shows

Assurance of ICB compliance with its statutory

responsibilities for the commissioning of NICE TAs, fulfilled

through their addition to the local Formulary within 3

months of publication (or 30 days for fast-track appraisals).

Identification and highlighting of issues relating to specific

TAs via the NICE Planning Advisory Group (NPAG)

Risks and mitigation

Risks:

The high proportion of NICE guidance which now

comprises TAs and HSTs, with NICE consistently

publishing around 100 per year.

The number of TAs being recommended through fast-

track processes with the associated commitment to fund

them within 30 days. Reduced time to consider any

emergent local issues from these or additional local

supporting clinical guidance required.

Mitigations:

Well established NICE Planning Advisory Group

(NPAG) process

TAs and HSTs prioritised on NPAG meeting agendas

New Senior Clinical Effectiveness Support Officer in

post since July with principal role focus on supporting

ICB NICE processes

Close links with the Devon Formulary Team

Next Steps &

Escalation

TA1057 Relugolixestradiolnorethisterone for symptoms of endometriosis is one of a number of TAs for drugs which require DXA scans that have been published over

the last couple of years, which has a cumulative effect on pressure on demand for service and has been highlighted to the ICBelective care demand management

group.

October 2025Exec Lead CMOClinical Effectiveness: NICE mandatory guidance

Statutory implementation period No. of TAs

No. added by

deadline

Standard 3 months from publication 16 16 100

 30 days from publication 6 6 100

Extended implementation period* 0 - -

Tab 4 Item 4.3b - NHS Devon Quality Report230 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

The ICB has a duty to consider NICE non-mandatory guidance when making commissioning

decisions.

The NICE Planning Advisory Group (NPAG) provides a forum for the ICB to consider the

resource and service implications for all newly published NICE guidance and guidelines. The

group advises relevant ICB leads on significant issues arising from NICE guidance and

guidelines and uncertainties for further consideration. It also identifies planned and

forthcoming NICE guidance and guidelines for forward planning purposes.

Relevant groups/

committees

NICE Planning Advisory Group (NPAG)

Current performance

Non-mandatory guidance yet to be considered by NPAG - by guidance type and time

since publication (as at 03/09/2025)

The above figures do not include the 11 pieces of non-mandatory guidance which are on the

agenda for the next NPAG meeting and for which reports are in preparation.

What the data shows

NPAG agenda planning is guided by NICE reporting from

providers to support informed meeting discussions. There

is a natural delay between NICE publication and baseline

assessments being undertaken by providers, particularly for

guidance of considerable length and depth, e.g. clinical

guidelines across multiple settings.

New links with provider colleagues have been established

following recent changes in staff (both in trusts and the ICB

with the new Senior CE Support Officer in post since July)

Risks and mitigation

Risks:

Flow of provider NICE reporting can be easily disrupted

by changes in provider staffing and/or processes. Relies

on establishment and maintenance of relationships with

provider colleagues to ensure continuity.

Mitigations:

Links with Quality team colleagues for escalation of

issues with unexplained provider non-reporting.

Does not impact time sensitive statutory processes and

fulfilment of commissioner responsibilities.



Would routinely take any guidance beyond a certain age

to NPAG in the absence of provider responses to

ensure this is considered and enable any potential

issues or concerns arising to be raised with providers.

Next Steps &

Escalation

Feedback given to NICE about baseline assessment templates (BATs) following provider concerns about the scale and depth of the BAT for NG246 overweight and

obesity management which replaced 7 older guidelines, resulting in 265 recommendations. Highlighted that where NICE guidelines update and replace several previous

guidelines resulting in a very large baseline assessment, this is burdensome for front line clinicians and results in an unrealistic and disproportionate amount of work to

review. Queried whether the practical implications such as this are considered when they undertake guideline reviews and publish supporting materials, or whether

there is scope to support providers and commissioners by more clearly identifying key areas to support subsequent review and implementation.

Response from NICE 03/09/2025: the national implementation team undertook a review last year and continue to explore options to make these tools more user

nges. The team are aware of the BAT for

NG246 and are working with colleagues to see how they can improve usability. They hope to use this learning to make other BATs with more

recommendations easier to use by producing something similar at publication.

October 2025Exec Lead CMO

Clinical Effectiveness: NICE non-mandatory guidance

and NICE planning process

Guidance type <6 months 6-12 months >12 months Total

Clinical guidelines 8 7 - 15

Antimicrobial prescribing

guidelines - - - -

Diagnostics Guidance - 1 - 1

Medical Technologies

Guidance - - - -

Interventional Procedures

Guidance 7 3 - 10

Health Technology

Assessment 13 - - 13

Public Health Guidance - 1 - 1

Total 40

Tab 4 Item 4.3b - NHS Devon Quality Report231 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

The ICB is a statutory partner within the Safeguarding Children Partnerships

including responsibility to commission and deliver health services into the Multi

Agency Safeguarding Hub (MASH) and health assessment and care for Children in

Care and Care leavers.

Relevant groups/

committees



Devon Safeguarding Children Partnership

Current performance



undertaken by Ofsted 30 September to 11 October 2024 and 13 to 16 January 2025.

The report, published 13 May 2025, gave an inadequate rating overall. Devon County

Council - Open - Find an Inspection Report - Ofsted. This is the second concurrent

inadequate rating, further to the 2020 inspection.

The inspection identified key tasks and actions that require partnership commitment

and coordination.

A multiagency plan has been developed that outlines the necessary partnership

strategies for enhancing outcomes for children and young people.

This plan will align with the Devon Safeguarding Children Partnership (DSCP)

priorities and support the implementation of the Families First Partnership

programme.

The Families First Partnership, including implementation of Multi-Agency Child

 will see a fundamental change in the way Children's

Services are delivered. This as an opportunity to strengthen strategic partnerships

and co-design and deliver the changes needed.

What the data shows

The quality of practice and the experience and

progress of children and young people in Devon

remains variable.

Risks and mitigation

Action has already been taken to respond to the

health system responsibilities in development of a

rapid action plan. NHS Devon will contribute to the

multiagency plan development and delivery.

Next Steps &

Escalation

NHS Devon and health providers are members of DSCP Business Group and will be involved in the development and delivery of the Families First DSCP Plan 2025-

2027. Progress of the plan will be monitored by DSCP Executives.

October 2025Exec Lead CNO

Safeguarding: Devon County Council (DCC) Inspection of Local

Authority Children's Services (ILACS)

Tab 4 Item 4.3b - NHS Devon Quality Report232 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

The National Safeguarding Steering Group has developed a suite of ICB statutory

safeguarding protocols, which outline the roles and responsibilities of individuals

across NHS funded care and commissioning organisations in relation to key statutory

duties.

The ICB Safeguarding team have benchmarked performance and compliance against

those protocols to inform strategic direction.

Relevant groups/

committees

NHS Devon Safeguarding Steering Group

Current performance

The protocols focus on the following statutory duties:

Child Protection Information System (CP-IS)

Domestic Homicide Reviews (DHRs)

Female Genital Mutilation (FGM)

Modern Slavery and Human Trafficking (MSHT)

Child Death Reviews (CDRs)

Domestic Abuse Sexual Violence and Serious Violence (DASV and SV)

Prevent

NHSE have directed that CP-IS needs to be implemented in all health services that

deliver NHS services for children by 30th Oct 2025.

There is no local pathway to support and identify FGM for either children or women.

Any children identified who are victims of FGM are currently signposted to London.

If a GP suspects FGM, there is no local offer to seek a second professional opinion.

What the data shows

Benchmarking of performance and compliance has

identified key priorities in the following statutory

duties:

CP-IS

Prevent

FGM

Risks and mitigation

CP-IS

Meetings have taken place with all LA leads and a

Devon system meeting is planned for the 2nd October

2025 to progress implementation.

Prevent

A Devon Health System meeting is being stood up to

support matrix working and progress of requirements

within this protocol

FGM

There is a gap in commissioning of these services

locally

Next Steps &

Escalation

1. Status report will be provided to the ICB Safeguarding Steering Group

2. The safeguarding team will extend this work to include provider organisations

October 2025Exec Lead CNOSafeguarding: NSSG Safeguarding Protocols

Tab 4 Item 4.3b - NHS Devon Quality Report233 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

The Families First Partnership (FFP) Programme aims t

o transform the whole system

of help, support and protection for children, to ensure that every family can access

the right help and support when they need it, with a strong emphasis on early

intervention to prevent crisis.

The FFP Programme sets an expectation that the joint and equal statutory multi-

agency safeguarding partners (LA/police/health) will implement Family Help, multi-

agency child protection teams and Family Group Decision Making processes. Health

engagement and participation will be required in the co-design and set up of these

services.

Relevant groups/

committees

Transformation Boards in each local authority area.

Safeguarding Children Partnerships

Current performance

All local authorities submitted their FFP plans to DfE at the end of June.

Local authorities are making internal changes to progress FFP reforms. Multi-agency

stakeholder engagement, collaboration and codesign has begun.

There are plans to second a strategic health leader to support the Torbay and

Plymouth FFP programme.

FFP governance will be held with local safeguarding children boards.

What the data shows

Families do not consistently receive the right support

at the right time, often only receiving services when

they reach crisis, and this results in increasing

numbers of children subject to child protection plans

or becoming looked after.

Risks and mitigation

Although there is currently no associated risk



part of the Working Together to Safeguarding

Children statutory requirements.

Grant funding has been made available to local

authorities to support this transformation work.

Next Steps &

Escalation

NHS Devon will continue to work with safeguarding partners to deliver the FFP programme. Progress will be monitored by the local safeguarding

children partnerships.

October 2025Exec Lead CNO

Tab 4 Item 4.3b - NHS Devon Quality Report234 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric



criteria for either a Rapid Review, Child Safeguarding Practice Review (CSPR) or

Safeguarding Adult Review (SAR) is met. Designated professionals work with partners to

ensure the quality of those reviews and to identify and progress any learning for the health

system.

Relevant

groups/

committees

Safeguarding Steering Group

Local safeguarding adult and child partnerships

Current performance

What the data shows

Safeguarding Adult Reviews (SAR)

There have been no reviews published in Q2 25/26.

There are currently 7 open SARs.

1 Review in Plymouth is nearing completion and will be

published in Q3

Safeguarding Children Reviews

There are 4 open CSPRs across the system

Identification of and response to non-accidental injury

and neglect remain a dominant theme in current child

safeguarding practice reviews.

Risks and mitigation

Risk that the learning from statutory reviews particularly regarding

non accidental injury and self-neglect is not resulting in system

change.

Mitigation: ICB supports the safeguarding partnerships with

disseminating learning from reviews and monitoring provider

action plans by attendance at their safeguarding governance

meetings.

Torbay and Devon Safeguarding Adult Partnership (TDSAP) held

a self-neglect conference to disseminate learning from reviews.

Newly revised self-neglect guidance has been disseminated to all

health safeguarding leads and published on the TDSAP website to

support staff alongside the Multi Agency Risk Management

meeting test and learn currently underway.

Next Steps &

Escalation

NHS Devon supports the multiagency partnership arrangements to complete reviews, implement recommendations and disseminate learning.

The progress of actions for health providers is monitored through provider safeguarding committees and through safeguarding partnerships processes.

October 2025Exec Lead CNO

Safeguarding: Statutory Safeguarding Reviews for Safeguarding

Children and Adults

Q2 24/25 Q3 24/25 Q4 24/25 Q1 25/26 Q2 25/26

Safeguarding Adult Reviews (SARs)

SAR Referral decision meeting (decision to close or proceed)

SAR New: Agreed in quarter

SAR Open & Ongoing

For noting: Q2 25/26 data only relates to

months 1 and 2.

Q1 24/25 Q2 24/25 Q3 24/25 Q4 24/25 Q1 25/26 Q2 25/26

Safeguarding Children Statutory Reviews

Serious Incident Notifications

Rapid Reviews

Open Child Safeguarding Practice Reviews (CSPR)

For noting: Q2 25/26 data only relates to

months 1 and 2.

Tab 4 Item 4.3b - NHS Devon Quality Report235 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

Section 42 (S 42) of the Care Act 2014 establishes a duty for local authorities to investigate

concerns regarding abuse or neglect of adults with care and support needs (whether they are

having those needs met or not). The aim of the S42 process is to establish facts and decide

what actions, if any, are needed to safeguard the adult. The ICB is a statutory partner of the

safeguarding partnership and has a role to ensure where abuse is suspected in healthcare

settings this is robustly investigated learning is identified and action taken to mitigate any risk.

The data supplied is regarding any S42 in healthcare settings the ICB is aware of and any

themes or trends.

Relevant groups/

committees

ICB Quality Assurance Meeting

Current performance

What the data shows

In Q2 25/26 there have been 11 new S42.2 cases opened

with health providers. Concerns featuring hospital

discharge particularly those transferring to care home

settings remains a concern.

There have been 6 S42.2 cases closed by local

authorities following investigation by providers.

4 cases were reported as substantiated and 2 cases not

substantiated.

Risks and mitigation

The delays within the local authorities safeguarding hubs

remain, however, progress is being made in tackling high

waiting list numbers. Collaborative partnership working has

contributed to this improvement.

The ICB safeguarding adult team meet monthly with the

providers & local authorities to ensure S42.2 cases are

quality assured and robustly reviewed to achieve optimum

progress for learning and case closure.

Next Steps &

Escalation

The safeguarding adult team continue to monitor and work with the quality team regarding provider discharge standards.

October 2025Exec Lead CNOSafeguarding: Safeguarding Adult S 42 enquiry data

12 S42.2 Enquiry Data 2024/25

Total number of new S42.2 enquiries Total number of closed S42.2 enquiries

S42.2 Themes - Aug 2025

Poor quality of care

Pressure ulceration

Poor discharge (Hospital)

Medication

Allegation

Communication a factor

Tab 4 Item 4.3b - NHS Devon Quality Report236 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

Metric name: Women and birthing people accessing specialist community perinatal

mental health services.

Definition: Number of women and birthing people accessing (1+contact) Specialist

Community Perinatal Mental Health and Maternal Mental Health services in the previous

12 months (rolling 12-month period)

Data source: Mental Health Services Dataset (MHSDS)

Relevant groups/

committees

Terms of reference are being developed for a system wide

Mental Health tactical group who will hold oversight. There will

need to be alignment with the development of contract review

processes that are currently underway.

Current performance

What the data shows

Whilst there is still a variation between the provider data and

the MHSDS data, MHSDS data is being used to complete

report. Resolution of this variation rests with providers and a

formal request for them to address will be taken to the MH

data and business intelligence group.

DPT are exceeding their target and have seen an increasing

upward trend across Q1. Livewell are also exceeding their

target.

Benchmarking of DPT nationally and regionally has been

completed which indicates that demand is higher than the

national and regional averages, variation in relation to

ethnicity accessing the services. Non-attendance rates are

low, with DPT being in the highest quartile for care contacts

per patient. DPT have an average of 4.2 with national

median and southwest average being 2.3 and 2.4

respectively.

The equivalent benchmarking data is not available for LSW.

Risks and mitigation

Low access target means that there is a high proportion of people who require the service but will not be able to access perinatal mental health support, which

inhibits the opportunity for equity, prevention and early intervention.

Risk of under identifying and under supporting women and birthing people with mental health needs in the perinatal period, potentially leading to poorer parental and

infant outcomes.

Mortality review learning has highlighted a gap in provision for perinatal mental health support for the mother/birthing person when the baby removed.

Perinatal Mental Health is not a priority within the 25/26 operating plan.

Mental health commissioning are working with Director of Women and Children to align the perinatal services within the wider LMNS.

Mental Health commissioners are working with providers, particularly DPT, to understand challenges in the pathways.

Next Steps &

Escalation

Mental health commissioning are working with Director of Women's and Children's to ensure that perinatal and other relevant mental health services are part of

the wider LMNS. In addition, as the recommendations from the recent mortality review are available, MH commissioning will work closely with the Director of Women

and Children's who is the lead on this review.

Mental Health commissioners are continuing to work with providers, particularly DPT, to understand challenges in the pathways. Once these are understood, the

appropriate actions or recommendations will be identified and implemented/monitored as appropriate.

Terms of reference are being developed for a system wide Mental Health tactical group who will hold oversight. There will need to be alignment with the

development of contract review processes that are currently underway.

October 2025Exec Lead CMOPerinatal Mental Health

Tab 4 Item 4.3b - NHS Devon Quality Report237 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

People in contact with mental health services aged 19 to 64

Definition: People with a Service or Team Referral open at the end of the reporting month

Median waiting time between referral and second contact for referrals accessing

community mental health services

Definition: The median of the time in days between referral and second contact for adults and

older adults that had their second contact in the reporting period

Data source: Mental Health Services Dataset (MHSDS), Devon wide.

Relevant groups/

committees

Terms of reference are being developed for a system wide

Mental Health tactical group.

There will need to be alignment with the development of

contract review processes that are currently underway.

Current performance

What the data shows

Devon ICB continues to achieve the community access

target, with data indicating that waiting times are reducing

and more people are having contact with MH services.

As of July 2025, the median wait time between referral to

second contact is 44 days (Plymouth 52 days; Devon and

Torbay 42 days) with approximately 4,315 with an open

referral still waiting for a second contact.

2024 saw the highest peak of referrals received to

community mental health teams since 2019.

The majority of community crisis referrals were routine

(70%) and 21% were urgent.

Risks and mitigation

There is a need to draw together an overview of demand

and capacity, equity of access, outcomes and

experiences aligned to community MH teams and

pathways.

The actions/mitigations aligned to the impact of the GP

contract will form a key part of this review.

Next Steps &

Escalation

Time lined action plan for drawing together an overview of demand and capacity across the community and UEC pathways which will require a commissioning and

quality focus. Future updates will be provided against this timeline.

The work to improve paired outcome reporting by secondary MH providers will be held by the MH system data and business intelligence group.

The community mental health team service specification to be reviewed by end of October.

Terms of reference are being developed for a system wide Mental Health tactical group. There will need to be alignment with the development of contract review

processes that are currently underway.

October 2025Exec Lead CMOCommunity Access and Waiting Times

Tab 4 Item 4.3b - NHS Devon Quality Report238 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

The Devon LMC wrote to all surgeries in Devon recommending that they review their

position regarding the physical health monitoring and investigations for people with

eating disorders, and, prescribing and drug safety monitoring of people on anti-

psychotic medications.

Relevant

groups/

committees

GP Collective Action (GPCA) System Oversight group.

Specific decisions will be taken through the correct governance routes for ICB sign

off.

Current performance

There is a need to manage immediate risks and mitigations whilst also working

towards more sustainable options.

Ongoing system group in place to provide oversight of the impact of GP collective

actions which is led by ICB Primary Care Medical Director, with their agreement are

additional meetings in place led by Mental Health Commissioning and Quality for the

Mental Health secondary care providers.

Current GP practice notice

The main impact is being experienced within DPT. LWSW are reporting impact within

their community physical health services and not mental health. They have reported

information pertaining to the impact on physical health services is being fed into the

system meeting and no action is being taken by the MH commissioning and quality

leads in relation to this.

What the data shows

DPT have undertaken an EQIA which has been shared with the ICB.

DPT have 4 risks on their corporate risk register in addition to an overarching risk

regarding the impact of GP collective action.

For 25/26 an estimated 11,475 patients are taking oral antipsychotics. 30-40% fall

into Cohort E (not open to secondary care, no serious mental illness, no

commissioned offer or pathway).

Risks and mitigation

There is a potential risk that the impact of the GP contract will further negatively

impact the effectiveness and efficiencies of Mental health providers.

The change in provision of ongoing prescribing and monitoring creates a risk to

the continuity of care for this patient group and where treatment needs to be

initiated a potential delay in accessing treatment.

There is a need to draw all information together so there is system understanding

of the risks and options, and clarification of the governance arrangements aligned

to any agreed options.

Procurement processes underway to secure a second private provider. Minimum

5-day period between practice notice and private provider commencement where

patients will have no clinical oversight.

There are weekly task and finish meetings in place to address the longer-term

commissioning arrangements for shared care arrangements aligned to anti-

psychotic medication.

There are weekly meeting between mental Health commissioning team and

secondary mental health providers to discuss challenges and identify actions

required to mitigate immediate impacts. These will be relayed to the lead of the

System Oversight group on a fortnightly basis.

Next Steps & Escalation

A Quality and Commissiong based evaluation of the current position and potential solutions to mitigate risks is in process of being drafted.

Re-drafted Shared Care guidelines for Olanzapine & Quetiapine (covering ~60% of prescribing) due for recirculation w/c 15th September 2025 in preparation for November Finance

Investment Group. Next phase: Risperidone & Aripiprazole (covering ~90% of prescribing) scheduled for Finance Investment Group January 2026 and LMC Feb 2026.

First draft interim shared care proposals have been received from secondary mental health providers. Further discussion are required to confirm costs and implementation timelines.

System workshop planned for 15th October to focus on high-risk areas: legacy patients, the cohort of people who have been identified as not open to secondary mental health services

and who do not have a Serious Mental Illness but are being prescribed (referred to as cohort E), and dementia patients.

Further comms to GPs required to provide certainty of shared care guidelines which could mitigate the risk of more practices giving notice.

October 2025Exec Lead CMOAnti-psychotic Prescribing and GP Contract Impact

GP Practice WEF Date # Patients Private Provider

Albany Surgery 08/7/2025 31 LaTahzan

Bovey Tracey &

Chudleigh 8/10/2025 83 TBC - procurement

Yelverton 01/11/2025 41 TBC - procurement

Mount Pleasant TBC 117 TBC - procurement

Tab 4 Item 4.3b - NHS Devon Quality Report239 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

Proportion of all attendances to A&E that were mental health related

Definition: Those recorded with mental health related chief complaint or mental health diagnosis

Proportion of mental health related attendances spending 12 hours or more in A&E

Definition: Those recorded with mental health related chief complaint or mental health diagnosis time

spent calculated between recorded arrival date time and recorded departure date time.

Data source: Emergency Care Dataset (ECDS)

All Devon ICB commissioned patients

Relevant groups/

committees

Urgent & Emergency Care (UEC) Demand and Growth Group

Tier 1 Week 3 regional oversight

System MHED group (Fri 19th Sept)

Provider CRMs

Current performance

What the data shows

The data does not reflect the experience reported in the system.

This may be due to data quality and shared definitions of delays

between system partners.

Since March 2025, all providers have seen a reduction in the

proportion of MH-related attendances waiting over six and

twelve hours in A&E (total time spent). However, the persistence

of 24-hour breaches suggests there may be other factors, such

as acuity or case complexity, influencing the longest waits and

warranting further investigation. It should also be noted that the

dataset does not record whether a physical health need is

present, which could also impact total waiting time.

Bed occupancy across services has remained consistently high

impacting patient flow.

Risks and mitigation

There is a risk to patient safety and experience because of

extended waits for a mental health bed. This will impact patients

waiting in Acute Hospitals and those waiting in the community

with medical recommendations in place.

Staff resource, staff skill mix, patient mix and environmental

factors will also impact patient safety and patient experience.

Next Steps & Escalation

The NHS England Mental Health, Learning Disabilities & Neurodiversity (MHLDN) Analysis team are about to commence a piece of work to review and standardise the definition of MH

attendances in ECDS over Quarters 3 & 4.

For known pressures aligned to bed capacity, work is ongoing to agree a system process aligned to delayed discharges/transfers of care no matter where the delay is. Work aligned to

delivery of the mental health inpatient strategy is now being led by the ICB (previously being led by the MHLDN Provider Collaborative). Demand and capacity work to understand need

aligned to mental health inpatient beds is underway, with commissioning discussions aligned to increasing Psychiatric Intensive Care Unit (PICU) capacity across the peninsular to be

commenced.

Providers reporting against high Impact actions will enable oversight of impact of actions aligned to reduce length of stay, improve bed availability and minimise inappropriate out of area

placements.

October 2025Exec Lead CMOMental Health Delays in Emergency Department

Tab 4 Item 4.3b - NHS Devon Quality Report240 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

Estimated Diagnosis Rate for People with Dementia

Diagnosis rate for people aged 65 and over, with a diagnosis if dementia recorded in

primary care, expressed as a percentage of the estimated prevalence based on GP

registered populations.

Data Source: GPES

Relevant

groups/

committees

Dementia is to be added to the 'falls & frailty group'.

The dementia diagnosis rate will remain a mental

health metric.

Current performance

What the data shows

Although experiencing improvement the indicator

remains below target and will not meet the target

without a process change.

Dementia prevalence across NHS Devon footprint is

expected to rise by 54% between 2023 and 2040. This

means that by 2040 it is expected that 33,734 people

will be living with dementia in Devon.

The NHSE target for Dementia Diagnostic Rate

nationally is 66.1% of predicted rate. At 59.7% Devon

is below the England average of 65%.

In Devon, 30% of adult and older adult beds in general

hospitals are occupied by patients who have a

dementia diagnosis.

There will be a 25% increase in the total over 65

population in Devon from 310,600 people in 2023 to

413,500 by 2040.

Risks and

mitigation

The strategy will form part of the ICB Health & Care

Strategy.

Services for older adults are under increasing

pressure due to rising numbers of people requiring

dual physical and mental health care.

Next Steps &

Escalation

There is a need to improve access for dementia diagnosis and post diagnostic support aligned to the Live Well framework for dementia

October 2025Exec Lead CMODementia

Tab 4 Item 4.3b - NHS Devon Quality Report241 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

This metric monitors:

Proportion of s117 reviews completed within 12 months of the last review or 6 weeks after

discharge from Hospital

IPP reviews whilst patients are in out of area hospital reviews.

Section 117 of the Mental Health Act 1983 outlines the provision of aftercare services for

individuals who have been detained under specific sections of the Act. These services are

jointly funded by health and social care bodies.

Out-of-

area hospital reviews focus on ensuring safe and appropriate care for patients placed in

hospitals outside their local area. These reviews aim to assess the quality of care, address

individual needs, and facilitate timely repatriation to local services when clinically appropriate.

Relevant groups/

committees

Devon ICB Quality Assurance meeting (QAM)

DPT IPP Panel / DGB

LDAN Steering Group

One Devon System Quality Group

Audit committee

Placements Quality and Cost Oversight Group

NHSE S117 Community of Practice

Current performance

What the data shows

IPP charts: Reviews currently at 78% Learning Disability

and Neurodiversity & Older Persons MH patients out of

area received safe and wellbeing reviews every 8 weeks.

For the Acquired Brain Injury cohort Devon ICB continue to

improve tracking of the cohort and working with NHS

providers to allocated key workers.

S117 table. Over the past 3 months the number of s117

eligible patients funded by Devon ICB has remained stable

at 476 . Reviews currently at 52%, it is noted that this figure

is based on data reported by providers, the data recorded

on care track does not always accurately report number of

reviews.

Risks and

mitigation

Risk for Devon ICB not meeting the statutory duties in

relation to s117 aftercare responsibilities.

Mitigation to continue with the joint working with NHS

providers / LA in Devon and NHSE region to review and

improve data reporting and implement improvements for

regional s117 benchmarking.

Next Steps & Escalation

Out of area hospital Quality Concerns have been raised via CQC and Northampton ICB regarding a provider. At short notice Devon ICB QA lead has travelled to

Northampton and completed a safe & wellbeing review. No immediate quality and safety concerns raised for the Devon funded patient. Devon ICB will continue to link in

with Northampton ICB / CQC

Section 117 aftercare Community of practice

Regional S117 Community of Practice (CoP) attended by South West region ICB's and South & East ICB. Presentations share re current challenges, data, finance and

statistics. s117 Maturity Matrix shared, good practice to be identified and presented at next meeting. Next steps - each ICB to complete s117 aftercare benchmarking

survey.

IPP Procurement (specialist out of area hospital) Devon system wide joint direct award (B) DPT to lead alliance with Devon ICB, Livewell and Torbay with the aim to

have volume discounts and level costs.

IPP / S117 Legal cases 4 cases, 2 linked to Court of Protection, 1 for housing and 1 for legal challenge that s117 costs have not been paid for by the local authority and

health.

October 2025Exec Lead - CMO

Mental Health: Devon ICB Individual Patient Placements (IPP) &

Section (S) 117 MHA

Tab 4 Item 4.3b - NHS Devon Quality Report242 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

Where patients in receipt of mental health services commit a homicide, NHS England will consider and, if

appropriate, commission an investigation. This process is overseen by NHS England's Regional

Independent Investigation team (RITT).

In February 2025 a review of the NHS care and treatment provided to Valdo Calocane by Nottinghamshire

Healthcare NHS Foundation Trust prior to the tragic events of 13 June 2023 was published. The review

identified clear failings in the care and treatment provided to Valdo Calocane and produced a series of

recommendations for Nottinghamshire Healthcare NHS Foundation Trust and NHS England.

NHS England » Independent mental health homicide report into the treatment of Valdo Calocane

Relevant groups/

committees

ICB Quality Assurance Meeting

Quality and Patient Experience Committee

(QPEC) via Quality Report

Current performance

Mental Health Homicide 3 current Devon cases in progress

Quality Assurance Review (QAR):

Developing quality improvement approach, working collaboratively with NHSE regional team, LWSW and

DPT. Multi-agency learning event scheduled for November 2025, further work indicated to map out the

programme of work to support the review. Peer networking with Cornwall colleagues in development of the

QAR.

Intensive Community Treatment Review

NHSE has requested the ICB and providers review their action planning in response to the Intensive

Community Treatment Review which has been informed by learning from the Valdo Calocane Independent

Investigation. Provider have reviewed their actions and progress. This request aligned with return required

by NHSE. Overall, there has been clear demonstrable progress by providers and the update showed that

there are clear governance processes within each provider through to executives. The tactical group being

proposed has system oversight as one of the key core priorities.

What the data shows

System improvement and assurance is in

place, alongside operational and delivery

improvement in progress because of

national learning.

Risks and mitigation

There is a risk to the sustainability of the

Quality Assurance Review in context of the

current ICB restructure work.

Next Steps &

Escalation

QAR programme mapping and event planning in progress, recognising the findings and recommendations of the NHS England Independent mental

health homicide report into the treatment of Valdo Calocane.

Bimonthly system meeting with NHSE Regional Team, next meeting 24th September 2025.

The Mental Health Tactical group will hold system oversight of the Intensive Community Treatment Review.

October 2025Exec Lead CNO/CMO

Mental Health: Independent Investigations (including Mental Health

Homicides)

Tab 4 Item 4.3b - NHS Devon Quality Report243 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

The Southwest Provider Collaborative (SWPC) provide specialist commissioning on

behalf of NHSE. The follow services, commissioned by the SWPC as part of the

regional offer, are provided in Devon through DPT and LWSW. DPT is the lead

provider for the SWPC:

Adult Secure Services

Inpatient Perinatal Services

Inpatient Adult Eating Disorder Services

Child and Adolescent Mental Health Tier 4 inpatient provision.

Relevant groups/

committees

System Quality Group (SQG).

NHS Devon ICB have initiated a quality review to map

the oversight arrangements of the commissioning of

specialist services. When completed there will be

improved clarity in the form of an accountability

framework.

Current performance

SWPC Quality Ratings:

What the data shows

Secure service at Langdon (DPT) quality

improvement group stood down 18th September 2025

due to exit criteria being met. Oversight returns to

business as usual.

The SWPC have commissioned a Peer Review of

Cofton Ward shared with the ICB and supporting

the Langdon Quality Improvement Group (QIG).

Areas of improvement are identified as governance,

workforce, patient safety culture, clinical pathways

and seclusion suite

Risks and mitigation

Oversight of these services is through the South

West Provider Collaborative (SWPC). Quality

review in place to map quality and commissioning

oversight.

The ICB receives weekly updates from SWPC.

SWPC reports through System Quality Group.

Next Steps &

Escalation

Mental health quality governance work quality review share learning and implement improvement identified through the review.

Cross reference Langdon RQR and QIG - share learning and implement improvement identified through the review.

October 2025Exec Lead - CMOMental Health: SouthWest Provider Collaborative

Service Line Devon

Provider

Quality Rating Details

Secure services DPT Intensive NQB Quality Improvement

Group (QIG) in place

Livewell Routine N/A

CAMHS Livewell Routine N/A

Perinatal DPT Routine N/A

Adult Eating

Disorder DPT Routine N/A

Other quality issues

Sowenna and

Plymbridge House

(LWSW CAMHs)

Both units are undertaking their own internal reviews and a regional,

multi-agency review in accordance with PSIRF is being developed.

LWSW have completed review, taking through internal governance.

Tab 4 Item 4.3b - NHS Devon Quality Report244 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

Reduce reliance on mental health inpatient care for people with a learning disability and

autistic people, to the target of no more than 30 adults or 1215 under 18s for every 1 million



Relevant

groups/

committees

National Reporting (monthly) through Assuring

Transformation (AT) .

Local reporting to LDAP (Learning Disability and Autism

Programme) ICB led.

SW regional reporting and review.

Current performance

What the data

shows

Current inpatient numbers (27) are outside the expected

trajectory,(20) mainly due to the change in stratification

of individuals who have a diagnosis of autism and are in

mainstream mental health beds. This is a common

pattern throughout the South West region and nationally.

Risks and mitigation

50% of people are placed out of area resulting in longer

length of stays away from family and community. Case

managers have to travel longer distances to quality

assure placement.

The Brook

If full complement of beds not open (10), or a new referral

does not meet the admission criteria, patients may need

to be placed in out of area beds at additional cost to the







by Patient Pathway Enablement Manager and Head of



Quarterly regional review of referrals and admissions in

line with standing operating procedure and contract

performance metrics reporting to SW region Learning

Disabilities & Neurodiversity (LDN) meeting.

Next Steps &

Escalation

Agreeing bed day rate by ICB finance lead and method of invoicing/payment from referring ICBs outside of Devon.

Continued attendance and monitoring of South West Regional Front Door panel referrals and decisions.

Host Commissioner review meeting Elysium, The Woodmill 14/08/2025

October 2025Exec Lead CMOLearning Disabilities & Autism: In Patient Care

Tab 4 Item 4.3b - NHS Devon Quality Report245 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

This metric monitors the proportion of LeDeR reviews completed within six

months of notification, as set out in the national LeDeR Policy (2021). The target

is 100% completion within six months, unless delays are due to statutory

processes or family wishes.

NHS LeDeR Policy

Relevant

groups/

committees

Quality and Patient Experience Committee (QPEC)

Quality and Learning into Action Group (QALIA)

LDAP Steering Group and Health Inequalities Meeting (LDAP)

Current performance

Proportion of All reviews completed within 6 months of notification (6

month rolling period)

What the data shows

Only 5% of reviews were completed within six months, with 2 meeting the

Key Performance Indicator (KPI). Devon is currently the 4th worst

performing ICB in the South West, compared to a top-performing area at

46%. The backlog remains largely static, with 37 overdue reviews.

While total completions are at a record high, the majority are already

over six months old so do not count towards the KPI.

Risks and mitigation

KPI underperformance continues due to limited capacity to complete

reviews on time. The risk is recorded on the Learning Disability, Autism &

neurodiversity (LDAN) & Mental Health team risk register within the ICB

Medical Directorate.

Key mitigations:

Oversight from QPEC and QALIA

Use of bank reviewers

Recruitment of 6 additional temporary reviewers, now trained and

commencing allocations from July 2025.

Without sustained reviewer capacity, the ICB remains at risk of failing to

meet its statutory duties on health inequalities, learning from deaths, and

patient safety under PSIRF and the Health and Care Act areas - to which

LeDeR is directly linked.

Issue is subject to Internal Audit report with limited assurance.

Next Steps &

Escalation

Begin allocation of reviews to newly trained bank reviewers

Monitor reduced inflow (average 4/month) for potential pressure relief

Escalation: Devon remains one of the lowest-performing areas regionally. Continued non-ility to meet its statutory

responsibilities supported by LeDeR insights and learning.

October 2025Exec Lead CMO

Learning Disabilities & Autism: LeDeR - % of Reviews Completed Within 6

Months

Learning from lives and deaths People with a learning disability and

autistic people (LeDeR)

Tab 4 Item 4.3b - NHS Devon Quality Report246 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

This metric monitors the proportion of completed LeDeR reviews that progress to a



A focused review is a detailed, in-depth assessment undertaken when the initial

review suggests potential for significant learning or concerns in the quality of care. It

provides critical insights that inform local and national LeDeR reports and supports

health inequality reduction efforts. A focused review is required when:

The individual was from a Black, Asian or Minority Ethnic background

There are concerns about care quality, coordination or integration

The reviewer identifies significant learning for the system

A family member requests a focused review

The person had a diagnosis of autism without learning disability

Relevant groups/

committees

Quality and Patient Experience Committee (QPEC)

Quality and Learning into Action Group (QALIA)

Learning Disability & Autism (LDAP) Steering Group and Health

Inequalities Meeting

Current performance

Proportion of completed reviews that were focused (6 month rolling period)

What the data shows

In June, 63 reviews were completed - the highest on record. However,

only 11% met the focused review threshold, far below the 35%

expected by NHSE. This is the second consecutive month at 11%, and

the lowest in the series.

While throughput has increased, the proportion of cases identified for

deeper learning has not kept pace. There have been no changes to

quality assurance processes.

The fall in proportion is therefore a reflection of increased throughput,

not reduced quality or missed opportunities for escalation.

Risks and mitigation

A specific risk related to low performance against this metric has not

been raised. The quality assurance process remains robust, with

multiple opportunities to escalate cases to focused reviews where

appropriate. The recent drop in proportion is due solely to the increased

number of reviews being completed.

Focused reviews can only proceed when national criteria are met - this

threshold has not changed, but review volume has risen sharply. The

current position may generate reputational concern, though assurance

processes remain unchanged and effective.

Next Steps &

Escalation

Report findings to QALIA and QPEC

Escalation: Persistent low rates risk compromising the quality of insight available to the ICB and national reporting. Targeted intervention may be required if July data

remains below threshold.

QALIA meeting outcome on initial review, concerns for improvement within themes on care co-ordination and MCA documentation on families' views. Action agreed

Devon ICS intervention, to convert initial review to focused review.

October 2025

Exec Lead CMO

Learning Disabilities & Autism LeDeR - % of Completed Reviews That Were

Focused

Learning from lives and deaths People with a learning disability and autistic

people (LeDeR)

Tab 4 Item 4.3b - NHS Devon Quality Report247 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

National key safety target:

50% reduction in intrapartum brain injury rates (from a 2016 baseline) by 2025.

Data source: NDAU

Brain Injury Surveillance Reports | Faculty of Medicine | Imperial College London

A reliable timely source for brain injury (as per the national definition) is yet to be defined and

confirmed whether NHSE will continue to commission NDAU to process this data. Alternative

data sources will need to be found.

Relevant groups/

committees

Devon Local Maternity & Neonatal System Board (LMNS)

SW Regional Perinatal Team (by exception)

Current performance

What the data shows

In 2021 the South West had the highest rate of brain injury

in England at 5.19 brain injuries per 1000 live births.

The national average was 4.19/1000.

Devon has a rate of brain injuries above the national

average at 4.94/1000.

Risks and

mitigation

No current system risk relating to this metric.

Next Steps &

Escalation

Continue implementation of Saving Babies Lives Care Bundles, specifically element 5: preterm birth which monitors the implementation of the PERIPrem care

bundle- a bundle designed to reduce mortality and brain injury rates for preterm babies.

The PERIPrem care bundle - Health Innovation West of England

 loting the approach.

Avoiding Brain Injury in Childbirth (ABC) | RCOG

October 2025Exec Lead CNOPerinatal: Intrapartum brain injury

5.99

4.11

4.75 4.94

4.56 4.25 4.16 4.18

3.5

4.5

5.5

6.5

2018 2019 2020 2021

Devon: Rate of Brain Injuries per 1000 Live Births

Devon

National

Tab 4 Item 4.3b - NHS Devon Quality Report248 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

85% of babies <27 weeks, <28 weeks for multiples or with a birth weight less than

800g should be born in a maternity unit with an onsite Neonatal Intensive Care Unit

(NICU).

This is monitored through quarterly Saving Babies Lives evidence validation, and we

are advised to use the South West regional BitRP figures.

Relevant groups/

committees

Devon Local Maternity & Neonatal System Board

(LMNS)

Southwest neonatal ODN

SW Regional Perinatal Team (by exception)

Current performance

What the data shows

In 2024/25 84% of babies meeting the criteria were

born in a maternity unit with an on site NICU. In

general the south west region does not achieve the

target level of 85%.

Babies may be born in the wrong place due to

precipitous birth, a lack of safety to transfer or other

units declining the transfer (which they may do for a

variety of reasons, including staffing or ward

capacity).

Risks and

mitigation

No system level risks relating to this metric.

Next Steps &

Escalation

The Neonatal Operational Delivery Network receive exception reports regarding each baby not born in a maternity unit with an on site NICU

 SWIFT South West Neonatal Network

October 2025Exec Lead CNOPerinatal: Born in the Right Place (BitRP)

Tab 4 Item 4.3b - NHS Devon Quality Report249 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

Clinical to clinician complex needs menopause advice & guidance service launched

in October 2024. Service utilisation data provided for:

1) Number of clinical sessions (clinician to clinician discussion of patient)

2) Number of advice requests (written)

Overview | Menopause: identification and management | Guidance | NICE

NHS England » Supporting our NHS people through menopause: guidance for

line managers and colleagues

Relevant groups/

committees

Devon Menopause Meeting



Current performance

What the data shows

Utilisation of Devon Menopause Service continues to

increase. Over half the surgeries in Devon (64 /117)

have now utilised the service.

Further information

Service is well received by clinicians with an

average rating of 4.9/5.

Total of 370 referrals made to Devon menopause

service over 9 months of activity. Currently this is

limited to clinician to clinician advice and guidance.

Outcomes for requests are consistently above the

acceptance threshold, indicating appropriate

referrals.

The two most common reasons for referral are

poor symptom control & medical conditions. There

is also an increase in referrals for testosterone &

premature ovarian insufficiency.

Risks and mitigation

There are no system level risks relating to this metric.

Next Steps &

Escalation

Devon menopause service have prepared a paper outlining the Devon Menopause Advice & Guidance (A&G) Service next steps whereby the

referring clinician sends an ERS advice and guidance request then the A&G clinician triages and converts to consultation if criteria met.

Full-service evaluation underway

Continued Menopause case drop-in workshops and continuous feedback reported

Routes to secure ongoing funding from October 2026 are to be investigated, seeking business as usual funding approaches.

October 2025Exec Lead CNOWomen's Health: Devon Menopause Service Utilisation

21 13 15 12 11 913 15

37 38 42

50 55

64 62

Oct-Nov

24 Dec-24 Jan-25 Feb-25 Mar-25 Apr-25 May-25 Jun-25

Number of sessions

Month

Devon Menopause Service Utilisation

Number of clinician sessions Number of advice requests

Tab 4 Item 4.3b - NHS Devon Quality Report250 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

Initial Health Assessment (IHA) is a mandatory health evaluation for children entering care of a local

authority (LA). It will identify any physical, emotional and developmental needs, creating a health care

plan to ensure appropriate medical, dental and mental health care is received. It must be completed and

returned to the LA within 20 working days of the child or young person entering care.

Review Health Assessment (RHA) is a mandatory health review/check-up for children in care and

provides an evaluation of a child or young person's physical, emotional and mental health. It must be

carried out every 6 months for children under 5 years and every 12 months for 5 years+.

Relevant groups/

committees

Torbay Council Corporate Parenting Board

Devon County Council Corporate Parenting Board

Plymouth City Council Corporate Parenting Board

Current performance

What the data shows

The data shows some variation across the One Devon

footprint in timeliness of assessments.

Improvements have been seen in some areas but remains

variable.

Exception reporting shows that the majority of late

assessments are due to delay in paperwork being sent to

health services. This is being reviewed on an individual basis

with an aim to see further reduction in delays.

Other reasons include CYP requesting a delay due to other

commitments (school play/exams)

Risks and mitigation

A Business Case regarding addressing Children in Care Nursing

Capacity and specifically Care Leavers Nursing capacity for 18-25

is in process - unapproved as yet.

Designated and Named Doctor vacancy. Recruitment underway

for Named Doctor in RDUH. Designated Doctor remains vacant.

Next Steps &

Escalation

Children in Care Health Assessment Escalation Standard Operating Procedure in draft form to be reviewed in partnership and signed off via governance routes.

Improvement Action Plan presented at Improvement Boards to inform partnership working and strategic joint commissioning.

Designated Nurse and Senior Analyst to design visual representation of CIC data on CYP dashboard and to corporate reports.

October 2025Exec Lead CNO

Children & Young People: Initial & Review Health Assessment for

Children in Care (CIC)

Core NHS Metric:

➢Initial Health

Assessment to

completed and

returned within

statutory time

frame of 20

working days of

child entering

care

➢Review Health

Assessment to

be completed

within statutory

time frame of 6

months (under

5s) and 12

months (over 5s)

Tab 4 Item 4.3b - NHS Devon Quality Report251 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Children and Young People: Special Educational Needs and

Disabilities (SEND)

Oversight and Governance

▪In March 2025, the Torbay SEND inspection found widespread and systemic failings in SEND provision, with

urgent improvements required. Area SEND inspection of Torbay Local Area Partnership

▪A Priority Impact Plan (PIP) has been developed with responsibilities set out for Torbay Council and NHS Devon.

The plan has been co-produced through engagement events as well as online and in-person meetings across the

partnership. These have been organised in line with the five priority areas with broad representation from local

authority, health, social care, parent carer and education colleagues.

▪A paper providing the outcome of inspection, action to date and the PIP have been presented to Board and the ICB

Executive Committee for assurance

▪Two strategic commissioning intensions have been developed to address NHS priority actions:



Children and young people, redesign and recovery of pathways under regulatory action (this can be seen on

the following slide).

▪

area over the last 12 months, with a Contract Performance Notice issued to Children and Family Health Devon

(CFHD) in January 2025.

▪There are early signs of improvement, for example implementation of the Speech and Language Easy Access Drop



reduced by 57%.

▪Preparation is underway for inspection in Plymouth City Council and Devon County Council.

▪For Plymouth, the partnership work and governance is strong and there is good emergent evidence that this is

positively impacting on children and family experiences.

▪For DCC they are currently undergoing a significant staff restructure which is impacting on pace of change and

cohesion of the partnership. To mitigate this Chief Nurse and Director level oversight remains strong.

Tab 4 Item 4.3b - NHS Devon Quality Report252 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

Partnership delivery of jointly commissioned services and statutory duties for children and

young people (0-25).

Core NHS Metrics:

-Timely access to needs led support and assessment measured by waiting times for

Autism, Community Paediatrics, Speech, Language Communication Needs and Children

Adolescent Mental Health Services/Mental Health School Teams - 18 weeks RTT

-NHS contributions to statutory Education, Health and Care Needs Assessment (EHCNA)

(RSA's) within 6 weeks 95%

Relevant groups/

committees

Devon Devon SEND Strategic Partnership Board

Torbay Torbay SEND Local Area Improvement Board

(SLAIP)

Plymouth Local Area SEND Partnership

Improvement Board

Current performance

What the data shows

The BI Data dashboard has been progressed and is

currently being tested.

Support for those waiting is a priority, including:

- Focused autism waiting list recovery work

- Implementation of Integrated Neurodevelopmental

Assessment pathway (INAP) November 2025

Slight reduction in EHCP timeliness for some providers due

to workforce and increased demand.

Risks and mitigation

ICB Corporate Risk - COR0024 - CYP current contracting





Extreme = 15

Mitigations –increase in early help and support model.

Additional funding to diagnostic pathways

Rapid action plan being initiated with CEO sponsorship

Next Steps & Escalation

Torbay Priority Impact Plan has been co-produced following March 2025 Local Area SEND Inspection Submitted to DfE/NHSE, awaiting review and sign-off.

Devon Accelerated Progress Plan in place. Monitoring visit with Department of Education (DfE) and NHSE 16th Sept 2025 (Due re-inspection Autmn 2025)

Plymouth SEND Strategic Improvement Plan in place. Monitoring visit with Department of Education and NHSE planned for Sept 2025 (Due re-inspection Autmn

2025)

Education Health and Care Plan (EHCP) Standard Operating Procedures (SOPS) implementation plan continues. Development of test of change process for EHCP

sign-off by Designated Clinical Officer/Designated Medical Officer to be initiated in October 2025.

Work with BI team to test dashboard and expand to include full data set in line with ICB and local area improvement requirements.

Progression of actions following partnership Neurodevelopmental Workshop and required implementation of INAP. Including mapping of all support offers for

families awaiting a neurodiversity assessment and alignment of clinical systems to facilitate record keeping, data reporting and monitoring.

Speech and Language link therapy model to be rolled out across mainstream schools in Torbay.

October 2025Exec Lead CNO

Children & Young People: Special Educational Needs and

Disabilities (SEND)







































     

Tab 4 Item 4.3b - NHS Devon Quality Report253 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Redesign and Recovery: Children and Young People (CYP)

Acute

▪-

specialties (where paediatric care is within adult services). These span across both admitted and non-admitted pathways.

▪A priority review of acute waiting lists has been undertaken and been presented to the CYP System Planning Group.

▪Children’s surgery is a system priority for the 2026/27 commissioning intentions and will be managed in line with the new

Health and Care Strategy.

This is in the discovery phase - meetings are being held with provider surgical Operational Leads to understand their

waiting list position and areas of concern, to discuss any strategies that are in place to tackle long waits and identify

where further system support is required to accelerate recovery.



▪Non-surgical outpatients: The above approach will be taken with Operational Leads to discuss the same issues that present for

children in non-admitted/outpatient pathways.

▪While CYP represent a smaller proportion of the overall waiting list, they often present with greater clinical complexity and

span a broader range of specialties and transitional age groups. This complexity demands a quality-focused approach to

prioritisation and visibility.

▪Prioritisation for CYP is more complex and based on adult orientated guidance that only considers mortality and time waited,

but prioritisation tool has been

developed and presented to providers in Devon and Cornwall to adopt in their specialties. This is being sponsored by the

Getting It Right First Time (GIRFT) programme.

▪To quantify operational pressures and the impact these may have on elective activity, agreed system-wide CYP metrics are to

be included on SHREWD (Single Health Resilience Warning Database).

▪Across the South West ICB region Devon is showing an improved position for CYP vs adult recovery. Learning to be taken from

Dorset or Gloucester, who have CYP recovery significantly higher than adults.

▪

manage activity effectively. This is being taken forward through the Systems Planning Group.

Background

Tab 4 Item 4.3b - NHS Devon Quality Report254 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

Recovery targets align with the NHSE Operating Plan Priorities for

2025/2026.

Improve the percentage of patients waiting no longer than 18 weeks

for treatment by March 2026, with every trust expected to deliver a

minimum 5% point improvement.*

Improve the percentage of patients waiting no longer than 18 weeks

for a first appointment by March 2026, with every trust expected to

deliver a minimum 5% point improvement.*

*Against the November 2024 baseline, all providers required to

increase their RTT performance to a minimum of 60% and

performance on wait for first appointment to a minimum of 67%

Reduce the proportion of people waiting over 52 weeks for treatment

to less than 1% of the total waiting list by March 2026.

Relevant

groups/

committee

CYP Joint Forward Plan (JFP) Delivery Board

Surgery in Children Operational Delivery Network (ODN)

Devon Elective System Delivery Group (NHSE led) - CYP inclusion being established

What the data shows

Data indicates there is currently: 13,614 CYP (0-18 years) waiting - compared to - Adults (19+

years): 157,733 waiting.

As of June 2025, national data indicates a slight improvement in elective recovery for CYP

across all specialties in Devon: CYP vs Adult +1.81%.

Provider position:

UHP remains below the 2019 baseline level for CYP recovery (-13.45%).

TSD is 33.33% above the baseline for CYP, with adult recovery at 23.18% above baseline.

RDUH is 56.21% above baseline for CYP, with adult recovery at 36.06% above baseline.

Currently within admitted and non-admitted pathways, there is a total of 2.95% CYP and adults

waiting 52 weeks + : requirement to reduce to less than 1%.

Current performance

Risks and mitigation

Corporate risk: COR0025 - Children & Young People Waits to Access Acute and Community

Health Services

Programme risks to note:

Pace of recovery: The elective recovery for children and young people is progressing more

slowly than for adults, posing a risk of prolonged waits and delayed care. This is a national

issue, not limited to Devon.

Fragmented Pathways: CYP are waiting across both adult and child-specific pathways,

increasing the risk of inconsistent care and reduced visibility of paediatric needs.

Complexity: CYP are experiencing delays in both surgical and non-surgical, admitted and non-

admitted pathways.

Workforce Constraints: The same paediatric workforce is responsible for both urgent and

elective care, which can lead to reduced capacity for planned procedures and increased

pressure on staff.

Developmental Impact of Long Waits: Extended waits for elective care can negatively affect

-term health consequences, increasing future

demand on services.

Inadequate Prioritisation Frameworks: Prioritisation is adult-focused, primarily considering

mortality and time waited. It does not account for paediatric-specific risks such as

developmental harm or long-term outcomes, disadvantaging CYP.

Next Steps &

Escalation

Review of specialised and non-specialised commissioned surgical work is being undertaken to support children and young people accessing surgery in the most appropriate setting

closest to home reducing travel to Bristol unless necessary; meetings being held with surgical Op Leads to understand waiting list position and understand mutual aid opportunities.

Non-admitted pathways; meetings to be held with paediatric Operational Leads to clarify: waiting list position, discuss barriers and issues to delivery of appointments, what ICB

facilitation is required and to confirm age waiting cohort to support accurate reporting.

The local prioritisation tool, developed by the Clinical Lead in Plymouth to identify risk and harm, continues to be socialised whilst a national version is currently in development. The

local initiative has received support from the NHSE Children and Young People (CYP) Transformation Team.

October 2025Exec Lead CNOChildren & Young People: Redesign and Recovery: CYP Acute

Tab 4 Item 4.3b - NHS Devon Quality Report255 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Redesign and Recovery: Children and Young People’s Community

Context: 

tion through the

Special Educational Needs and Disabilities (SEND) inspection framework.

 pathways,

the commissioning arrangements are not cohesive and mean that the pathway is being delivered across multiple organisations. This

builds in inefficiency and clinical variation. There are also performance issues within the current Children and Family Health Devon

(CFHD) contract.

A Strategic Commissioning Intention: Children and young people, redesign and recovery of pathways has been developed.

Neurodiversity, Speech, Language and Communication Needs (SLCN), and CYP mental health are the key pathways in focus for this

commissioning intention. Following the discover, design and delivery methodology, and with CEO oversight, rapid action is being taken.

This includes redesign of clinical pathways and identification of funding that can be repurposed to increase the pace of improvement.

Options for how to commission the redesigned clinical model will be presented to ICB Executive Committee (ExCo) in October.

Neurodiversity (inc. ADHD and Autism):

System level workshop was held on 3rd September to agree the delivery model building on previous discovery and design work

including:

▪Integrated Neurodiversity Assessment Pathway: Geographically phased.

▪Needs-led support offer - progressed in the Torbay Local Area in the first instance, and then the Devon County Council footprint.

▪CYP Neurodiversity Strategy: signed off by the Devon, Torbay and Plymouth SEND Boards. Development of Torbay and

Plymouth aligned implementation plans are in progress in each Local Area.

▪Wait List Performance Data / trajectories: Work complete to collate wait list performance data and trajectories from all providers.

Ongoing work to automate this process for a recurrent data dashboard. Led by the ICB Director of Business Intelligence.

▪Wait list Recovery Project: The 24/25 project plan has concluded, and the locality groups are supporting ongoing implementation

of MDT Assessment sessions. The spend of non-recurrent investment in 25/26 is being overseen by the SRO group (ICB and health

providers) and is aligned to the outputs of the neurodiversity workshop in September.

▪Transformation Projects: Partnership for INclusion of Neurodiversity in Schools (PINS) 25/26 - Potential offers for the Menu of

Support being collated. Provider for prerecorded material confirmed.

Speech, Language and Communication Needs (SLCN)

▪Despite additional resources for SLCN in Plymouth, the Livewell Southwest (LSW) recovery trajectories have not been met. This is

due to continued and sustained increase in demand for SLCN and for statutory EHCP assessments. LSW continue to adjust

recovery trajectories and realign workforce to mitigate risk.

▪Implementation of a new SLCN model across Devon and Torbay: Based on the Balanced System approach, CFHD have an

implementation plan to be delivered between now and January 2026. This is already having a positive impact on children waiting,

particularly for under 4 age group.

Background

Tab 4 Item 4.3b - NHS Devon Quality Report256 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

In line with the recovery targets within the NHSE Operating Plan Priorities for 2025/2026

Improve the percentage of patients waiting no longer than 18 weeks for first appointment by March

2026

Reduce the proportion of people waiting over 52 weeks by March 2026.

The trajectories will be provider dependent and are being negotiated.

Relevant groups/

committees

Devon:

Improvement Partnership Board

Devon SEND Strategic Partnership Board

Torbay:

 

Torbay SEND Local Area Improvement Board (SLAIP)

Plymouth:

Plymouth Children's Services Improvement Board

Local Area SEND Partnership Improvement Board

ICB:

Neurodiversity and SLCN SRO group

CYP Joint Forward Plan (JFP) Delivery Board

Current performance

Autism: Data as of August 2025, providing referrals and waiting lists status across all providers of the

service.

Autism Waiting Times Profiles per provider data can be found on the following slide, along with

Speech, Language and Communication Needs (SLCN) data.

What the data shows

Caveats on data: TSDFT Data was not neuro specific. Definitions

between referrals and accepted clarity also required (teams aren't

reporting active caseload).

One Devon position:

There has been steady growth in referrals over the past year,

which is forecast to continue into the second half of 2025/26,

an increase from around 650 referrals per month to 750 per

month by March 2026

Referral growth is highest at CFHD, RDUH and TSD

The waiting list and caseload have increased to around 8,300

and are forecast to continue to rise to around 9,000 by March

2026

CFHD, Livewell and TSD have seen around 10% growth,

although there have been reductions at RDUH and UHP

Long waits have continued to grow and are predicted to

increase in line with referral and waiting list/caseload sizes

Over 52 week waits would increase from around 4,500 to

5,500 by March 2026 and 18-week performance would remain

low at 18%

Further information on the following slide for individual providers.

Risks and mitigation

Corporate risk: COR0025 - Children & Young People Waits to

Access Acute and Community Health Services

Risk:

Demand for neurodiversity diagnostic assessments continues to

exceed capacity and wait list continue to grow which will impact

delivery of planned performance trajectories.

Mitigation:

Ongoing optimisation across providers, increased capacity as far

as possible within the resource available.

Steps &

Escalatio

Next steps:

INAP implementation for the Torbay and Devon area planned for 1st November; workforce and IT system solutions being worked through with providers.

Development of needs led support in Torbay and Devon to reduce the demand for referral for assessments.

Provider led plans to recover waiting lists internally, using existing resource and non-recurrent investment in 25/26.

October 2025Exec Lead CNO

Children & Young People: Redesign and Recovery: CYP Community

Neurodiversity (Autism)

Organisation No. of Referrals No. Removed from

the Waiting List

(closed pathways) No. Still Waiting

May June May June May June

UHP 40 42 68 52 435 450

CFHD 138 208 146 160 6,775 6,879

RDUH 35 39 29* 31* 54 40

TSD 49 96 47* 83* 323 282

LSW 19 22 16 16 143 140

Total 281 407 277 311 7,730 7,791

Tab 4 Item 4.3b - NHS Devon Quality Report257 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Redesign and Recovery: Children and Young People’s Community

Autism Waiting Times Profiles per provider: long waits & 18 week %

CFHD (over 5):

Circa 100 per month imbalance between closed pathways

and referrals leading to a continued trend of increasing

waiting list and long waits

Needs additional 100 closed pathways per month as a

minimum to keep waiting lists flat, additional 200 per month

to begin to reduce waits

CFHD (under 5):

20 extra closed pathways per month than referrals resulting

in a gradual waiting list and long wait reduction but static 18

week performance

Needs additional activity to speed up waiting list reductions

and improved waits

TSD:

Around 25 less closed pathways per month than referrals

results in a long wait increase and falling 18 week

performance

Note: likely data quality with either referrals or stops as the

waiting list has fallen when referrals have been greater than

stops

RDUH (autism):

The waiting list is falling sharply for Autism but 18-week

waits have risen and performance fallen (based on very

small numbers, e.g. there were 17 over 18 week waits in

May 2025)

LSW:

3 less closed pathways per month than referrals results in a

gradual waiting list and long wait increase which reduces 18

week performance

Needs additional activity to speed up waiting list reductions

and improved waits

UHP:

Between 25 - 30 more closed pathways per month than

referrals results in a gradual waiting list and long wait

reduction, increasing 18 week performance.

Tab 4 Item 4.3b - NHS Devon Quality Report258 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

In line with the recovery targets within the NHSE Operating Plan Priorities for 2025/2026

Improve the percentage of patients waiting no longer than 18 weeks for first appointment by March

2026

Reduce the proportion of people waiting over 52 weeks by March 2026.

Livewell Southwest (LSW) trajectory has been agreed; CFHD is currently being negotiated.

Relevant groups/

committees

Devon:

Improvement Partnership Board

Devon SEND Strategic Partnership Board

Torbay:

 

Torbay SEND Local Area Improvement Board (SLAIP)

Plymouth:

Plymouth Children's Services Improvement Board

Local Area SEND Partnership Improvement Board

ICB:

Neurodiversity and SLCN SRO group

CYP Joint Forward Plan (JFP) Delivery Board

Current performance

Number of referrals; Number of CYP waiting over 18 weeks; Number of CYP waiting over 52 weeks

What the data shows

Caveats on data: Devon position:

Referrals/ Request for help patterns tend to increase at start of

school term and drop off during holiday periods.

Devon and Torbay numbers waiting has consistently

decreased since April 2025. With new model of delivery being

implemented is estimated that <18 weeks will be met by

December 2026. This is based on modelling used by other

areas who have already implemented the Balanced system of

SLCN delivery. Despite this the July 2025 total number of

children waiting in Devon and Torbay (3703) is significantly

higher than in July 24 (3582). Currently there are 429 >104

Weeks.

Is Plymouth waits continue on an upward trend, although no

one over 78 weeks and the numbers over 52 weeks waiting is

stabilising.

Risks and mitigation

Corporate risk: COR0025 - Children & Young People Waits to

Access Acute and Community Health Services

Risk:

Demand for SLCN assessments continues to exceed capacity and

wait list continue to grow which will impact delivery of planned

performance trajectories.

Mitigation:

Ongoing optimisation across providers, increased capacity as far

as possible within the resource available.

Next Steps &

Escalation

Next steps:

Torbay: Meeting to take place in September to finalise outcome measures. Agree date to close down referrals and transition to full easy access offer.

Devon: Joint letter to be sent in July from ICB/DCC. Meeting to take place in September to agree outcome measures and link to available data to support this.

Plymouth: Await service mapping findings to be shared at SSLB, this was delayed until September/October. Paper to presented at October Plymouth SEND Board.

Strategy Development: SLCN strategy now developed with involvement of partners and was shared with ND/SLCN System Improvement Group and signed off on 8th September

2025.

October 2025Exec Lead CNO

Children & Young People: Redesign and Recovery: CYP Community

Speech Language and Communication Needs (SLCN)

Organisation April May June July August

Number of referrals

(Devon)

CFHD 184 200 201 246 77

Number of referrals

(Torbay)

CFHD 16 35 35 25 11

Number of referrals

LSW 114 107 130 96

Number of CYP

waiting over 18

weeks (Devon)

CFHD 2610 2655 2703 2602 2487

Number of CYP

waiting over 18

weeks (Torbay)

CFHD 376 387 366 320 267

Number of CYP

waiting over 18

weeks

LSW 423 422 423 434

Number of CYP

waiting over 52

weeks (Devon)

CFHD 1717 1777 1803 1708 1593

Number of CYP

waiting over 52

weeks (Torbay)

CFHD 222 236 228 200 171

Number of CYP

waiting over 52

weeks

LSW 55 52 52 44

Tab 4 Item 4.3b - NHS Devon Quality Report259 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Redesign and Recovery: Children and Young People’s Community

Speech, Language and Communication Needs (SLCN) waiting position and weeks waiting

Livewell Children waiting in

Plymouth continues to grow

although there are no over 78

weeks. July 2025 total number

of children (709) is higher than

in July 24 (669). Plymouth

trajectory to meet <18 weeks by

March 2026.

CFHD Children waiting

in Devon and Torbay is

decreasing overall with

the highest improvement

in the 0-to-5-year age

range.

Tab 4 Item 4.3b - NHS Devon Quality Report260 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Redesign and Recovery: CYP Mental Health & Emotional Wellbeing

Emotional Health and Wellbeing (EHWB) service

The Young Devon Partnership is the provider of the newly commissioned emotional health and wellbeing (EHWB) service, which

targets support earlier in a young person's journey, using the iTHRIVE framework, to try to prevent mental ill health. The service

went live on 1st July 2025 and will support 5,000 young people 11-17 years old. It is also providing a tailored intervention for

Young People with SEND and/or Children in Care (CIC) between the ages of 8-25.

The partnership is developed from local organisations Young Devon, Space, Encompass and the Plymouth City Council Youth

Service.

There are four offers within the model

1. Community-based advice & guidance a Youth Work Wellbeing offer.

2. Community-based help therapeutic interventions.

3. Digitally-based advice & guidance online resources and self-help.

4. Digitally-based therapeutic interventions.

The service is working with Young people to co-design the name and branding of resources of this new service. They are also

jointly working with both young people and partners to develop a new digital platform for booking. The service is holding a lunch

event on Thursday 25th September where young people will reveal the name.

The service is self-referral and there will be system-wide comms for parents/carers, families, and partners within the CYP system

following the launch event.

Mental Health Support Teams (MHSTs)

NHS Devon are continuing with the rollout of MHST and have committed to a further two teams in the wave 13 cohort to be placed in

East Devon and Plymouth to begin training in September and January respectively. Within the NHS Devon footprint there are14 fully

mobilised teams, seeing approximately 90,000 CYP (to raise to 105,00 when 16 teams) across 221 Education settings.

The MHST work with Education is critical to the SEND offer, to tailor their offers to the presenting needs of the pupils, with support from

young people who have taken on the role in their school as Mental Health Ambassadors. Throughout the summer MHST worked with

local partners within the community such as the Young Devon Partnership to deliver a robust offer of support within community settings,

aligning resources and information.

The MHSTs are well valued within the system, with good feedback from partners, education settings and CYP and their families. This

can be seen within the graph in the next slide, where teams within NHS Devon are seeing more CYP than other support teams in other

ICBs.

Background

Tab 4 Item 4.3b - NHS Devon Quality Report261 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

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Metric

Mental Health Support Teams (MHST)

Each MHST is expected to provide sufficient capacity to deliver services to a population of c.7000 to

8000 pupils, or between 10 and 20 education settings.

 

children and young people aged 0-25 will be able to access NHS-funded mental health services by

2023/24

Relevant groups/

committees

Devon:

Improvement Partnership Board

Devon SEND Strategic Partnership Board

Torbay:

 

Torbay SEND Local Area Improvement Board (SLAIP)

Plymouth:

Plymouth Children's Services Improvement Board

Local Area SEND Partnership Improvement Board

ICB:

CYP Joint Forward Plan (JFP) Delivery Board

CYP Emotional Wellbeing & Mental Health Group

Mental Health Support Team Steering Group

Current performance

What the data

shows

-Local and national access metrics continue to show achievement

of the access standard across One Devon.

-The Emotional Wellbeing & Mental Health Service mobilised on

01/07/25 and will be holding the launch and naming of the new

service on 25/09/25

-The In Reach Discharge Service continues to move forward

through the competitive procurement process

Risks and mitigation

MHST

Risk: There is a risk that ,if funding for MHST remains on a

year-on-year allocation, that recruitment and rollout of

teams will be impacted.

Mitigation: A 4-year rollout plan for MHST to reach 100%

coverage detailing timeframe and locations for mobilisation

of teams in the remaining areas with agreed funding.

Next Steps &

Escalation

Mental Health Support Teams in Schools:

Continuation of management and progression of MHST programme, including MHST expansion project. Collation of data for MHST audit submission. Growth in the access target is

expected to continue as NHS Devon 1) Mobilises the WHWB service 2) Supports the rollout of 2 wave 13 MHST

Awaiting notification from NHSE of when updated Eating Disorder guidance is published

October 2025Exec Lead CNO

Children & Young People: CYP Mental Health & Emotional

Wellbeing (MHWB)

Tab 4 Item 4.3b - NHS Devon Quality Report262 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Redesign and Recovery: CYP Mental Health & Emotional Wellbeing

Access Target (national)

Performance has shown consistent growth over the past two years, with recent months seeing accelerated increases. If

this trajectory continues, the rolling 12-month figure is expected to remain well above target. Growth in the access

target is expected to continue as the emotional wellbeing and mental health service is mobilised and when the two

wave 13 teams begin training.

Length of wait for CYP for CAMHS

2025/26 work plan identifies a need to reduce long waits. Progress is continuing, and there are now 6 children waiting

more than a year for Children and Young Peoples Mental Health Services, a reduction from 11 children at the end of

Q1. The number of referrals seen within 18 weeks is at 76% in August, this has seen an improved trajectory since the

end of Q1. The number of referrals still waiting over 18 weeks remains at 630; 27% of the 2113 CYP still waiting. In Q1

this figure was rising but improvements have been made, and a downward trend can be seen since July.

Children and Young Peoples Eating Disorder Target (National)

Urgent referrals are above target with CYP being seen after the 1 week timeframe.

Routine referrals have reduced in and are currently not meeting the target. NHS Devon are working in partnership with

the South West Provider Collaborative and the South West Paediatric Mental Health Champions Network, to develop a

more consistent approach to supporting CYP with Eating Disorder Needs in Acute Paediatric Settings.

Devon Children & Young People’s Emotional Wellbeing & Mental Health Strategy

This has been supported by system partners and has progressed through the SEND boards. Implementation plans are

now being developed within each of the three local authority areas via the Torbay Emotional Wellbeing and Mental

Health Group, the Plymouth Emotional Wellbeing and Mental Health & Neurodiversity strategy implementation plan

working group and the Devon Healthy Me Group.

Background

Tab 4 Item 4.3b - NHS Devon Quality Report263 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

Access Target (national) The number of CYP aged under 18 with at least one contact in a 12-month rolling

period receiving NHS-funded support

18ww

Length of wait for CAMHS

Eating Disorders

The Access and Waiting Time Standard for Children and Young People with Eating

Disorders states that National Institute for Health and Care Excellence (NICE)-concordant

treatment should start within a maximum of 4 weeks from first contact with a designated

healthcare professional for routine cases and within 1 week for urgent cases

Relevant groups/

committees

Devon:

Improvement Partnership Board

Devon SEND Strategic Partnership Board

Torbay:

 

Torbay SEND Local Area Improvement Board (SLAIP)

Plymouth:

Plymouth Children's Services Improvement Board

Local Area SEND Partnership Improvement Board

ICB:

Neurodiversity and SLCN SRO group

CYP Joint Forward Plan (JFP) Delivery Board

Mental Health Support Team Steering Group

Current performance

Access

Eating Disorders

What the data shows

Access Target

Performance has shown consistent growth over the past

two years, with recent months seeing accelerated

increases. If this trajectory continues, the rolling 12-month

figure is expected to remain well above target.

Eating Disorders

Routine referrals seen within four weeks

Performance has declined in recent months following a

period of sustained improvement through mid-2024 to

early 2025 and is now at its lowest level in over a year.

Immediate action may be required to reverse the

downward trend.

Urgent referrals seen within one week

In June 2025, 100% of children and young people with an

eating disorder (urgent cases) were seen within one week,

exceeding the 95% target. This follows a dip in early 2025,

with performance now fully recovered to the previous high

levels maintained throughout 2024.

Risks and mitigation

If children with eating disorder do not access support

within 4 weeks for a routine appointment, their health may

deteriorate resulting in a greater level of service

dependency and intervention. This is being mitigated by

action to address recruitment and offer of advice and

information resources.

Next Steps &

Escalation

Growth in the access target is expected to continue as NHS Devon 1) Mobilises the WHWB service 2) Supports the rollout of 2 wave 13 MHST

Awaiting notification from NHSE of when updated Eating Disorder guidance is published

October 2025Exec Lead CNO

Children & Young People: CYP Mental Health & Emotional

Wellbeing

Tab 4 Item 4.3b - NHS Devon Quality Report264 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

MRSA is an indicator healthcare associated infection (HCAI).

National target for MRSA for Devon is 0 cases for 2025/26.

MRSA differs from other monitored infections, as there is a national

expectation of zero cases.

https://model.nhs.uk/home

Relevant groups/

committees

Devon Health Protection Committee

Quality Assurance Meeting

Health Protection Delivery Meeting

Executive Committee

Current performance

What the data shows

There were a total of 9 cases of MRSA bloodstream infection

between April 2025 and end August 2025, below 2023/24

figures from the same period (13).

Trend data must be taken in the context of small numbers.

Investigations into all healthcare-onset cases have been

undertaken, and learning applied (example: screening criteria,

timely commencement of suppression therapy).

An intervention has taken place into reducing transmission

rates in people who inject drugs by improving the primary care

environment, and a further recent outbreak demonstrates the

high levels seen in this population. A deep dive into all cases

may be undertaken, however learning from other systems is

that this is a time-intensive process.

Risks and

mitigation

No specific risks on register.

Next Steps &

Escalation

Deep dive into Devon MRSA cases to determine themes and best reduction approach.

October 2025

Exec Lead CNO

Infection Management:

Methicillin Resistant Staphylococcus Aureus (MRSA)

Tab 4 Item 4.3b - NHS Devon Quality Report265 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

Methicillin-sensitive Staphylococcus aureus (MSSA) bloodstream infections

are a key indicator of healthcare-associated infections (HCAIs).

National target: None set for MSSA

 

AprilAugust 2025: 150 cases

 

https://model.nhs.uk/home

Relevant groups/

committees

Devon Health Protection Committee

Quality Assurance Meeting

Health Protection Delivery Meeting

Executive Committee

Current performance

What the data shows

There have been a total of 150 cases of MSSA blood stream

infections (BSI) in Devon from 1st April 2025 to end August

2025, below 2023/24 figures from the same period (157).

Trend data shows a slight long-term increasing trend, driven by

both hospital onset and community onset cases.

There is local work ongoing in each Trust on MSSA reduction,

and it is included in Trust annual plans, with specific focus on

indwelling devices. This work has been effective in reducing this

category of causes; however, overall MSSA continues to

increase.

The Devon system has applied for funding from NHS England

for a system antimicrobial position, focusing on MSSA

reduction. The outcome of this application is not yet known.

Risks and

mitigation

No specific risks on register.

Next Steps &

Escalation

Securing of regional funding for a system antimicrobial coordinator, principally to focus on MSSA reduction.

October 2025

Exec Lead CNO

Infection Management: Methicillin Sensitive Staphylococcus Aureus

(MSSA)

MSSA trends in Devon, 2021- August 2025 (SPC chart)

Tab 4 Item 4.3b - NHS Devon Quality Report266 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

E. coli bloodstream infections are a key indicator of healthcare-associated infections

(HCAIs).

 

Trajectory for AprilAugust 2025: 391 cases

Actual cases recorded: 503 cases



(450 cases for the same period in 2023/24).

https://model.nhs.uk/home

NHS Standard Contract 2025/26: Minimising Clostridioides difficile and Gram-

negative bloodstream infections

Relevant groups/

committees

Devon Health Protection Committee

Quality Assurance Meeting

Health Protection Delivery Meeting

Executive Committee

Current performance

What the data shows

What the Data Shows

April–August 2025: 503 cases of E. coli bloodstream infection

 

 

Trend: Sustained above-mean run from March to August 2025

Possible contributing factor: hot summer weather

leading to increased dehydration

Similar trends observed in other regional Trusts

Response Measures

Case investigations: All cases reviewed, with deep dives

conducted per PSIRF model

Local interventions:

Hydration improvement initiatives

Catheter care enhancement

Optimised prescribing for urinary tract infections

Risks and

mitigation

Risk Register: No specific risks currently recorded

Mitigation Actions:

Continued implementation of localised infection control

measures

Monitoring of environmental and seasonal factors

Sharing of learning across regional Trusts to identify common

drivers and effective interventions

Next Steps &

Escalation

Develop and implement Devon-wide strategies for E. coli reduction

Strengthen collaboration across Acute and Community providers

Enhance data analysis to identify patterns and target high-risk areas

Escalation

If elevated case numbers persist, escalation to the Executive Committee may be required to support strategic planning and resource mobilisation

October 2025

Exec Lead CNO

Infection Management: E. coli

E. coil trends in Devon, 2021- August 2025 (SPC chart)

Tab 4 Item 4.3b - NHS Devon Quality Report267 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

lives

Metric

Clostridioides difficile (C. difficile) is a key indicator of healthcare-associated

infection (HCAI).

 

Trajectory for AprilAugust 2025: 161 cases

Actual cases recorded: 196 cases

This places Devon above the national trajectory, despite being lower than the

same period in 2023/24 (242 cases).https://model.nhs.uk/home

C. diff technical report NHS Standard Contract 2025/26:

Relevant groups/

committees

Devon Health Protection Committee

Quality Assurance Meeting

Health Protection Delivery Meeting

Executive Committee

Current performance

What the data shows

There were a total of 196 cases of C. difficile infection between

April 2025 and end August 2025, below 2023/24 figures from

the same period (242).

This is above nationally-set trajectory (161).

There was been a national, regional and local rise in C. difficile

from January 2024 to December 2024. No cause has been

identified, and changes to case recording have been

implemented to help identify the underlying causes. Cases

have returned to fluctuation around baseline levels, although

some Trusts have reported higher numbers over the summer.

Investigations into all hospital-associated cases have been

undertaken, with deep dives as appropriate (per Patient Safety

Incident Response Framework model).

All community associated cases are reviewed by the individual

localities, with follow up where learning is identified.

Risks and

mitigation

Risk Register: No specific risks currently recorded

Next Steps &

Escalation

ICB to improve visibility of community onset cases, and continue to monitor Trust reduction plans and overall numbers.

ICB to engage with regional C. difficile collaborative led by Elizabeth Beech.

ICB-led Acute Trust collaboration and sharing.

An exploratory survey of C. difficile for primary care has been circulated, however has had minimal response. Alternate strategies to encourage response

have been implemented (targeted highlighting to practices with a recent case, sending the survey through different routes).

October 2025Exec Lead CNOInfection Management: C. difficile

Tab 4 Item 4.3b - NHS Devon Quality Report268 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

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Metric

Historically, Devon lacked a community swabbing pathway for asymptomatic or

mildly symptomatic contacts during outbreaks of avian flu and other high-

consequence infectious diseases. This gap was significant during recent incidents

and has now prompted targeted commissioning activity to establish appropriate

response mechanisms.

An additional gap (antiviral prophylaxis out of hours) has been identified and

resolved.

Relevant groups/

committees

Devon Health Protection Committee

Quality Assurance Meeting

Health Protection Delivery Meeting

Executive Committee

Current performance

Since April 2025, there have been six avian flu outbreaks in the bird population, with

five confirmed incidents of human exposure to avian flu in Devon.

These highlighted a gap in out-of-hours antiviral prescribing, which has now been

resolved through commissioning with PPG, the current out-of-hours provider.

Community swabbing services have been commissioned in:

Torbay & South Devon (via Torbay Acute Trusts)

Plymouth & West Devon (via Livewell Southwest)

These services offer risk-assessed swabbing within 48 hours for eligible

individuals.

A similar service has been agreed for Northern & Eastern Devon but is not yet

operational.

What the data

shows

Human exposure incidents: 5 (AprilSeptember 2025)

Avian outbreaks (bird population): 6

Commissioned swabbing coverage: 2 of 3 localities (Eastern

locality pending)

Antiviral prescribing gap: Closed as of Q3 2025

Risks and mitigation

Identified Risks

Commissioning Gap in Eastern Locality: A risk is currently

recorded on the risk register due to the absence of a

commissioned community swabbing service in the Eastern

locality, which includes East and North Devon. This limits the



Mitigation Actions

Antiviral Provision Resolved: Upon identification of the gap,

the Devon ICB team implemented a rapid interim solution,

followed by the commissioning of a long-term service through

the existing out-of-hours provider (PPG). This swift action

closed a potentially high-impact gap in outbreak response

capability.

Next Steps &

Escalation

Continue to explore alternatives for provision of swabbing service in Eastern locality.

Monitor service responsiveness to outbreak situations and evaluate/improve as required.

Monitor readiness of services to respond to HCID, especially the newly commissioned services.

October 2025Exec Lead CNO

Infection Management: Avian flu / high consequence infectious disease

swabbing (HCID)

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Metric

Historically, the Devon CIMS service operated without formal performance metrics

or structured reporting, due to its rapid establishment during the COVID-19

pandemic.

Over the past six months, a governance reassessment (following a formal finance

review) has led to the development of a refreshed intentions document, which now

outlines clear quarterly and annual reporting expectations.

These metrics will begin to be captured and reported from November 2025,

providing a foundation for ongoing service evaluation and accountability.

Relevant groups/

committees

Devon Health Protection Committee

Quality Assurance Meeting

Health Protection Delivery Meeting

Current performance

The service continues to deliver outbreak support and infection control advice

across community settings, including care homes, residential facilities, and

primary care.

Key developments in the last three months include:

Stakeholder engagement in reviewing service scope and governance.

Creation of a refreshed intentions document, detailing reporting expectations

and aligning with ICB oversight.

Preparation for quarterly reporting, to be shared via this quality report and the

Quality Assurance Meeting.

While formal performance data is not yet available, anecdotal feedback from

providers indicates continued high demand and value placed on the service.

What the data shows

Structured data collection is now underway, with the first full

quarterly dataset expected in Q3 2025 (Q2 data). This will include:

Number of outbreaks supported.

Timeliness and effectiveness of infection control advice.

Provider satisfaction and engagement levels.

Resource utilisation and capacity indicators

Narrative on progress against the seven ambitions of the South

West IPC Strategy.

This data will inform future funding reviews and service development.

Risks and mitigation

Risk Register: No active risks currently recorded.

Funding: The service has operated on static funding since

2020. Service leads have raised concerns about capacity

constraints, particularly as demand remains high.

Mitigation: Funding levels will be reviewed once sufficient

performance data is available to assess value and

sustainability.

Governance: Previously limited oversight has now been

addressed through the new reporting framework and ICB

involvement.

Next Steps &

Escalation

Compile and submit the first quarterly report in November 2025.

Continue face-to-face trust visits to maintain provider relationships and gather qualitative feedback.

Monitor and evaluate service delivery against new metrics.

Escalation

Any emerging risks or capacity issues will be escalated via the Quality Assurance Meeting and the Devon Health Protection Committee.

Funding review to be initiated once Q4 data is available, with escalation to ICB if service continuity is at risk

October 2025Exec Lead CNO

Infection Management: Community infection management service

(CIMS)

Tab 4 Item 4.3b - NHS Devon Quality Report270 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Other Infection Management Reporting:

Other Infection Management –Key Updates

Tuberculosis: A new pan-Devon business case is being developed, informed by

Getting It Right First Time (GIRFT) recommendations, to strengthen service capacity.

Equity Through Standardisation: Providers have called for consistent IPC policies

and risk assessments across Devon, especially with wider adoption of the Epic IT

system.

Primary Care Engagement: IPC promotion is being explored via the Devon Training

Hub. Identified training demand presents an opportunity to build capability and

consistency in primary care.

ICB Commissioning: Pathways for High Consequence Infectious Disease swabbing,

assessment, treatment, and prophylaxis have been developed. A testing meeting with

lab and microbiology teams is scheduled to assess outbreak scalability.

October 2025Exec Lead CNOInfection Management: Other Reporting

Tab 4 Item 4.3b - NHS Devon Quality Report271 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

This metric forms part of the new Patient Safety domain for the 2025-26 NHSE Oversight

Framework and supports the delivery of the UK second five-year National Action Plan for

Antimicrobial Resistance.

The measure reports the percentage of children aged 0-9 who have been prescribed at least

one antibiotic in the last 12 month period in primary care. ICB performance is assessed as

MET or NOT MET against a fixed national target of at or below 27%. This benchmark is

based on data from the 12 month up to March 2020

Relevant groups/

committees

This Data is reviewed by the Devon Antimicrobial

Stewardship Group

Current performance

What the data shows

The highlighted bar is Devon ICB benchmarked against all

ICBs in England. Devon ICB fall below the required 27%

and is assessed under the 25/26 Oversight Framework as



We are amongst the lowest prescribers of antimicrobials to

children under 10 in primary care in England with only 4

ICBs lower on this metric all of which are in the South West

The overall monthly trajectory (not shown) of Devon ICB is

downwards and therefore is expected to continue to be



Risks and mitigation

None currently

Next Steps &

Escalation

Whilst as an ICB we are meeting this target there is practice level variation with 23 practices currently above the 27% target.

The Medicines Optimisation Team regularly share data with practices. This data will be updated and shared with practices to encourage a focus on this topic.

There is a regional webinar to support implementing actions in GP practices to reduce antimicrobial prescribing to children where appropriate on 2nd

October 2025. This

will be publicised widely to encourage attendance from primary care in Devon.

October 2025Exec Lead CMO

Antimicrobial Resistance: Percentage of children (aged 0 9)

prescribed antibiotics in the last 12 months

Tab 4 Item 4.3b - NHS Devon Quality Report272 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Vaccination Optimisation (VO)

▪The committee is asked to note the progress on increasing vaccination uptake and plans for the 25/26 winter vaccination campaign.

▪Slides are provided to summarise current vaccination uptake as follows:

VO slide 1 –Lifetime Vaccinations for 0-5-year-olds

VO Slide 2 - Complete Routine Immunisation Schedule

▪The Winter 2025/2026 Flu Campaign commenced on the 1st September 2025 for maternity patients and children, with vaccine being available at most

sites from the second week of September. All other cohorts can be offered flu vaccinations from 1st October to 31st March 2026. FHCW, 2-3- year-

olds and clinically extremely vulnerable (CEV) patients are priority cohorts for flu vaccinations in the 25/26 campaign.

▪Trusts have developed winter staff vaccination plans that include increased education offers, earlier promotion, increased access to on-site

vaccinations and a focused 2-week campaign in November to encourage staff to get their flu vaccination before the end of November.

▪The Vaccination Optimisation team will work with practices who fell below the national average last year for 23-year-olds flu uptake. For the first time,

from the 1st October, community pharmacies will be able to offer flu vaccinations for 23-year-olds. To date, 47 community pharmacies across Devon

have applied to be commissioned to undertake this work and are currently undergoing an NHSE approvals process.

▪The Vaccination Optimisation team will continue to work with practices and the outreach team to maintain covid and flu vaccination offers to

underserved and CEV cohorts through a daily review of uptake data and adapting offers according to where the lowest uptakes are shown to be.

Monitoring of flu uptake will be included in Trust and system management of UEC winter plans.

▪Covid cohorts for this winter mirror spring cohorts, which were limited to 75+, residents in older adult care homes and severely immunosuppressed

patients. For the first time since covid vaccinations were introduced, due to the reduced risk, there is no eligibility for covid vaccinations for 65-74-year-

olds, carers, CEV or FHCW in the 25/26 winter vaccination campaign.

▪Ongoing work includes a funded offer to 55 GP practices to undertake project work to increase vaccination uptake for lower uptake cohorts, such as

ethnic minorities and children in care across the 0-19 age range. Projects are being delivered between 1 July and 30 September and will be evaluated

to evidence value for money in providing nudge funding to increase vaccination uptake.

Vaccination Optimisation updates aim to always report on children's vaccinations and will rotate reports on other vaccination programmes.

Background

Tab 4 Item 4.3b - NHS Devon Quality Report273 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

The table below shows uptake by Local Authority for routine 0-5 year-olds vaccinations which fall under the

Section 7a vaccination programme. The World Health Organisation (WHO) target is for uptake to be at 95%or

above.

Data is updated quarterly and annually through the publication of COVER statistics

Relevant

groups/

committees

NHSE is responsible for commissioning Section 7a vaccination programmes.

Current proposals are that vaccination commissioning will be the responsibility

of ICBs from April 2027 (previously proposed for April 2026). The ICB has a

Vaccination Oversight Board, with system membership, which oversees

strategy and delivery of vaccination programmes.

Current performance

COVER statistics record uptake % data per childhood vaccines quarterly and annually per reporting year, at Local Authority, ICB, Region and National level. The table above shows the latest annual report data for

2024-2025, published on the 28th August 2025. Entries marked green are hitting the 95% WHO target, whereas those in orange sit between 90-94.99%. Red entries fall below 90% and are a cause for concern. The

table also visualises trend data per vaccine entry, comparative to the 2023-2024 reporting year.

This data has been published by NHSE and UKSHA and can be shared beyond this forum.

What the data shows

Comparative to 2023-2024, both NHS Devon ICB and the SW Region has seen an increase in uptake across

every vaccination delivered to 0-5s. Additionally, uptake across each vaccine within NHS Devon for 2024-2025

is higher than the Regional and National figures.

The 4-in-1 uptake in the pre-school cohort has the lowest uptake across each Local Authority. MMR-2 is the 2nd

lowest.

Since the last publication of annual COVER data we can see the following significant changes:

Devon LA saw primary 6 in 1and Meningitis B uptake rise from 94.90%and 94.87%to 95.10% and

95.18%, surpassing the WHO target. Devon LA pre-school uptake of HibMenC rose from 93.40%to

95.00%, meeting the WHO target.

Plymouth LA primary uptake of MenB rose from 94.90%to 95.40%, whilst booster uptake of HibMenC and

MMR 1 increased from 93.30%and 93.50%to 95.00% and 95.10%, meeting and surpassing the WHO

target.

Torbay LA uptake for the primary PCV vaccine rose from 94.80%to 95.20%, surpassing the WHO target.

Meningitis B booster progressed from a red to amber rating, increasing from 89.75%to 90.63%. Uptake

for the pre-school MMR1 vaccination increased from 94.30%to 95.50%, surpassing the WHO target.

There were no significant declines in uptake in any vaccine in any of the Devon system local authorities.

Risks and mitigation

Uptake of 0-5s routine vaccinations has been falling since 2020 in many

systems and there is an ongoing national media campaign to encourage

parents to catch-up with 0-5s vaccinations. Changes to the national schedule

for immunisations for 0-5s come into effect from January 2026, which will

increase the number of vaccinations at 18 months but will see a reduction in

the number of vaccinations in the pre-school category. Changes include:

First PCV13 dose moved from 12 weeks of age to 16 weeks of age.

Second MenB dose brought forward from 16 weeks of age to 12 weeks of

age.

Cessation of routine Hib/MenC (Menitorix®) offer to those turning 12

months for those born on or after 1 July 2024.

Removal of monovalent HepB dose at one year for infants on the

selective HepB pathway schedule born on or after 1 July 2024 .

Introduction of an additional (fourth dose) of DTaP/IPV/Hib/HepB

(hexavalent) vaccine at a new routine appointment at 18 months for

children born on or after 1 July 2024.

Second MMR dose moved from 3 years 4 months to the new routine 18-

month appointment for children born on or after 1 July 2024.

The ICB supports the system by raising awareness of the changes both

through provider networks and through communications to parents, carers

and mobilising community education offers.

Next Steps &

Escalation

Ongoing work includes a funded offer to 55 GP practices to undertake project work to increase vaccination uptake for lower uptake cohorts, such as ethnic minorities and children in care across the 0-19 age

range. Projects are being delivered between 1 July and 30 September and will be evaluated to evidence value for money in providing nudge funding to increase vaccination uptake.

October 2025Exec Lead CNOVaccination Optimisation Lifetime Vaccinations

Tab 4 Item 4.3b - NHS Devon Quality Report274 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

October 2025Exec Lead CNO

Vaccination Optimisation Complete Routine Immunisation

Schedule from 1st July 2025

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Metric

Mixed Sex Accommodation (MSA) Breaches: A breach of the guidance on mixed-sex

accommodation occurs when a patient is placed in shared sleeping areas with a member of

the opposite sex, or when they must pass through opposite-sex areas to reach toilets or

bathrooms without acceptable justification. While NHS providers have a zero-tolerance

approach, breaches are monitored through a data collection system with a breach rate

indicator, and efforts must be made to rectify them as soon as possible.

Venous Thromboembolism (VTE): A VTE (venous thromboembolism) assessment is a

process of evaluating a patient's risk of developing a blood clot in their veins, typically

performed on admission to a hospital for patients over 16. Healthcare professionals use

standardized risk assessment tools to identify factors like immobility, existing clots, or

bleeding risks. The goal is to determine the need for interventions like mechanical

prophylaxis or pharmacological prophylaxis (such as low molecular weight heparin), and to

implement a care plan for managing the individual patient's risk. The target is for 95% of

patients to receive appropriate risk assessment.

Fuller Inquiry Phase 2: In accordance with the terms of reference, Phase 2 of the Inquiry

will look at the broader national picture and consider if procedures and practices in other

hospital and non-hospital settings, where deceased people are kept, safeguard the security

and dignity of the deceased.

Relevant groups/

committees

System Quality Group (SQG)

What the data shows

MSA: Within Devon the highest breach rate

sits within TSDFT (10.2 per 1000 episodes of

care). Although there has been a significant

decrease from April - May (208 to 94).

VTE:UHP gave an update on VTE figures as

a regional outlier. Assurance was provided

indicating it is a recording issue as data is not

currently captured in maternity or Same Day

Emergency Care (SDEC) day cases- SDEC

is an agreed exemption from the UHP

Medical Director.

Current performance

Provider specific issues raised through the System Quality Group:

Mixed Sex Accommodation (MSA) Breaches: It was noted that regionally the SW is the

second poorest performer of MSA.

Venus Thromboembolism (VTE): The South West is a regional outlier with both UHP and

RDUH failing the 95% target..

Fuller Inquiry: Phase 2 report Providers are undertaking a baseline assessment against the

health-related recommendations from the Fuller Inquiry (October 2024). To report back at

the September Regional Quality Group.

Risks and

mitigation

Risk to patient experience and safety.

Next Steps &

Escalation

MSA: The ICB has sent Key Lines of Enquiry (KLOE) to each provider re consistency in reporting and accuracy of information for feedback to region by

19 August and then Devon's September SQG.

VTE: It is the lack of reporting in Maternity which highlights UHP as an outlier. RDUH have implemented a 'spot check' and note compliance is better

than data collection evidences.

Fuller Inquiry: Providers to report back at the September Regional Quality Group.

October 2025Exec Lead CNO/CMOSystem Escalations

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Metric

The regulator for the health and social care sector in England is the Care Quality Commission

(CQC). They are responsible for ensuring the quality and safety ofc are across a range of



CQC inspect services across the following five domains:

Are they safe? Protection from abuse and avoidable harm.

Are they effective? - Care, treatment and support lead to good outcomes.

Are they caring? Staff involve and treat people with compassion, dignity and respect.

 - Services are organised and focused on need.

Are they well-led? The leadership, management and governance ensure high-quality

care.

Other regulators that feature in this report include Ofsted, the Office for Standards in Education,

Children's Services and Skills; and the Health and Safety Executive (HSE)

Relevant groups/

committees

ICB Quality & Patient Experience Committee (QPEC)

System Quality Group (SQG)

Current performance

CQC Ratings table correct as of 15/09/2025

What the data shows

Devon Partnership NHS Trust (DPT) - Langdon Hospital:

The CQC and Health and Safety Executive (HSE) have both visited the unit

and have flagged concerns regarding staffing and quality of care. CQC

issued a section 29a warning notice to DPT on 5 June 2025.

Royal Devon University Healthcare NHS Foundation Trust (RDUH):

CQC have completed their initial inspection of the Nightingale Hospital

Exeter. No immediate concerns highlighted. Subsequent discussions have

highlighted an incident which should have been reported as a Never Event

(retained foreign object).

University Plymouth Hospitals (UHP):

Report published14 August 2025 for UHP surgery - from inspection in April

2025. Increased rating to GOOD overall. Previously Requires Improvement.

Inspectors found two breaches of regulations relating to dignity and respect

and staffing. Derriford Hospital remains rated as Requires Improvement

Overall.

Risks and

mitigation

Requires Improvement indicates risk to quality of care; patient experience

and safety.

Next Steps &

Escalation

DPT: Rapid Quality Review initiated see next slide

RDUH: Trust has undertaken appropriate investigation in response to the incident and classification has been updated appropriately.

UHP: CQC has asked the trust to submit an action plan setting out how they plan to address the issues.

October 2025Exec Lead CNO/CMORegulatory Update: Care Quality Commission (CQC)

Tab 4 Item 4.3b - NHS Devon Quality Report277 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

Metric

Providers are required to complete an annual Quality Account.

NHS England » Quality accounts requirements

The following providers have completed a quality account, 2024/2025 priorities are detailed below to Acute and

Mental Health providers. .

Relevant groups/

committees

System Quality Group (SQG)

Current performance

What the data

shows

The larger providers have completed an

annual Quality Account

Further work is identified to increase

provider uptake in completing a Quality

Account

Risks and mitigation

No ICB risks identified

Next Steps &

Escalation

Quality accounts are reviewed annually through System Quality Group

October 2025Exec Lead CNO/CMOQuality Improvement: Quality Accounts

Devon Partnership Trust

1/ Children and young people

2/ People with serious and complex

needs

3/ Eliminating barriers to good care

4/ Inpatient services

5/ Physical health

6/Embracing technology and digital

solutions

University Hospital Plymouth



care

2/ Improving staff recommendations of care - staff experience and

recommender scores will improve by 10%

3/ Reduce Healthcare acquired avoidable infections by 50%

4/ Reduce harm from clinical deterioration by 50%

5/ Reduce Pharmacy medicines-related incidents causing harm by 25%

Royal Devon University Hospital Trust

1/ Maternity Improvements

2/ Improving Experience for patients on

waiting lists

3/ Improving the Safety and Quality of

Discharges

4/ Patient Safety Incident Response

Framework Maturity and Cultural

Development

5/ Supporting Shared Decision Making

6/ Improving access to Interpretation and

Translation services

Torbay and South Devon Foundation Trust

1/ Promoting the Early Detection and Treatment of Sepsis

2/ Strengthening the Quality of Mental Capacity Act Assessments

3/ Reducing Waits for Urgent and Emergency Care and for Patients Awaiting

Planned Care or Treatment

4/ Engaging and Collaborating to Safely Transition to an Electronic Patient

Record in April 2026

5/ Embedding the Patient Safety Incident Response Framework

6/ Reducing Healthcare Inequalities

7/ Equality Impact Assessment Process Embedded in Service Change

Southwest Ambulance Service

Foundation Trust

1/ Improving compliance with the Falls

Care Bundle

2/ Public Access Defibrillators

3/ Implementation of the Learning

Disabilities and Autism Plan

4/ Enabling the frontline - improving on

scene times

Livewell Southwest

1/ Neighbourhood alignment: targeted support for high-need individuals,

strengthen neighbourhood based integrated teams and help grow and sustain

wellbeing hubs.

2/ Sustainability and growth: modernise how we work, spend wisely, cut

waste,, make the most of our spaces, grow to give back and providing

services within available resources.

Accounts also received from Practice Plus Elective Care, Ramsey Mount

Stuart and Rowcroft.

Tab 4 Item 4.3b - NHS Devon Quality Report278 of 278Meeting in public - 16 October 2025 - Supporting Information-10/10/25

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