Norfolk and Waveney Sustainability and Transformation Plan

Our plan for changing health and social care in Norfolk and Waveney

Our population is growing, people are living longer and the type of care that is available through advances in medicine and technology is changing. The demand for services across health and social care is therefore outstripping current provision. We want to improve how we care for people in Norfolk and Waveney. We also know that our current services are not sustainable if they continue as they are now.

As local health and social care organisations, we are working together to improve our services and to help you to take more control of your own health and wellbeing. We have developed a vision for health and social care in Norfolk and Waveney, which is based on what people have told us about how they want and how they want to be cared for.

Our vision is to provide high quality services that support more people to live independently at home, especially older people and those with long-term conditions, like heart disease, breathing problems, diabetes or dementia.

Our focus will be on helping you to keep as healthy and well as possible and for those at the end of their life that they have more choice and control about the services they want and need.  At the moment we spend most of our time and money treating illness, and not enough on prevention and keeping people healthy and well in the first place.


What we are proposing to change

This document is a summary of our Delivery Plan. It sets out our plan for the work we will do by 2020 to achieve our vision for health and social. You can read more about the background to the work we are doing in these documents, available on the Healthwatch Norfolk website –

  • ‘In Good Health – Why health and social care services in Norfolk and Waveney need to change’ (September 2016), which set out the challenges we face.
  • ‘In Good Health – Our proposals for changing health and social care in Norfolk and Waveney’ (November 2016), which set out some of our initial ideas for how we could tackle the challenges facing health and social care.

Since we published these two documents we have done more research and planning, and continued to speak to and engage with patients, service users, the public, our staff and local organisations. We have also reviewed and renewed our financial forecasts.


Here is a summary of the changes we are proposing to make over the next few years:

  • Focus on how we can help you to keep healthy and well and prevent illness.
  • Further integrate health and social care teams, so that wherever possible, when you need services you are cared for at home or near to where you live, and that your support is better coordinated.
  • For those at the end of their life offer more choice and control over the services they need.
  • Make the services provided by our three main acute hospitals more sustainable, by supporting our hospitals to work more closely together, providing more equitable access to services and reducing the amount of people who have to access services outside of Norfolk and Waveney, in particular for Maternity Services.
  • Focus on providing more services in general practice and the community so that those who need specialist and emergency care in hospital can be treated more quickly.
  • Reduce waiting times and improve the outcomes for people who have cancer.
  • Improve maternity services by making them more personalised, family friendly, safer and by making sure every woman has access to information to enable her to make decisions about her care.
  • Find ways of better managing the increasing demand for health and social care services by reducing duplication, addressing our workforce challenges through training and with the help of new technology where appropriate.
  • Improve mental health services for children, young people, working age adults and older people and reduce the amount of people who are placed out of the county.

We will continue to work with patients, service users, the public, our staff and local organisations to develop our plans. You can find out more about how to have your say at the end of this document.


Our hospitals providing you with specialist and emergency care

Our three main hospitals are highly valued local institutions that play a major role in health services, but they are under unsustainable pressure. There have been big increases in the number of people visiting A&E, being admitted to hospital in an emergency and going to hospital for day treatments. There are also national shortages of some key staff groups.

Our hospitals need to be able to focus more closely on patients who need specialist or emergency care. When you do need to go to hospital, we want to make sure that our A&E departments are able to treat you swiftly throughout the year. If you have to be admitted, we want to give you the care you need and ensure that there is not any delay in getting you home. In the first instance we want to improve and ensure sustainable services in emergency care, radiology, urology, cardiology, cancer, and maternity. In later years we will review other services.

Our plans include:

  • Setting-up a Norfolk and Waveney Urgent and Emergency Care Board (UECB) to set the strategy for and coordinate the work of the three A&E departments, to help us meet the national target of treating people who attend A&E in four hours.
  • Recruiting more doctors and nurses who can talk to people calling the NHS 111 telephone service, so that people can quickly and easily get health care advice.
  • Having more consultants available to provide advice and guidance to GPs and doctors working in A&E about how to treat patients, to help prevent unnecessary emergency admissions to hospital and referrals to specialist services at hospitals.
  • Helping to make the process quicker and smoother for people who are medically fit and ready to be discharged from hospital to return home. We know we can get some patients home quicker and carry out better assessments of their ongoing, longer-term needs when they are at home and doing their usual everyday tasks, rather than keeping them in hospital until they’ve been assessed.
  • Developing a Norfolk and Waveney cancer strategy for 2017-25
  • A plan for improving maternity services.
  • Reviewing radiology, urology and cardiology services to see if we can identify whether there are better ways to use all of the capacity available between our hospitals and to manage the demand for these services.
  • Moving towards the five local NHS clinical commissioning groups and the three main hospitals in Norfolk and Waveney working more efficiently and effectively together.
  • Reviewing the hospitals’ procurement, payroll, information management and technology, finance and human resources services to identify whether there are opportunities to be more efficient by collaborating.


Managing the increasing demand for health and social care services

We want to find ways of better managing the increasing demand for health and social care services. We already have a plan in place for tackling the number of people waiting for treatment. We will build on our existing plan to help us meet our target of patients being treated within 18 weeks of being referred for treatment.

Our plans include:

  • Reviewing why there are differences in the number of people being referred for treatment by their GP and other primary care professionals across Norfolk and Waveney, to make sure that patients are being given the right care, in the right place, and at the right time, whilst maintaining patient choice.
  • Taking pressure off busy outpatient services by holding some clinics into the community, including ophthalmology (which treats diseases and injuries of the eye), IV therapy (giving people medication and fluid replacement via their veins), dermatology (which treats skin conditions) and ear, nose and throat services. Not everything needs to be treated in a hospital. We want more of our services to be provided near to where you live so you don’t have to travel to hospital.
  • Reviewing the way in which people are referred, assessed and treated for ear, nose and throat services, gynaecology services, musculoskeletal services (namely spinal and paediatric fractures) and general surgery.
  • Reviewing the criteria for getting some services, known as clinical thresholds, to see if they are right and to make them more consistent across Norfolk and Waveney. At the moment the criteria for getting some services is different depending on where you live – we want people living in Norfolk and Waveney to be able to get the same level of care, no matter where they live.
  • Developing a new ambulatory care and diagnostics centre at the Norfolk and Norwich University Hospital. This service will identify and treat patients who can be looked after all in one day, so that these patients don’t have to make separate visits to hospital to be assessed, diagnosed and treated.


Improving mental health services

Too often in the past mental illness has not received the same level of priority as physical health. We are committed to changing this and to making it quicker and easier for you to get support if you have a mental health problem. We want to make sure that everyone who needs mental health services get the right help, at the right time and in the right place.

Our plans include:

  • Reviewing why there are differences across Norfolk and Waveney in the number of people being referred to crisis services and the numbers of people being admitted to hospital, and developing recommendations for addressing these.
  • Looking into ways to improve the quality of referrals to mental health services.
  • Improving access to psychological therapies by increasing the number of people for whom psychological therapies is available for. We will specifically aim to increase services for people with a physical health condition where a psychological therapeutic approach could be more effective at improving their health and wellbeing.
  • Developing crisis cafes so that is it easier for people to get immediate help during the daytime and in the evening. The aim of the service is to reduce the number of people who experience long waits in accessing appropriate services in a mental health crisis.
  • Creating a new service to help people who have experienced emotional distress and crisis to return to work after a mental health admission to hospital.
  • Enhancing and expanding the service that supports people experiencing a psychotic illness, such as schizophrenia or bipolar mood disorders. Evidence shows that treatment at the earliest point for psychosis reduces further psychotic episodes in later life. It also allows for people to be treated more readily in the community as opposed to in-patient settings.
  • Creating a new service that will directly help women with serious mental health problems, before and after giving birth. It will also train and advise health and social care professionals to be able to help mothers they work with who need support.
  • Redesigning mental health services for children and young people to make it easier and quicker for children and young people to get help they require.
  • Employing a specialist mental health nurse to assess, help and if necessary admit people presenting with mental health illness.
  • Redesigning mental health services to provide localised support for people to support their housing and welfare needs. To focus that support to increase individual’s independence, reduce the number of people in residential care and support them in the community.


Support to keep yourself and your family healthy and well

Our plan has a strong focus on supporting you to keep healthy, well and more in control of your own long-term health. At the moment we spend most of our time and money treating illness, and not enough on keeping people healthy and well in the first place.

When you do need treatment or care, our goal will be to treat you as early as possible, before your condition gets worse and requires urgent care. This means we need to identify problems sooner. And if you have a long-term condition, such as heart disease, breathing problems, diabetes or dementia, we need to give you better support to manage it.

Our plans include:

  • Expanding the NHS Diabetes Prevention Programme which focuses on reducing the risk of people getting type 2 diabetes to West Norfolk, Great Yarmouth and Waveney so that it covers the whole of Norfolk and Waveney.
  • Developing plans to improve treatment for heart disease, diabetes, breathing problems and cancer, by looking at the organisations from across the country that are providing these services the best and making changes to what we do locally so that we achieve similar standards.
  • Employing people to work at GP surgeries and in other community venues like libraries who you can talk to about improving your health. Evidence shows that there are times when activities, such as going to walking groups, befriending services or book clubs, can be more effective at improving someone’s health than prescribing medication, or can help improve the health of someone who is taking medication.
  • Training all health and care staff to be able to provide advice and support about healthy living when they meet people as part of their job. This will help to prevent people from developing a long-term health condition, such as heart disease, breathing problems, diabetes and dementia.
  • Reviewing the service which provides advice to patients at our three main hospitals about alcohol consumption, to reduce the number of people being re-admitted to hospital with alcohol related conditions.
  • Reviewing the service which provides advice and support about healthy eating and physical activity with a view to extending the service so that it can help more people.


Supporting primary care and GP services

Primary care services are provided by your local GP surgery or health centre, and are led by GPs and other health professionals. They provide general medical care, referrals to specialists and may provide services such as health checks, contraceptive services and immunisations.

We want to work with our GPs to make primary care services more reliable and able to cope with the rising demand for health and social care services. We also want to make it easier for you to get help from your GP surgery.

Our plans include:

  • Training reception staff at GP surgeries to be able to better direct patients to the most appropriate place to get help, for example by directing people to their local pharmacy.
  • Offering more consultations with GPs online using Skype or Facetime.
  • Running a campaign to reduce the number of people not attending their appointments at their GP surgery, so we can give the appointment to someone else.
  • Integrating different computer systems to reduce duplication, improve communication and make it easier for patients to cancel and re-book appointments online.
  • Investing in training for GPs and practice managers.
  • Supporting GP surgeries to work together and share back office services to help them be more efficient and able to cope when they are faced with challenges.
  • Improving support for people with a long-term condition, for example by running campaigns and training staff to better help people to manage their conditions at home.
  • Increasing the support provided to GP practices, for example by having staff from clinical commissioning groups visit each GP surgery twice a year to discuss their referrals to hospitals and specialist services, and by developing the programme that is already in place for GP surgeries to peer review other GP surgeries.
  • Employing more pharmacists to work as part of your GP service so that they can help with prescriptions, day-to-day medicine issues and some consultations.
  • Developing a bid to recruit 50 GPs from abroad to work in Norfolk and Waveney.
  • Developing a programme that will help to keep GPs working in Norfolk and Waveney and not leaving the profession.


Integrated care, provided closer to home

We know that being cared for at home, near to your family and friends, is almost always better for you than being in hospital or residential care. So we want to develop health and social care services that are provided in your own home or close to where you live, and which bring together GPs, community services, hospital services, social care and other council services, the independent sector and the voluntary sector.

We want you to get the right care, at the right time and in the right place. By working with you to better plan your care, we can reduce the number of times you have to tell your story at each stage of the process and be more effective at improving your health and wellbeing.

Our plans include:

  • Developing 20 teams based around GP practices across Norfolk and Waveney made-up of people from all sorts of different professions, including community health services, mental health services and social care. So instead of patients having to go to lots of different places to get different specialist services, you will get coordinated care from a team of people working together in your neighbourhood.
  • Developing an intermediate care strategy for Norfolk and Waveney. This is short-term care that’s provided free of charge for people who no longer need to be in hospital but may need extra support to help them recover. It lasts for a maximum of six weeks and can be provided in someone’s home or in a residential setting.


How we will work together

To create this plan your local health and social care services from across Norfolk and Waveney have been working together in partnership. The challenges we face locally are similar to those being faced by the rest of the country, which is why we are one of 44 Sustainability and Transformation Partnerships working to create modern health and social care services that are fit for the future.

To achieve everything set out in this plan we need to make some changes to the way that we plan and buy health and social care services in Norfolk and Waveney. We will create a joint committee for planning and buying health services together.

The committee will be made-up of representatives from the five local NHS Clinical Commissioning Groups and Norfolk County Council.

It will decide on the priorities for health and social care services locally and then make sure that the right services are in place to meet our priorities. Planning and buying services together will make the care people receive more coordinated and better value for money.

To help make these changes we have also appointed an independent chair of our Sustainability and Transformation Partnership. We will continue to work with patients, service users, the public, our staff and local organisations to develop our plans.


How you can find out more and get involved

We need local people and organisations to share their experience, views and ideas about how we can create sustainable health and social care services. There will be opportunities for you to get involved at every stage of our work.

Visit to find out more about our work and how you can get involved and work with us to improve health and social care services. We will regularly update these pages with opportunities for you to have your say.


Produced by Norfolk and Waveney Sustainability and Transformation Programme

  • NHS Great Yarmouth and Waveney Clinical Commissioning Group
  • NHS North Norfolk Clinical Commissioning Group
  • NHS Norwich Clinical Commissioning Group
  • NHS South Norfolk Clinical Commissioning Group
  • NHS West Norfolk Clinical Commissioning Group
  • East Coast Community Healthcare CIC
  • East of England Ambulance Service NHS Trust
  • James Paget University Hospitals NHS Foundation Trust
  • Norfolk County Council
  • Suffolk County Council
  • Norfolk Community Health and Care NHS Trust
  • Norfolk and Norwich University Hospitals NHS Foundation Trust
  • Norfolk and Suffolk NHS Foundation Trust
  • Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust
  • Norfolk Independent Care
  • Norfolk and Waveney Local Medical Committee
  • Healthwatch Norfolk and Healthwatch Suffolk
  • Norfolk and Waveney district, borough and city councils


For more information and to see the latest documents, go to: Healthwatch Norfolk