Performance report

About us

NHS South West London Integrated Care Board (ICB) is committed to the four core purposes of Integrated Care Systems: 

• Improving outcomes in population health and healthcare  

• Tackling inequalities in outcomes, experience and access  

• Enhancing productivity and value for money  

• Helping the NHS to support broader social and economic development 

NHS South West London is dedicated to our role to lead and support our system and partners in the delivery of these four core purposes.   

Our goal over the next five years is to enable South West Londoners to Start Well, Live Well and Age Well. Our ambition is to make real and tangible improvements in health and care for local people.   

The ICB is a statutory organisation bringing together the NHS to improve population health and establish shared priorities for local people, as well as being responsible for deciding how the NHS budget for South West London is spent. 

This annual report covers from 1 April 2024 to 31 March 2025.   

NHS South West London serves around 1.5 million people across our six diverse boroughs: 

• Croydon 

• Kingston 

• Merton 

• Richmond 

• Sutton 

• Wandsworth 

We are responsible for overseeing the annual South West London NHS System budget of £X.X billion, which covers the costs of running the organisation as well as the NHS services commissioned for the local population. The majority of these NHS services are delivered in our six places, but some services will be commissioned from NHS organisations outside the South West London patch. These NHS services include hospital services, community services, mental health, learning disability services, continuing healthcare, local primary care services and prescribing.  

The total South West London ICB budget covers: (figures to be updated for 2024/25)  

• £XXX million with South West London providers 

• £ XXX million for acute providers outside of South West London 

• £ XXX million with South West London places (excludes community services with South West London Providers reported above) 

• £ XXX million on Continuing Healthcare 

• £ XXX million on delegated primary care 

• £ XXX million on dental, ophthalmic and optometry services 

The South West London system also has a delegated NHS capital budget which can only be used by NHS organisations of £xxx million. There is a further £xx million available from NHS England for GP IT and primary care improvement grants in 2024/25. These budgets can be further supplemented in-year by additional national NHS or external funds secured through bidding processes. 

Our Constitution, developed with the engagement of system partners and other stakeholders, sets out our purpose, powers, and governance and leadership arrangements to ensure the effective discharge of our duties and responsibilities. 

Read our constitution and standing orders  

Read the handbook to the NHS constitution 

This explains each right and pledge in the NHS Constitution and the legal sources of both patient and staff rights and outlines the roles we all play in protecting and developing the NHS. These rights have been continued by the NHS South West London Integrated Care Board. 

Our South West London Integrated Care System

NHS South West London was established on 1 July 2022 when we took on statutory status alongside the other 41 ICSs in the country. Building on the partnership work from previous years, NHS South West London has been working collaboratively with our partners to lead the development of our system including in the development of our Joint Forward Plan and Integrated Care Partnership Strategy.   

South West London ICS: Places  

South West London is committed to working with local communities and neighbourhoods to make sure we respond to local health needs. Our places with delegated responsibilities, aligned to our six local authorities, and are an important part of our system. These six places work closely with NHS providers, local authorities, primary care, the voluntary sector and local communities to deliver on the key purposes of place:  

• Support and develop primary care networks which join up primary and community services across local neighbourhoods  

• Simplify, modernise and join-up health and care including through technology and by joining up primary and secondary care where appropriate  

• Understand and identify – using population health management techniques and other intelligence – people and families at risk of being left behind and to organise proactive support for them   

• Coordinate the local contribution to health, social and economic development to prevent future risks to ill-health within different population groups 

Our role in delivering health and wellbeing strategies

We are committed to working with our local Health and Wellbeing Boards to develop plans that support the health and wellbeing of our residents. Across each of our place partnerships, we have developed Health and Care Plans that support the delivery of each borough’s Joint Health and Wellbeing Strategy. These strategies are developed by the Health and Wellbeing Board, to meet the health needs identified in the borough’s Joint Strategic Needs Assessment (JSNA). Each of our Place leads for Health represent their place on the local authority Health and Wellbeing Board along with representatives from local NHS acute, mental health and community providers, Healthwatch, community and voluntary sector and other partner organisations.   

Read the Health and Care plans for each place

Our place-based partnerships 

We have a strong history of partnerships at place level, and these continue to grow each year. Our place-based partnerships lead the detailed design and delivery of integrated services across our local communities and neighbourhoods.  

Our place partnerships involve the NHS, local councils, community and voluntary organisations, residents, people who use services, their carers and representatives and other community partners with a role in supporting the health and wellbeing of the local population. 

We have been developing ways of working with our partners at place including local authorities, NHS provider trusts, Healthwatches and voluntary and community sector. We have examples of place partnership below, that show the delivery of borough health and wellbeing strategies and health and care plans.   

Croydon 

Croydon is the largest of our South West London boroughs and the largest London borough overall by population. It includes Coulsdon, Purley, South Norwood, Norbury, New Addington and Thornton Heath. Croydon is also the South West London borough with the widest health inequalities, these are unfair differences in health and health outcomes. 50% of the most deprived South West London residents live in Croydon and 40% of residents who are most likely to have physical and mental health conditions. With 52% of the population being from Global Majority, Croydon is also the most ethnically diverse local authority within South West London. 

The local NHS, Croydon Council, Voluntary and Community Sector (VCS) partners collaborate as the ‘One Croydon Alliance’ to meet the health and care needs of local people. During this year the Alliance made progress in making improvements for residents including Frontrunner, Integrated Neighbourhood Teams and Health Communities Together. 

Reducing health inequalities 

Access to healthcare services alone is not enough to tackle the complex health challenges faced by people affected in Croydon. Some examples of how we work together as a system to reduce health inequalities in Croydon include our reablement service, our integrated discharge team and the Expert Patient Programme. 

Our initiatives to support residents to reduce length of stay and supporting residents to regain independence after a hospital stay – also known as reablement – have been recognised by NHS England as a frontrunner nationally. Our new integrated discharge team includes blended health and care roles and a dedicated housing officer to support people to return home safely with the care they need, working with them to regain their independence more quickly and optimising the opportunity to stay at home. 

We have broadened the scope of our Integrated Care Networks Plus team to include network facilitators and frailty coordinators to work across the system to support the holistic needs of residents with the highest needs in community settings.  

Working with our partners in the Asian Resource Centre and Croydon BME Forum, our Expert Patient Forum helps to identify and support residents with high blood pressure, diabetes and chronic obstructive pulmonary disease. The six-week course helps residents to find solutions to common problems and feel more confident to manage their conditions. Topics include managing symptoms, planning for the future and communicating with family, friends and healthcare professionals as well as culturally appropriate healthy eating. 

Improving access to diagnostic services 

Croydon’s Community Diagnostic Centre, which opened in Purley in January 2024, is an excellent example of how services can be brought closer to home, providing patients with easier access to vital diagnostic tests. Purley Community Diagnostic Centre is a ‘one stop shop’ for NHS testing, which has helped us reduce waiting lists and provides care closer to home.  

Since the launch of our centre in Purley, we have been able to provide 5,321 extra tests and in total 38,200 procedures and tests for Croydon patients from February to November 2024. Combined with community initiatives including the Expert Patients Programme and mobile screening and community-based blood pressure monitoring, run from barbers’ shops in Croydon, our work helps to empower people to manage their own health and helps to reduce health inequalities across the borough. 

Supporting families to give children the best start in life  

Supporting families to give children the best start in life remains a top priority in Croydon. Family Hubs are a new way of bringing together all the support you may need as a family from pregnancy through to young people turning 19 years or 25 if they have a disability. Our family hub opened in the south of the borough in August 2024 and provides a wide range of services for local families including social activities, maternity and midwifery services, infant feeding and oral health improvement and mental health support.  Designed to meet the health and care needs of local communities, it also provides a range of more targeted interventions including support for children with special educational needs, support to help reduce parental conflict and youth justice services. Further hubs are planned to open over the next two years.   

Croydon’s strengthening voices partnership formed at the end of 2024 and brings together representatives from across the health and care system, including Croydon Hospital, children’s mental health teams, primary care and the local authority. Meeting with head teachers from a range of local primary and secondary schools, we are looking at how we can strengthen joint working between education and health. Together we have developed a joint action plan to address a range of issues including a joint training package for parents to support their children and young people which includes topics like autism and girls, anxiety, challenging behaviour and managing the transition from primary to secondary. We have also been working closely with Croydon BME Forum to provide culturally appropriate mental health support in schools. 

Kingston 

As well as Kingston upon Thames, the borough includes Surbiton, Chessington, Malden Rushett, New Malden and Tolworth. There is a six-year gap in life expectancy between the most and least deprived men, and a four-year gap for women with the gap widening over the last decade. The number of people over 65 is above the London average at 14.4% of the total population and the number of people over the age of 80 is set to grow by 37% in ten years. 

Local NHS organisations, the council and voluntary and community services in the borough are working together towards goals set out in its health and care plan, in partnership with local communities. This year the partnership delivered a range of programmes to deliver its aims. 

Improving mental health services for children and young people in Kingston and Richmond  

This year we have been working to improve and streamline children and young people’s mental health support. This involves putting in a place a single lead provider in Kingston and Richmond, as well as other initiatives. The different organisations involved in caring for young people, as well as parents and carer representatives, are involved in the planning process – including education, public health, primary care and the voluntary sector. 

Our plans are based on feedback from children, young people, and families – as well as an independent review we commissioned. Families highlighted concerns around long waiting times, the need for better communication about available support, and improved engagement between therapists and families, particularly when therapy takes place in schools. The review found that while current providers positively contribute to different aspects of care, a single provider would improve coordination and reduce delays.  

Volunteer exercise programme to reduce falls 

A programme which helps elderly residents maintain their independence after a fall was expanded this year, through the addition of a volunteer exercise programme. This programme is funded as a year-long pilot by Kingston Hospital Charity’s Innovation Fund. 

Trained volunteers visit patients and residents for eight weeks, delivering one-to-one or group rehabilitation exercise classes. The results have shown patients have increased confidence in daily activities, and a 30% increase in confidence to cope at home. A measure that indicates how healthy someone is has more than doubled, and 100% of participants showed improvements in physical fitness, mobility, and independence. The programme is set to expand, aiming to reach more frail and elderly residents across Kingston and Richmond.  

Expanding virtual ward services in Kingston and Richmond   

A key focus of the Kingston and Richmond team this year has been supporting the delivery and development of the local virtual wards service. The service sees people cared for at home, when they would have traditionally been in hospital. It combines remote monitoring, home visits, and advanced diagnostic tools to support people outside of the hospital setting.  

In the past year, 558 patients have been cared for, with a low readmission rate of 8% and an average length of stay that aligns with NHS recommendations. Currently, people are admitted to a virtual ward from hospital, but in the next year a new model will be in place to enable admission from community settings. This will help people avoid unnecessary hospital stays altogether. The service is also broadening the range of conditions people can be supported with from home, including frailty-related issues, chronic obstructive pulmonary disease (COPD), and heart failure. Strengthening GP engagement is another key focus, encouraging referrals and integrating virtual ward services into community care.  

Merton 

Merton includes Wimbledon, Mitcham, Morden, Raynes Park, Colliers Wood, Wimbledon Park, South Wimbledon and Eastfields. The gap in life expectancy between the 10% most deprived and the 10% least deprived in Merton is 7.7 years for men and five years for women. Of the 340,000 population in South West London that have the most health needs, 29,000 are located in East Merton. 

Health and care organisations in Merton work together to reduce inequalities and provide truly joined-up health and care services with and for all residents, so they start, live and age well in a healthy place. During this year a range of activities and initiatives have had a positive impact on the health and wellbeing of local people.  

Supporting mental health in schools and children with special education needs  

The Merton Schools Wellbeing Team work across both primary and secondary schools in the borough, supporting the wellbeing of children and young people by providing an additional source of support to young people, their families and the schools they go to. Support is offered in a number of ways including confidential, non-judgemental spaces for young people to explore difficulties, 1:1 sessions and workshops for parents and staff in school to keep emotional health at the centre of school life. 

Additional support for children with Special Educational Needs in Merton includes a mental health support team working across the four Special Educational Needs schools in the borough.  

We have also worked hard to reduce the waiting times for community paediatrics at St Heliers from 52 weeks to 21 weeks, bucking the national trend. Our community paediatrics team make sure support is available whilst waiting for assessments and treatment. In addition, we send out packs of advice to all families of children under five who are awaiting neurodevelopmental assessment, with support for children over five being led by the Children and Adolescent Mental Health Services, CAMHS.  

We have also made significant progress on reducing the over fives waiting time for neurodevelopmental assessment which are now down to 42 weeks. We know we have more to further improve this support and will continue to work hard to bring these waiting times down.   

Enhanced rehabilitation at home service supporting people when they leave hospital  

We have changed the way that people are rehabilitated after a hospital stay to allow more people to be discharged to their own home with a therapy package. Using the Home First approach to hospital discharge, up to 250 people each month are assessed by a multi-disciplinary team of therapists who provide an integrated, person-centred approach to aid the transition from hospital to home. A therapist will carry out an assessment to identify needs, including a full safety check to help to improve independence and wellbeing as well as enabling people to remain involved in their community networks. This service supports Merton residents to safely regain independence and learn or re-learn daily skills while increasing their self-confidence so that they avoid re-admission following discharge.

Wellbeing activities at the Wilson hospital and a vision for East Merton 

A daily programme of wellbeing activities and support launched at the Wilson hospital in May 2023. The Wilson Wellbeing centre was refurbished by the NHS in 2019 and used as a Covid-19 vaccine centre during the pandemic. It is now a space in east Merton that the community can go to for support, or to get together to learn new skills – boosting their mental and physical health and combating loneliness.  

A programme of activities has been running Monday to Friday on the Wilson hospital site over the last two years. These range from food and clothing banks, gardening, coffee mornings and book clubs, to wellbeing support for those affected by homelessness and advice around domestic abuse. The Wilson Wellbeing Steering Group, responsible for overseeing the activity programme, has commissioned local charity Jigsaw4u to develop and deliver the support that local people need now.  

Plans to build a brand-new health and wellbeing centre on the site also progressed this year, with the project confirmed as a priority, despite the ICB’s financial challenges. A draft business case is being prepared to take the project to the next stage. 

We are now working with our partners to design an integrated health care model to help support and improve the health of those living in East Merton. In parallel, we continue to work with the voluntary and community sector and care coordinators in GP practices to support our most vulnerable communities.  

Health and wellbeing coaches  

To support the wider determinants of health, Merton GP practices have evolved to respond to the needs of local people with the appointment of new kinds of healthcare professionals who address the social factors that influence health. One example is Wideway Surgery, who now refer patients to health and wellbeing coaches to provide lifestyle coaching to help people manage their long-term conditions as well as care coordinators to support people to get treatment that’s right for them. They work to give people the time they need to find solutions to their issues, with a focus on prevention, helping them to change their lives for the better.  

Coaches support patients to make changes relating to diet, physical activity and exercise as well as guidance to help with stress, low self-esteem and low-level anxiety or depression. Review sessions at six and then 12 months allow residents to assess their progress and set new goals for the next six months.  

Respiratory hublets 

In March 2023 we launched an integrated multi-disciplinary, multi-organisational hublet team to provide respiratory diagnostic testing, treatment and management for residents. 

The service, which offers flexible appointments, including evenings and weekends, ran throughout 2024/25, aiming to reduce hospital admissions, inappropriate prescribing, and improve health outcomes and quality of life. 

More than 1000 patients used the service this year across three hub sites in Merton, and there have been less than 1% DNAs (did not attend). 

Richmond 

Improving health and wellbeing in Richmond, including Barnes, East Sheen, Mortlake, Twickenham, Teddington and Hampton. The number of people over 65 is above the London and national average at 16.2% of the total population and 19,604 (36%) people have more than one long term condition. There are also an estimated 4,600 children aged 5-19 years old with a diagnosable mental health disorder. 

The Richmond Place health and care partnership works together to improve the health and wellbeing of children, young people, adults and older people. During this year the partnership achieved a lot through working together. 

Proactive anticipatory care across Kingston and Richmond 

Proactive Anticipatory Care (PAC) focuses on frail and typically older people – those with multiple long-term conditions who are increasingly needing urgent care as their health deteriorates. The idea behind PAC is to support people to stay healthier and more independent at home for longer, which reduces the need for urgent healthcare. At the centre of the PAC model is a frequent multi-disciplinary team meeting which includes representation from a dedicated core team of professionals from different local organisations. 

The PAC model continued to support residents across Kingston and Richmond this year. Since April 2024, around 870 new patients have been discussed at the PAC team meetings which means around 2,270 patients in total have been discussed and have benefited from personalised input from the multidisciplinary team and goal-centred care co-ordinators.  

Young volunteer mental health ambassadors 

A new programme was launched this year, working to train 125 young volunteers to become mental health ambassadors in schools across Richmond. The programme involves year six and year nine pupils from 25 Richmond primary, secondary and Special Educational Needs schools. The aim is to use peer-led support to create safe spaces for young people to have open conversations; build confidence in discussing wellbeing; and reduce stigma. Approximately 1,500 young people will be supported by the ambassadors over a three-year period, and the students trained are also playing an active role in shaping the mental health culture of their schools.  

Central London Community Healthcare Trust (CLCH) is delivering this project, which builds on an existing scheme in neighbouring Kingston. The team at CLCH also work with teachers and mental health leads to co-develop mental health action plans for their schools. 

Health checks and advice through community outreach  

Richmond charity Ruils and local GPs have partnered this year to bring healthcare advice directly to more than 100 local residents, outside of the traditional GP practice setting. The aim of the project – called ‘Health in your hands’ – is to make healthcare more accessible to people who might not engage with the NHS otherwise. Through basic health checks and advice, the scheme detects health conditions at an earlier stage and supports people to proactively manage any existing conditions – connecting people to other available services. Support focuses on identifying individuals at risk of or diagnosed with conditions like diabetes, asthma, cancer, depression, and high blood pressure. 

A community health worker organises outreach events – engaging residents during local events, health fairs, and visits to public spaces. Plans are underway to expand the project, with recruitment for a second community health worker to extend the programme across the borough, continuing to meet residents where they are, and support their overall wellbeing.  

Improving digital tools in care homes in Kingston and Richmond 

In the past year, new digital innovations have been implemented in care homes across Kingston and Richmond, aimed at improving the health and wellbeing of residents. A new Digital Practice Educator role has been introduced, which supports care home staff to put new technologies in place, such as electronic records. This work helps care home staff to better manage people’s conditions and organise the support they need.  

We have also introduced more advanced digital tools, including remote monitoring devices for people’s vital signs, electronic medicines management, and an electronic health record that follows a resident should they be admitted to hospital (the eRedBag pathway). In addition, an interactive technology has been introduced which aims to make care home residents feel happier – residents interact with digital devices which encourage them to be sociable and interact with others. Plans are in place to expand these digital initiatives, ensuring that more care homes across Kingston and Richmond benefit from these transformative technologies in the year ahead.  

Sutton 

Sutton includes Beddington, Belmont, Carshalton, Cheam, Hackbridge, St Helier, Rosehill, Wallington and Worcester Park. Sutton is within the top 10% most densely populated of all local authorities in England. The population has grown by 10% between 2011 and 2021 and 17% (36,000) of Sutton residents are in the core 20 or most deprived population in South West London – median age 35 years. 

Health and care partners in Sutton have a shared vision and principles to deliver preventative, proactive and reactive health and care – at the same time as supporting local people to play an active role in maintaining their own wellbeing as a community. This year the partnership has delivered a range of initiatives and interventions. 

Advancing support for people with learning disabilities 

Organisations across Sutton have continued partnership work this year to improve the health, wellbeing and independence of people with a learning disability. Our aim is to build an inclusive and supportive borough where people with learning disabilities and their families are empowered and valued. The programme involves a range of focus areas including annual health checks, meaningful employment and supporting residents to live the place they call home. 

For annual health checks, we are increasing access through GP practices, helping to improve people’s health through prevention and detecting any conditions early. We are reviewing the needs of Sutton residents living outside the borough to assess if they could be better supported by returning to the borough. We are also working to expand access to meaningful employment opportunities – and where people are in work, ensuring they have short breaks that support wellbeing and social participation. Looking ahead, we are working to host our next partnership conference in Summer 2025, which will focus discussions on digital inclusion and exclusion. We will explore how technology can better support the lives of people with learning disabilities.  

Supporting families through targeted early help  

An initiative to ensure families can access the support they need when it matters most continues this year – aiming to empower families to be part of the solutions that shape their future. Over the past year, 305 parents have completed parenting programmes face-to-face and 266 parents have accessed support through the online universal parenting programmes. 

The Targeted Early Help Service provides multi-agency support for families identified with Tier 2 needs under the Local Safeguarding Children Partnership threshold guidance. A specialist Support Worker works with eligible families to understand their circumstances through a home visit and Early Help Assessment. Following the assessment, a tailored family plan is developed a supported by a Team Around the Family which meets regularly. Support is typically provided for up to six months, with regular progress reviews. After this period, families receive a Resilience Plan to celebrate their achievements and guide them in addressing future challenges. 

Integrated Neighbourhood Teams focusing on cardiovascular disease 

Work has continued this year to develop Sutton’s Integrated Neighbourhood Teams (INTs) – which bring together professionals and the community to ensure that people receive the right care, at the right time, in the right place. There are four INTs in Sutton – Cheam and South Sutton, Central Sutton, Carshalton and Wallington. The INTs have identified preventing and tackling cardiovascular disease as their first shared priority and are exploring evidence, data, and opportunities to build on in their local area to meet their goals.  

Through an INT, health and care professionals support local people by working together, make decisions using real-time data. For residents, INTs mean they have a single point of contact for health and care support, only needing to share their story once. This approach aims to empower people to take proactive steps for their health and receive efficient signposting to the right services. Online support groups and community networks further enhance access to advice and social connection. This way of working also helps reduce duplication between different organisations and staff are trained on the latest research and guidance. INTs also support proactive resource allocation to prevent health crises and ease pressure on hospitals and emergency services.  

Wandsworth

This inner London borough includes Battersea, Tooting, Putney, Balham, Roehampton, Furzedown and Southfields. It has the second largest population in inner London with 327,506 residents. Wandsworth has one of the youngest populations in the country as well as one of the fastest rates of population growth in London. Half of the adult population is classified as overweight or obese. 

Improving cervical cancer screening uptake for women from South Asian backgrounds  

A drive to increase cervical cancer screening uptake amongst Asian communities in Wandsworth has continued this year following a workshop bringing together residents and stakeholders from health, public and voluntary and community sectors. Data shows that Wandsworth has some of the lowest cervical screening coverage in England particularly in Asian communities. Listening to local communities about the particular barriers south Asian women face in accessing cervical screening has led us to work together to try and improve uptake in Wandsworth. In partnership with the Institute for Voluntary Action Research, Wandsworth has been tackling health inequalities by working together to remove potential barriers including language, culture and misinformation to make sure as many women as possible take up the offer. The group has worked with the local community to co-design projects including extending the choice of appointment times, taking account of caring responsibilities, producing culturally appropriate communications that are more accessible to overcome language barriers, increasing community outreach both on the ground and on social media and ensuring that female health professionals carry out cultural sensitivity training. 

Minimising waits and maximising patient choice for physiotherapy services 

GPs and physiotherapists at St George’s University Hospitals NHS Foundation Trust have worked together to design new flexible services with the aim of minimising waits and maximising patient choice. Based on the experience of service users and local people’s views, Vita Health Group are offering a range of appointment times, including evenings and weekends and alongside routine care, people are also encouraged to access the getUBetter app for self-care at a time that works best for them, meaning that they acquire the knowledge and confidence for better long term health to make daily life easier alongside having the best treatment for their conditions. 

Wandsworth Neuro Navigators  

The Wandsworth Community Neuro Team is based at St John’s Therapy Centre in Battersea. A specialist inter-disciplinary therapy team, including specialist nurses, a psychologist and dietitian, offer neurological rehabilitation and disability management to people with an acquired neurological condition.  

The team works with patients to identify their goals and suitable interventions and offers a package of between four to 12 weeks.  

The team is able to organise early supported discharge for stroke patients with the aim of supporting them back into their own home, away from hospital maximising their independence as quickly as possible. Patients are seen in hospital before they leave the service to discuss their individual goals and rehabilitation needs, and are then offered a therapy package lasting around four to six weeks. 

Support includes specialist self-management and group programmes focusing on how people may adjust to their new needs and help manage their fatigue. Emotional and psychological support is also available as well as support services including help to stop smoking, advice on sensible drinking, weight management and physical activity.   

South West London ICS: Provider Collaboratives

Our providers are working closely together to:  

• reduce unwarranted variation in outcomes and access to services
• improve outcomes in population health, healthcare and tackling inequalities 
• promote better quality care and best practice 
• increase our resilience across systems – capacity, improving recruitment and retention 
• achieve the benefits of working together at scale.  

There are three provider collaboratives in South West London:   

South London Mental Health Partnership is made up of:  

• South West London and St George’s Mental Health NHS Trust

• South London and Maudsley NHS Trust

• Oxleas NHS Foundation Trust 

South West London Acute Provider Collaborative is made up of:  

• Croydon Health Services NHS Trust 

• Epsom and St Helier University Hospitals NHS Trust

• Kingston and Richmond NHS Foundation Trust

• St George’s University Hospitals NHS Foundation Trust

Royal Marsden Partners is made up of: 

• all South West London and North West London organisations supporting the NHS cancer pathway, including primary, acute and specialist providers and screening services. 

Our collaboratives have delivered significant achievements in the recovery of acute services following the pandemic, high quality cancer care and efficiency and high-quality care in Mental Health placements.  

Leading our system and working in partnership across South West London

***KLOE A2: How has the ICB provided system leadership as appropriate system and worked in partnership?  ***

We are committed to a collaborative leadership approach for the benefit of local people across South West London. We have an experienced team of people working within our ICB, our partnerships and providers. 

Our role as an ICB, means that we lead the development of our system alongside our partners across South West London. Key areas in which we take on this leadership role, as well as our assurance function, include:  

• Setting strategy

• Managing our money

• Improving performance

• Improving quality

• Tackling our joint workforce issues

• Addressing health inequalities

• Socio economic development including the role of our partners as anchor institutes

We work with our partners and lead on the development of our key system strategies and plans.   

As well as having strong governance and strategies in place, we work together across the system to ensure our services are efficient and high performing for the benefit of local people. 

To support the delivery of our work, our organisation is structured into the following six directorates:  

We also have teams supporting delivery at each of our six Places.  More information about our teams and how we support them is included in the staff report section of this annual report.  

Integrated Care Partnership strategy  

***KLOE A1: How effectively has the ICB developed strategies and plans?***  

***KLOE E1: How has the ICB contributed to the wider strategic priorities of its system? ***

We developed our Integrated Care Partnership Strategy for 2023 to 2028 with our ICP partners and published this in July 2023.   

Over the past seven years, our partnership has strengthened, and we have grown more confident in how we work together. However, like many systems across the country, we are operating in a more challenging financial environment and with local health and care needs continuing to grow, working differently is now more important than ever. By collaborating at scale across South West London – when it is right to do so – we can focus our efforts and investment on the priorities that will make the greatest impact. Our Integrated Care Partnership Strategy explains how we have listened to one another’s challenges, reviewed data and evidence, and sought the views of local people across our six boroughs to shape how we tackle key issues together. 

Our strategy, identifies six shared priorities:  

• Tackling and reducing health inequalities 

• Preventing ill-health, promote self-care and supporting people to manage their long-term conditions 

• Supporting the health and care needs of children and young people   

• Focusing on mental well-being 

• Supporting older and frail people in the community  

• Workforce 

In addition, we have identified four areas of focus to embed in all our work:  

• Equality, diversity and inclusion  

• Championing the green agenda  

• Elevating patient, carers and community voices  

Reviewing our progress: ICP strategy stock take  

During 2024/25, we undertook a stocktake of our ICP strategy, looking across all six priority areas to review our progress and identify ways to strengthen collaborative working: This stocktake explored: 

• overall progress against delivery plans 

• how governance structures support collaboration and decision-making 

• engagement and participation across workstreams 

• interplay between system-wide and place-based actions 

• resource or capacity constraints impacting delivery 

• confidence in achieving our ambitions by 2028. 

The stocktake confirmed that most workstreams have made good progress through strong partnership working, reflecting significant commitment from health, local government, and the voluntary sector.

Much of this momentum has been powered by our ICP Priorities Fund, which was established to accelerate partnership-led initiatives that directly address our shared priorities. For example, it provided resources to launch an inclusive Park Run for children and young people with special educational needs and disabilities (SEND), funded a Dementia Friends training drive aimed at making our communities more supportive for older people, and expanded efforts to recruit and retain key roles under the Workforce workstream.  

Meanwhile, other actions have progressed more slowly than anticipated, often due to competing pressures on operational capacity and finances. The review also highlighted a need to clarify which elements of the strategy should be delivered at the system level and which are best led by our six borough-based partnerships, ensuring that responsibilities remain clear and that resources are targeted where they can make the greatest impact. 

By continuing to work together in this way, we can navigate the financial and operational pressures facing the ICB and our wider partners while delivering real improvements in health and care for people across South West London. Our shared commitment remains to keep local people and communities at the heart of everything we do, ensuring that our ICP Strategy is both ambitious in its vision and responsive to the health and care needs of our communities.  

Our Joint Forward Plan 

Our Joint Forward Plan describes how NHS partners across South West London are working together over the next five years to meet the needs of local people. The ambitions outlined in our plan are built from our understanding of the health needs of people in South West London, the health inequalities that exist and importantly the views, experiences and concerns of our people and communities. ​ 

We published our first Joint Forward Plan in March 2023 and agreed that we would review our plan at the beginning of each financial year. You can read our first review of our Joint Forward Plan on our website. Our review updates our assumptions and priorities and provides a snapshot of key successes from our 2023/24 delivery plan, outlines actions for 2024-29 and provides additions or amendments to specific areas arising from new publications, guidance, and policy.  

As the NHS in South West London, our collaborative approach has helped us maintain our position as a high performing system in London, and ensured we perform well against NHS targets and priorities, including referral to treatment times, elective care and vaccination delivery. There is no doubt that this is a challenging time for health and care services, but we are recovering well from the pandemic, and we will continue to work together to improve further. We are clear that achieving the ambitions in our Joint Forward Plan will need us all to work together differently, as we shift our focus from treatment to prevention, support people to make healthy choices, and improve our services and the way we provide care.  

Our focus is to:  

• Prevent ill health and support people to self-care  

• Reduce health inequalities  

• Keep people well and out of hospital  

• Provide the best care wherever people are accessing our services  

• Use technology to improve care  

• Manage our money  

• Make South West London a great place to work  

• Deliver the NHS’ requirements of the Integrated Care Partnership Strategy.  

Our Joint Forward Plan outlines our level of ambition, the context we are working in for each part of plan, the views of people and communities, the actions we will take to deliver our priorities, and our critical finance, workforce and digital enablers. The last few years have shown us that when we come together, we can make real and tangible improvements to the health of local people.  

We want to ensure that our ambitions are clear and respond to the needs of our patients, carers, residents and staff.  We have developed our Joint Forward Plan for the next five years which you can read more about on our website.   

This annual report includes a reflection on how we have delivered for the first year of our Joint Forward Plan since it was published in June 2023.  Each of the chapters that follow outline what we have delivered in each setting of care.   

The 10-Year Health Plan  

In October 2024, the Government and NHS England launched a national engagement exercise to shape the new 10-Year Health Plan, focused on building a health service fit for the future. Throughout 2024/25, NHS South West London played an active role in supporting this engagement, working to ensure that the voices of local people, staff, and partners were heard. 

The 10-Year Health Plan focuses on three major shifts in healthcare: 

• Analogue to digital – embracing technology to improve care 

• Hospital-based to community care – supporting more people closer to home 

• Treatment to prevention – focusing on helping people stay healthy 

Our goal was not only to contribute to the national conversation but also to shape the future of health and care in South West London and across our six places, by creating opportunities for meaningful conversations that ensured a diverse range of voices helped shape both the national plan and our local priorities.  

Listening to local people and voluntary sector and community groups 

Between November 2024 and January 2025, we hosted several engagement opportunities to ensure local people and voluntary sector and community groups could share their views: 

• South London Listens (20 January 2025): More than 30 members of our South London Listens partnership joined a public engagement event, hosted by our Chair, Mike Bell, in partnership with Citizens UK. Participants shared their thoughts in small focus groups, exploring the three key shifts and how they would impact local communities. 

• South West London VCSE Listening Event (29 January 2025): More than 80 representatives from voluntary, community, and Healthwatch groups gathered in Wimbledon to discuss what matters most to their communities. Hosted by our Chair, Mike Bell, and Deputy Chief Executive, Karen Broughton, the session featured Place Leads facilitating local discussions and a ‘dotmocracy’ exercise, allowing attendees to prioritise issues important to their communities. 

• Winter Engagement Fund Events: Our partners helped share information about the plan across 350 community events throughout November and December, ensuring local people, especially those from underrepresented groups, could have their say. 

Engaging system leaders and partners 

Bringing together senior leaders from health, social care, local authorities, and voluntary sector partners ensured that the ICB’s submission to the national engagement exercise was joined-up and reflected how national priorities could be applied locally, aligning with community needs and the wider vision for the South West London system. 

• System Leaders Virtual Event (19 November 2024): More than 90 senior leaders attended an engagement session chaired by Mike Bell. Breakout discussions focused on the challenges and opportunities around the three big shifts, with leaders highlighting the importance of joined-up services, accessible digital tools, and a stronger focus on prevention. 

• ICB Board Response (2 December 2024): The South West London board submitted its organisational response to the national consultation, reflecting insights gathered through staff, community, and partner engagement. 

Listening to our staff 

The experiences and insights of health and care staff are crucial in shaping future services. Their frontline perspectives help identify practical solutions, highlight challenges, and ensure that changes truly meet the needs of our workforce – present and future as well as our patients and local communities.  

• All Staff Briefing (22 January 2025): Over 400 ICB staff joined an all-staff briefing to share their views. Through breakout workshops, staff discussed the three shifts and explored what changes could make the biggest difference to patients and colleagues. 

• Staff engagement across South West London: NHS trusts across South West London ran their own staff sessions, encouraging responses through the national Change NHS portal. Staff from Croydon Hospital Trust were also selected to take part in a London-wide engagement event in February 2025. 

Feedback from all these sessions has been submitted to NHS England through the Change NHS portal and will help shape the final 10-Year Health Plan, set to be published in Spring 2025. 

Delivering the operating plan guidance or 2024/25 

***KLOE B3: How successfully has the ICB delivered against its 2024/25 operating plan? *** 

***KLOE B4: Has the ICB delivered against the priorities set out in the 2024/25 planning guidance? ***

The NHS operational planning guidance for 2024/25 sets out the following “key tasks”: 

• recover our core services and productivity, specifically to: 

• improve ambulance response and A&E waiting times 

• reduce elective long waits and cancer backlogs and improve performance against the core diagnostic standard 

• make it easier for people to access primary care services, particularly general practice 

• make progress in delivering the key ambitions in the Long-Term Plan   

• continue transforming the NHS for the future 

In addition, systems were required to recover productivity and deliver a balanced financial position.  

Our submitted plans, which were agreed with NHS England, set out that the system would deliver the required targets and trajectories set out in the guidance.  This included achievement of the 78% A&E target, reducing the number of 65 week waits and further reducing the cancer backlogs.   

NHS South West London continues to be one of the best systems nationally in ensuring access to care for its patients.  Despite needing to manage the pressures that have resulted from Industrial Action during the year, we have continued to deliver our required activity to achieve the 62-day cancer target, the faster diagnosis standard and our elective recovery target.  Whilst we have a small number of over 65 week wait patients, our overall total has reduced from 2023/24 levels and we continue to make progress. 

Recent data shows that we have met the ask to improve our 4-hour A&E response, exceeding the national target of 78% for March 2025. We continue to work with system partners to ensure patients have access to urgent care in the right place.   

Whilst there are a reduced number of tangible mental health and learning disabilities targets for 2024/25, South West London performs strongly against the measurable metrics with dementia diagnosis rates above the national threshold, full annual physical health checks for people with a serious mental illness or with a learning disability in-line to deliver against their respective targets.  We continue to experience an increase in acuity of mental health patients resulting in longer length of stay which means that we are sometimes reliant on ‘out of area placements’ for mental health support.  Work is ongoing to minimise this. 

Read more about our performance against these standards

Recovering activity

Reduce long waits

Urgent and emergency care capacity

Mental health, people with a learning disability and autistic people

Engaging clinical care professionals in our work 

***KLOE A6: How has the ICB taken advice from clinical experts? ***

Clinicians and other healthcare professionals in NHS South West London have an essential role within our health and care system: as clinical leaders, those working with patients daily, those transforming care pathways, teaching a new generation of health and care professionals and pursuing research excellence. 

In South West London, we work with local clinicians and other healthcare professionals to develop the right high-quality services for local people and to ensure clinical stewardship of the commissioning decisions being made. We support and resource clinicians and professionals from a variety of backgrounds to lead programmes of work and support the development of our cross-system strategies. 

In 2024/25, we became a GMC training location for postgraduate public health medical training which enables us to host public health registrars, GP trainees and other specialities. We continued to host SPIN fellows (fellowship opportunities for newly qualified and early career GPs and General Practice Nurses and nurses new to practice, within one year of joining general practice) working on a range of projects including diabetes, developing multimorbidity approach to long term conditions and immunisations. 

We are committed to supporting clinical leadership and research, collaborating with our research and education leaders in our provider trusts, primary and community care and supporting the professional development of healthcare professionals.   

In South West London we have nine clinical networks for areas of care: cardiology, ear, nose and throat services (ENT), gastroenterology, general surgery, gynaecology, ophthalmology, respiratory, trauma and orthopaedics and musculoskeletal and urology. Clinical networks enable patients, professionals and organisations to work together on large scale, long-term programmes of quality improvement.   

Finance summary

***Final year figures will be updated when available  ***

***KLOE D1: How far has the ICB balanced finances as a commissioner and a system leader? NEW *** 

***KLOE D2: How effectively has the ICB delivered against its efficiency plans? ***

NHS South West London is responsible for investing the funding we receive to maximise the health of the local population and overseeing the delivery of services by NHS organisations within the geography to both the South West London population and beyond. This section summarises the ICB’s annual accounts including the controls assurance and auditor’s statements. Our performance against the key financial performance indicators is summarised below. 

Funding we received 

We received £3.7bn in funding for 2024/25 and had a surplus of £x million at 31 March 2025. This formed part of the wider draft South West London ICS financial position (breakeven after £120m fixed cost support). We worked alongside the system to try and minimise any additional spend and maximise savings, whilst focussing on delivering high quality healthcare to as many people as possible. 

Within the funding received there are certain requirements and conditions as to where and how these can be spent. We made sure that we met all of these requirements in year, with the key areas being: 

• Ensuring we continue to increase our investment in mental health services called the mental health investment standard (an additional £20.3 million was spent in year) 

• We received £426.9 million for delivery of services in primary care across general practice, dental, ophthalmic and pharmacy services 

• We remained within the funds allocated for running the ICB (£30.5 million)  

We also led the systemwide capital programme (£x million spend in year) and worked alongside providers to ensure delivery of key programmes of work such as investment in digital solutions and the opening of a new Intensive Treatment Unit at Croydon University Hospital. 

How we spent our funding 

We received £3.7bn funding of which over half of this expenditure was on acute services (£2.1bn). Mental health services received £386m, community health services £292m and continuing care placements £174.9m. We invested £266m into primary care (including prescribing) and £152.4m on dental, optometry and pharmacy services. The ICB spent £30.5m on running the organisation which is in line with the allowed level of spend. 

An analysis of the ICB’s net expenditure in 2024/25 is set out below. 

Updated pie chart to be included once 2024/25 figures are available 

Ensuring value for money 

We want to ensure we maximise value for money and invest our money to enable high quality services for our populations. Key to this is ensuring we continuously review our spend to ensure we are as efficient as possible. Part of this approach is our savings programme of £38.5m, which was delivered in full, with 69.3% of the savings being recurrent. While we don’t have to work to a specific threshold for agency spend, we ensured we had robust processes in place to review recruitment and minimise the need for high-cost posts, so the maximum level of funds went to direct healthcare. 

Further to this, we supported the wider system with identifying opportunities and sharing best practice to support the delivery of their organisational savings targets. This included providing oversight and analysis of spending patterns and performance against the agency threshold.  

Financial governance and reporting 

We have clear financial governance arrangements for managing spend during the year. These operated in accordance with guidance received from NHS England and Improvement, the ICB’s Standing Financial Instructions, Scheme of Delegation and Standing Orders.  

In year we have continued to test and the strengthen our controls using various tools, as well as benchmarking them against other organisations across the ICS. Our financial policies are continuously reviewed to ensure they align with any new national requirements. 

Going concern 

The accounts have been prepared on a going concern basis. Public sector bodies are assumed to be going concerns where the continuation of the provision of a service in the future is anticipated, as evidenced by inclusion of financial provision for that service in published documents. 

2025/26 planning guidance and financial outlook (draft) 

We have developed a financial plan for 2025/26 which is a breakeven against the expected funding allocation. This forms part of the wider ICS financial plan, which is under significant pressure to continue to deliver improvements in planned care within the funding envelope. This makes delivering current services challenging and increases the requirement for efficiencies and improved productivity across all healthcare providers.  

As a consequence, the ICB continues to lead the system in the development and oversight of a transformation plan to support all organisations to reach a position where they are able to deliver high quality services to the population within their financial envelopes. This is overseen by the system-wide Missions Board.  

The programme of work continues to be reviewed and developed with the 2025/26 focus on maximising productivity of the planned care pathway, ensuring the workforce is aligned with demand and minimising the use of high-cost resources. This is as well as improving the urgent and emergency care pathway, to minimise the length of time patients need to be in hospital. 

Our collective system ambition is to enable the redirection of funds into continuing to address health inequalities and preventing illness. 

Assuring delivery of performance and constitutional standards

Full year data will be available in May and will be updated for the final submission  

***KLOE B2 How has the ICB assured the performance and delivery of the organisations it contracts? ****

NHS England assesses the performance of each ICB through a large number of national metrics. The performance measures (below) represent a cross section within the 2024/25 priorities and operational planning guidance. 

These measures help us to monitor and improve the time patients have to wait to access services in South West London. They also tell us where we need to work with our partners to improve the care that our patients receive.  

A number of important metrics are reported through a monthly ICB Performance Report. The accountability for all the metrics is apportioned across collaboratives and Place within their Partnership Delivery Agreements, and they are reported through the ICB’s oversight framework. 

Elective 

Referral to treatment  

The NHS Constitution gives patients the right to have their non-urgent, consultant-led treatment start within 18 weeks of a referral. 

Following the unprecedented increase in people waiting for treatment after the Covid-19 pandemic, the national priority was to reduce the longest waiting patients. This was measured by,  ICBs working to a trajectory to reduce the number of patients waiting over 65 and 52 weeks. 

For 52 week waits, these increased to 2,538 at the end of February 2025. Whilst this is more than expected, we continue to work with our partners to further reduce waiting times. This includes working to improve our productivity by sharing capacity across NHS hospitals, undertaking initiatives to improve services and reducing inequalities of access, supported by of our Clinical Networks and using independent sector provider capacity, where necessary. 

Diagnostic test waiting times  

Timely access to diagnostic services is essential to support the 18-week referral to treatment pathway. This measure looks at the proportion of patients waiting for a test within fifteen key diagnostic areas. ICBs were given a target to ensure 95% of patients receiving these tests wait no more than six weeks.  

We have made some progress towards this goal by delivering more diagnostic tests than in the financial year 2019/20, before the impact of Covid-19.

Urgent and emergency care 

Accident and Emergency four hour performance (all type) 

A&E waiting times are important for both better clinical outcomes and patient experience. One of the government pledges is that no patient should wait longer than four hours in A&E from arrival to admission, transfer or discharge. In 2024/25, the national plan was to ensure that a minimum of 78% patients arriving in A&E were seen in four hours by March 2025.

We have programmes of work in place for preventing unnecessary admissions and improving internal processes which expedite safe discharge from wards to make the best use of resources. We have invested in a range of initiatives in A&E departments to appropriately reduce demand where patients can access the services they need without attending the emergency department. These include frailty services at the front-door, additional therapy and pharmacy services.   

12-hour breaches 

The initiatives to reduce demand on A&E, where alternative urgent care services exist, as well as those projects to improve flow through the urgent and emergency care system, will also lead to reductions in 12-hour breaches. 

In addition to physical health, a South West London Mental Health Improvement Plan is in place, focussed on improving the pathway for patients presenting in mental health crisis at A&E and reducing delayed transfers of care through schemes such as step-down hostel capacity. The new virtual Section 136 hub has been implemented and is showing benefits with fewer patients conveyed. Work is ongoing to address delayed transfers of care.  

60-minute ambulance handover breaches  

The difficulty with moving patients through their pathway and discharging patients from hospital means that the Emergency Department must hold onto patients whilst waiting for beds to become available on a ward. This means ambulances arriving are unable to handover patients to the hospital immediately. 

This ambulance handover performance measure reports the number of patients waiting over 60 minutes to be transferred to the A&E department.   

Two hour urgent community response 

This measure reports on the urgent community response (UCR) service which aims to provide an assessment and short-term intervention to adults experiencing a health or social care crisis. This support is provided at home, which is often preferred by individuals, and can prevent an unnecessary admission to hospital. 

We continue to work with care homes and 111 providers to increase the referral of suitable patients to the UCR service. In February 2025, South West London achieved 83% of all new requests responded to within two hours, against the national target of 70%.  

Cancer waiting times 

The timely diagnosis and treatment of cancer is vital to support improved outcomes for patients.  

As well as working towards earlier diagnosis of cancers by 2028, there were two cancer waiting time standards which were prioritised, nationally, for 2024/25.  These were: 

• 28-day faster diagnosis standard – patients should be diagnosed with a cancer or benign diagnosis withing 28 days of referral. 
• 62 days referral to treatment (85% standard) – patients should start cancer treatment within 62-days from referral. 

We have delivered strong performance against the cancer waiting times standards in South West London compared to the rest of London and England.  

We continue to work in partnership with RM Partners (the West London Cancer Alliance) which includes NHS acute providers, community services, primary care, commissioners, public health and the voluntary sector to maintain and improve access to cancer services across South West London. 

Cancer 62-day GP referral (commissioner) 

Although this was below the national standard of 85%, this was above the National average and exceeds the 2024/25 ambition of 70%.  

Cancer 28-day faster diagnosis standard (commissioner) 

Mental health and learning disabilities 

Dementia 

A timely diagnosis enables people living with dementia, along with their carers and families, access treatment and support. This enables them to plan in advance how best to manage the impact of the condition; working together with professionals in primary and secondary care services to deliver personalised care plans.  

Severe mental illness (SMI) 

This indicator monitors the proportion of people on the severe mental illness (SMI) GP register receiving six physical health checks within the last 12 months. People with SMI often have a lower life expectancy than the rest of the population due to preventable physical health problems. Therefore, a scheduled annual health check provides an additional opportunity for people with a diagnosis of SMI receive personalised support from their GP. 

Talking therapies 

Around one in six adults in England suffer from a common mental health problem like depression or an anxiety disorder. NHS Talking Therapies provide evidence based psychological interventions for adults. Two key metrics are the reliable recovery rate, which looks at the proportion of people that are moving to recovery after two or more sessions. The other is the access rate based upon the expected prevalence rate of people with anxiety and or depression. 

Whereas access figures show that 33,941 people started treatment between April 2024 and February 2025, which is below our target of getting 36,223 people to start treatment, by this point in the year. 

Annual learning disability health checks 

The standard is to provide annual health checks to people with a learning disability aged 14 years or older. This helps to identify previously unrecognised health needs which may be serious or life-threatening. The 2024/25 national target was to ensure 75% of people on their GP’s learning disability register received an annual check.   

We remain committed to improving the provision of learning disability health checks across South West London. Our learning disabilities clinical leads in each borough are working with individual GP practices to help them to maximise the uptake of annual health checks. This includes making sure that continuous training and support is provided to GP practice staff.  

Addressing health inequalities

***KLOE C1: Has the ICB exercised its functions consistently with NHS England’s statement on information on health inequalities and encouraged its partner trusts to do the same? *** 

Our commitment to reducing health inequalities 

Tackling health inequalities is one of our ICB core commitments. We made health inequalities a key priority in our Joint Forward Plan and in the South West London Integrated Care Partnership Strategy.   

Health inequalities refer to the differences in health outcomes between different population subgroups such as differences in how long we live or healthy lifespan.  

Inequalities in health are largely due to inequalities in society and the unequal distribution of the social determinants of health. These occur across several demographics: gender, age, ethnicity, socio-economic groups, geography, religion, sexual preference, etc.   

There are also vertical inequalities in the utilisation of healthcare in terms of education, income and occupation.  

To reduce health inequalities in South West London, we work together to target the wider determinants of health through our Integrated Care Partnership. This includes:  

• reducing the number of people who are economically inactive 

• working together on ‘upstream’ factors – the factors that impact health beyond someone’s individual characteristics  

• developing Anchor Institutions – large organisations whose long-term sustainability is tied to the wellbeing of the populations they serve 

• the creation of social value in our local economy 

Our ambition  

We want to see everyone living in South West London having equal access to quality care and the reduction of heath inequalities.    

How are we doing this?  

We have made tackling health and healthcare inequalities a priority in our Integrated Care Partnership Strategy and in our Joint Forward Plan. Working in partnership across South West London, we aim to: 

• address the wider determinants of health and wellbeing 

• scale up innovation to improve outcomes for people in our most deprived areas and our most vulnerable people 

• empower our communities to improve their health and wellbeing 

Reducing health and healthcare inequalities requires prevention, community empowerment and individual empowerment and self-care.   

Over the past year, we have built upon the work we did in 2023/24 to better understand our population’s heath and healthcare needs, invest and implement effective preventative initiatives, innovation such as digital inclusion, and working with our communities to improve their health and wellbeing. We have also invested in our community sector through our Investment Fund and have strengthened our governance structure to enable closer partnership work.   

Throughout 2024/25, we have exercised our functions consistently with NHS England’s views as set out in their statement on health inequalities. We have supported our partner trusts to include information on health inequalities within their annual reports. This will encourage better quality data, completeness, increase transparency, and provide a tool to monitor improvements in reducing inequalities.   

For example, St George’s ‘Outstanding Care Together’ programme included looking at their existing healthcare inequalities and there are plans to better address these going forward.    

1.7.2 Improving data intelligence and innovation 

Use of local intelligence is key to help identify emerging issues and to monitor changes in health and healthcare inequalities. Over the past year, we have been developing ways to capture social inequalities in health and healthcare using Health Insights, South West London’s health management system.    

This platform brings together real-time data from health and care organisations across our Integrated Care System, creating an integrated health and care record for each patient. These are used to create dashboards on different topics; for example, long term conditions and vaccination uptake.   

All dashboards enable monitoring by different equality dimensions – such as ethnicity, deprivation, gender, age – which we can use to discover inequalities in delivery or care and health inequalities.   

The data can be filtered for specific groups who experience poor health disproportionately and can be accessed by organisations across our health and care system, including GP practices and hospitals.    

Building on this existing information, we developed a health inequalities explorer dashboard which launched in January 2025. This is providing local, granular data relevant to South West London which is helping us to summarise inequality at scale by giving a score to highlight where the largest number of perceived inequalities and missed opportunities exist. 

1.7.3 Understanding our population’s health and healthcare needs  

To understand our population’s health and healthcare needs, we measure health inequalities across the following eight domains:  

• elective recovery (planned treatment)  

• urgent and emergency care  

• respiratory (breathing issues)  

• mental health  

• cardiovascular disease (heart and blood vessel diseases)  

• diabetes  

• oral health (teeth)  

• maternity (pregnancy and birth) 

We assess inequality in these domains by looking at the three factors which we know contribute to inequality in South West London: 

• deprivation (how poor an area is) 

• ethnicity 

• gender 

A score is calculated for each domain and displayed in tables – known as an inequality dashboard – to help us measure the inequalities more easily . Where the score is above 0.3, it suggests significant inequality.  

Inequality dashboard, scores across eight health domains 

Elective recovery

Urgent and emergency care

Respiratory

Cardiovascular disease

Diabetes

Oral health

Learning disabilities and autistic people

Maternity and neonatal

Areas of health inequality identified across eight health domains 

The following table shows how many times we found significant inequalities in the score for each factor across each of the eight domains. The numbers correspond to the number of times significant inequalities were found. 

*Defined as having an inequality coefficient greater than 0.3

Domains with significant inequality 

Domains with no significant inequality 

Limitations  

This method is helping us to develop our understanding of inequalities in South West London; however, it can be influenced by low population numbers – particularly when looking at very specific indicators – and inequality does not always mean inequity, so we are using these insights alongside our understanding of population need when considering service design. 

South West London Health Inequalities Investment Fund  

South West London Integrated Care Partnership established a Health Inequalities Investment Fund in September 2022 to support the delivery of the partnership’s strategic priorities. Using health inequalities funding from NHS England, the fund aimed to give partners the opportunity to suggest innovative projects that could have a big impact on health and wellbeing across South West London.  

In 2024/25: 

• 39 projects were funded for 15 months to the end of March 2025, 19 of which were new projects.    

• Most projects were for mental health (25% of existing projects, 39% of new projects).   

• 20% of existing projects were on prevention (11% of new projects),  

• 10% of existing projects were for children and young people (6% of new projects) and  

• 10% of existing projects were for homelessness (11% of new projects).  

• 1/3 projects (existing and new) were focused on community empowerment and increasing equity of access to services.   

• 90% of successful applicants were from the voluntary sector.   

Each project was reviewed quarterly by the Health Inequalities Delivery Group which discusses the learning from each borough.    

The final evaluations will be shared and the working relationships between voluntary sector, communities, NHS and local authority will continue despite the Investment Fund ending in March 2025.     

Three of the projects in 2024/25 were provided across South West London:  

Health and wellbeing days for the homeless 

Led by homeless charity Spear, these days provide access to health and wellbeing services for people experiencing homelessness and seeking asylum in South West London, including vaccinations, fibroscans, blood borne viruses testing, breast screening, diabetic retinopathy screening, health checks, smoking cessation and referrals to relevant services (such as drug and alcohol). Attendees also receive hot meals, goody bags, haircuts and financial advice.   

All 22 planned health and well-being days were delivered, reaching over 1,300 people, which exceeded their target. The project made positive progress in supporting the homeless population. Each quarter, between 70-75% of attendees reported that they were better informed about available health services, more confident to approach health services and more confident about managing their own health as a result of engagement. 

Core Connectors 

A national programme which received further investment through the Health Inequalities Investment Fund. It builds on learning from many other community-based initiatives and ‘connector’ roles including vaccine champions, peer advocates and social prescribing link workers. Read more about the Core Connectors programme. 

Community health and wellbeing workers.   

Community Health and Wellbeing Workers (‘Chewies’) are based on a model successfully implemented in Brazil. The model consists of individuals from a neighbourhood who are trained on a wide range of health and social care issues and then visit the households they are responsible for in their own community. Read more about the Community Health and Wellbeing Workers in the Wandsworth Place section of this report.  

Empowering the community  

****KLOE C4: How has the ICB accelerated preventative programmes aimed at those at increased risk of poor health outcomes? ***

Community empowerment is a key objective for health inequalities in our Integrated care Partnership Strategy. It refers to the process of enabling communities to increase control over their lives. We routinely work on community empowerment through our prevention work where we have 35 different types of community link workers including social prescribers. We also deliver health and wellbeing checks in the community and are working on developing integrated neighbourhood teams.    

Core 20 connectors programme 

The National Core20 Connectors programme was a three-year national programme by NHS England as part of its Core 20 plus 5 approach. It builds on learning from many other community-based initiatives and ‘connector’ roles including vaccine champions, peer advocates and social prescribing link workers. This pilot programme ended in March 2025.  

In South West London, further investment was made into the programme through the Health Inequalities Investment Fund. The programme recruits and trains community connectors to capture insights and experiences and work alongside health and care partners to improve access to prevention and screening services for the following five clinical priorities: 

• severe mental illness 

• chronic respiratory disease  

• early cancer diagnosis and  

• cardiovascular disease prevention  

There are approximately 200 paid and volunteer community connectors recruited from Core20 communities from every borough. We also have maternity connectors who share information with our maternity services and others to influence service developments.  

More than 300 events and activities were delivered during the three-year programme, and more than 5,000 people engaged from within our Core20 communities.  

University of Roehampton (a partner in our South West London Health Research Collaborative) has been commissioned to evaluate the programme with a report on its impact due in April 2025 

Community health and wellbeing workers 

Community Health and Wellbeing Workers are based on a model successfully implemented in Brazil. The model consists of individuals from a neighbourhood who are trained on a wide range of health and social care issues and then visit the households they are responsible for in their own community.  

This began in Battersea in 2023 and was extended to the remaining five boroughs in 2024 through funding from the Health Inequalities Investment Fund.  

In 2024/25, around the programme delivered health checks, screenings and immunisations to around 1000 households. Residents were also signposted to community activities.  

Approximately 25-35% of eligible households were engaged within three months. Several important insights have emerged, including the discovery of people with high medical needs not currently receiving formal healthcare or A&E and the number of the people who are struggling to access services.  

Importantly, the pilot has shown that intervention is possible and acceptable to residents. University of Roehampton is evaluating the programme with a report on its impact expected in April 2025.  

Health navigators project 

In Sutton, the Health Navigators Project (also funded by the Health Inequalities Investment Fund) works with residents in the Sutton area.  

Services include blood pressure and BMI checks along with NHS App support and health ‘signposting’ directing to other key services.  

Health navigators engage with residents through GP surgeries, borough events, community groups and estates events. Typically, the project delivers two or more sessions per week across the borough.  

The project has a committed and engaged group of 55 volunteers, and delivered over 2,000 health and wellness checks across 12 months.  

Many of our volunteers have gone on to secure paid work in the health sector. The project has also found that awareness levels and usage of the NHS app remains very ‘mixed’ and there is a lot of scope to educate and inform in this area to benefit local people to access services. 

Improving uptake and coverage of immunisations and vaccinations 

Improving uptake and coverage of immunisations and vaccinations across South West London is important to protect the population from communicable disease.    

During summer 2024 we launched a new programme of grants aimed at parents of children aged under five living in our Core 20 areas to encourage uptake in the MMR vaccine and other childhood vaccines. The grants scheme was developed with the Voluntary, Community and Social Enterprise Alliance.  

In autumn 2024, we launched a further voluntary sector engagement programme promoting the seasonal uptake of covid and flu vaccine. This was supported by face-to-face outreach alongside targeted social media campaigns digital advertising and the availability of information in the languages spoken by our communities.   

Addressing healthcare and health inequalities relating to immunisations is important as post Covid-19 pandemic, we have seen a decline in national uptake and coverage in many of the national immunisation programmes. In South West London there is a growing gap between our least and most deprived areas, particularly for flu vaccination.  

We have an outreach immunisation team who are expanding vaccination sites for flu and Covid-19 vaccinations to include community spaces such as libraries, places of worship, children’s centres, and secondary care environments, concentrating on underserved areas.   

Our outreach team has developed a network of contacts and locations within the voluntary sector and refreshes its regular offer of clinics in response to uptake and local need. The team can support a range of providers working across health care and other settings, such as schools, with delivery of vaccinations.   

Research support network 

For 2023/24 and 2024/25, we awarded funding from NHS England Research Engagement Network (REN) to grow diversity in research. Through this funding, we have set up the South West London Research Support Network, to help local communities, voluntary sector organisations and individuals become more aware of research practices and engage in their own projects.  

Over a cup of tea or coffee, people can learn from one another and develop skills and confidence to become more integrated in the research sphere and potentially leading a project themselves.  

In 2024/25, we used a mix of face-to-face and online cafés to deliver on topics such as how to do an evaluation, survey, write a research bid and do a literature review. We try to host the cafes in accessible locations, working with South London Partnership to source locations that the councils have repurposed or regenerated.    

As each café only hosts 30 people, places fill up fast and feedback has been overwhelmingly positive. We are also developing peer researchers (people with lived experience) and community researchers to be an active part in this network as their lived experience and understanding of a social or geographical community can help generate information about their peers.   

Dental health 

Since 1 April 2023, we have been responsible for dental commissioning in South West London and recognise that many people still struggle to find regular NHS dental care. We are currently looking at where our activity is provided, how contracts are performing in areas of higher need and deprivation. We aim to rebalance activity where there is unused capacity, directing activity to areas with highest need. 

In October 2024, we held our first Dental Day, bringing together dentists, public health experts, Healthwatch, and community groups to address the challenges in accessing dental care across south west London. This event marked the start of a collaborative effort to improve dental service for our communities.  

We are also piloting innovative local initiatives in schools and care homes in areas of higher need, to identify patients who would then be treated at the local practice. The NHS is planning dental reform with guidance expected early in the new financial year. We expect focus on prevention, inequalities and urgent care. 

For Core20plus5 children, we started delivering an oral health project to improve teeth brushing in three to five-year-olds in Wandsworth in September 2023. This project will run for 12 months.      

Tackling digital exclusion 

Digital exclusion is where some people in our community have unequal access or don’t have the ability to use digital devices or technologies. This may be because they don’t have access to the devices that they need or don’t know how to use them. 

Reducing digital exclusion is a priority for the ICB and we are involved in a number of partnership initiatives to improve digital engagement, usage and exclusion across South West London.  

Read more about how we’re reducing digital exclusion in [Digital section] 

Governance structure 

The Health Equity Partnership Group has oversight of all the work being done on health equity (healthcare and health inequalities). This group meets quarterly and reports to the Integrated Care Board, to the Integrated Care Partnership and to NHS England and London Prevention and Equity Board.    

Health equity is achieved through prevention work, community empowerment and individual empowerment and self-care.   

The group oversees and delivers the health inequalities and prevention aims of the Integrated Care Partnership Strategy and the Joint Forward Plan. The group meets monthly and is supported by three ‘action’ groups:  

• Prevention Delivery Group 

• Health Inequalities Delivery Group  

• Immunisation Delivery Group 

• and the South West London Health Research Collaborative 

The group focuses on what we can do at scale or in collaboration and monitors the progress of Place based and South West London level projects that were funded by the Health Inequalities Investment Fund in 2024/25.  

***KLOE C3: How successfully has the ICB restored priority services in an inclusive way? ***

Over the past year, work has moved on from recovery post Covid-19 pandemic to addressing the ongoing healthcare inequalities in care and access. The SWL Acute Provider Collaborative (APC) has a focus on the health inequalities related drivers of missed outpatient appointments.  

For example, local and national data shows that residents living in the most socially deprived areas (Core20 postcodes) often face more barriers to accessing hospital care. Over 2024/25, the SWL APC worked on developing ways of engaging more proactively with these residents, to improve care access.   

Similarly, the ICB has also been developing workstreams on reducing inequity in avoidable ED admissions, outpatient pathways, and primary care cancer diagnosis pathways. This programme of work started in 2024/ 25 but will continue throughout 2025/26.   

What have we done?  

Our Population Health Management Health Insights reporting has been further developed to dissect and overlay a lens to our South West London waiting list as a whole but also at specialty level. This has been incredibly valuable as we have a more granular understanding of our demand profile. The dashboard continues to look at key demographic information for those on our waiting lists including long-term conditions, age, gender, ethnicity, and deprivation and this has been key to our outpatient and pathway development.  

This means we have been able to continue to:  

• Evaluate the impact of elective recovery plans on addressing any identified or unresolved disparities in waiting lists, including for clinically prioritised groups of people. 

• Evaluate the impact of the surgical hubs in South West London and align to the development of the Croydon Surgical Hub and how these have been able to support elective recovery but also how they serve the future model of care. 

• We have also undertaken a review of our frequent attenders’ profile across our five Trusts by linking our South West London waiting list data with the dataset we have from primary care. We have done further analysis on this by deprivation, ethnicity and long-term conditions for the patients on waiting list which has shown us that: 

• A small number of ‘frequent attender’ patients account for a larger proportion of the total referrals waiting for treatment and ‘consultant-led activity’ when looking at the national and wider south west London data 

• At the time of analysis, approximately 13 to 15% of patients on our patient treatment list were on more than one pathway 

• 7% of South West London patients accounted for 32% of the consultant led appointments. Patients on the Croydon Healthcare Services waiting list have got the highest Core 20 deprivation score at 36.8%, 36.4% of Black and Asian Ethnic patients and 12% of patients are diagnosed with depression as a long-term condition.  

• A workstream reporting to our Outpatient Board was established with an initial action for all organisations to validate local findings and report back on individual actions.  Initial investigation suggests there is a direct correlation between patients not attending their appointments when those patients are on multiple pathways.  

Another key area of focus last year was to work towards tackling inequity in waiting times within South West London and supporting London where we can.  

Specific examples this year have included:  

• St George’s providing mutual aid support to Kingston in lipid services to help stabilise and reduce the growing waits at Kingston Hospital. This has meant waits have reduced from 110 people waiting for 52 weeks to less than 50 people. We are doing this whilst we consider a more sustainable South West London model for this service. 

• Supporting South East London’s children’s ear nose and throat services to reduce the number of people waiting 78 and 65 weeks, enabling people referred from South West London to be treated locally – meaning they are seen more quickly – while shortening the waiting list in South East London. 

• We have revamped and launched a revised system mutual aid framework.  Opportunities to provide mutual aid and address inequities in waiting times are addressed at the fortnightly South West London system group facilitated and coordinated by our Acute Provider Collaborative. 

Whilst inequity and inequalities offer different challenges and response, we recognise by underpinning the analysis of our patient treatment lists we get a more granular understanding as to where we can target specific health inequalities across our system. 

• Last year we began a major work programme to increase the use of the trusts’ patient portals and NHS app to improve patients’ ability to manage their outpatient appointments and ongoing care from their smartphones. Digital inclusion is an important focus of this work.  

• We have committed to piloting a South West London referral support service for Ear, Nose and Throat (ENT) during 2024/25, which will address waiting time inequity to access ENT secondary care services between our six boroughs and will make that all patients access the same steps in their pathways. 

• We have committed to developing new models of care for cardiometabolic secondary care services next year, to reduce the number of multiple appointments that patients are currently asked to attend. This work will take into account the role of social deprivation and other health inequalities in these conditions. 

Our priorities for 2025/26 include:   

• Expand on the work already started to improve outpatient care access for the Core20 population 

• Explore additional evidence-based ways of tackling health inequalities experienced by people waiting for care on waiting lists 

Acute care

Acute care provides time sensitive and rapid interventions to people in areas such as planned or elective care, urgent and emergency care, cancer, and maternity services. Services include preventative care, diagnostics, outpatients, day-case and inpatient treatment as well as rehabilitative care. Services are delivered mainly in hospital settings but also in the community. 

We have four NHS acute trusts in south west London:   

• Croydon Health Services NHS Trust   

• Epsom and St Helier University Hospitals NHS Trust  

• Kingston Hospital NHS Foundation Trust  

• and St George’s University Hospitals NHS Foundation Trust  

They work together in a group called an Acute Provider Collaborative to improve the quality of services and clinical outcomes for people in south west London.   

The main priority of the collaborative is to improve planned care in hospitals – making the most effective use of their collective resources, improving efficiency and quality – so that patients are seen in the right setting at the right time.   

Our trusts also work with partner organisations to integrate health and care services in each borough as well as throughout South West London.   

We want to deliver outstanding acute care and services that meet the needs and expectations of local people and improves their outcomes, access, and experience. We want to work with partners to improve the health and wellbeing of local people, reduce health inequalities and increase preventative care. We want to ensure the sustainability of services into the future, building and empowering our people and investing in modern estate and digital tools to support improved care.  

Last year, our actions to achieve this included:  

Working to improve patient outcomes, access and experience 

• We have continued to make every effort to ensure timely access and reduced waiting times so that no patient is waiting over 52 weeks for treatment. We now have the lowest percentage of 52 week waits compared to other ICBs in the country. We have continued working together across our hospitals to provide mutual aid where surges in demand or inequity in access has been identified at a specific hospital or across the system.  

• Through the Acute Provider Collaborative, we have maximised the use of surgical capacity while also reviewing and readjusting the flow of patient activity to support system needs – for example Croydon has provided lung function tests and echocardiograms for Epsom and St Helier patients. 

• Work has been done to ensure the roll-out of a single referral model for ear, nose, and throat services. 

• We have worked to reduce waiting times at all stages – from patients needing an ambulance through to people leaving hospital for home. 

• NHS South West London has supported the ongoing improvement in the experience patients have of NHS care. Areas of focus include improving:  

• the hospital environment focusing on safety, quality, and experience of care for inpatients including ward accreditation schemes.   

• the amount of time it takes to respond to complaints.   

• experiences of patients and their carers when they are discharged from acute hospitals, providing them with better education and resources to feel supported.  

Developing more preventative care and providing right care in the right place 

• Work in 2024/25 has primarily been focused on better identification of risk factors such as alcohol, tobacco and excess weight and optimisation of secondary prevention for example screening and compliance with treatment in long-term conditions such as diabetes and cardiovascular disease.    

• There are nine clinical networks in South West London, which include a wide range of projects to promote preventative approaches and early intervention in the community. 

Addressing health inequalities and ensuring there are no barriers in patients accessing acute hospital services 

• All acute trusts in South West London have undertaken analysis on how they can reduce healthcare inequalities and have developed plans or strategies on how they can contribute to the reduction of health inequalities. 

• Through the Acute provider Collaborative we have developed ways of engaging more proactively with Core20 residents, to improve access to care. Work is ongoing at each acute trust to address other barriers to access. The Acute Provider Collaborative (APC) has been working to understand how health inequalities relate to missed outpatient appointments. For example, local and national data shows that residents living in the most socially deprived areas often face more barriers to accessing hospital care. 

Investing in infrastructure to ensure modern welcoming environments with which to deliver care   

• Surgical capacity continues to be maximised in Kingston and Croydon with the help of operating theatre improvement programmes. 

Transforming outpatients by investing in digital technology so patients have control over their outpatient journey  

• NHS South West London has invested in digital technology so patients can take control of their outpatient experience and can access and manage their appointments online. Work to expand the patient portal has seen almost 500,000 people register so far – nearly 75% of those invited. 

• We have carried on our work with primary and community care colleagues to expand GP advice and guidance and ways of referring people so they receive support quickly without the need for a specialist hospital visit. For example, clinical networks have focused on access to specialist advice, including the launch of a ‘happy hour’ for urology services – informal sessions that allow primary care clinicians to connect with urology leads. 

• By allowing patients to organise follow-up appointments where it is safe to do so, we have reduced unnecessary visits to hospital and improved productivity. 

Promoting choice and personalisation for patients and their carers 

***KLOE B5: How has the ICB promoted choice and personalisation for patients and their carers and/or representatives? ***

Personalised care represents a new relationship between people, professionals and the health and care system. It provides a positive shift in power and decision making that enables people to have a voice, to be heard and be connected to each other and their communities. 

It’s about integrating services around the person, including health, social care, public health and wider community services. It provides an all-age approach, from maternity and childhood right through to end of life, encompassing both mental and physical health and recognises the role and voice of carers. 

It recognises the contribution of communities and the voluntary and community sector to support people and build resilience. 

All patients also have a legal right to choose which hospital they are referred to for their first outpatient appointment, when they are being referred for treatment. 

Patients should be able to decide between a minimum of five hospitals, using information about waiting times, travel distances and quality to help them make a choice using the NHS App or website, or with help from their GP or the National Referral Helpline. 

Last year, our actions to achieve this included: 

Promoting choice and personalisation 

• Worked with GPs to ensure that they can consistently promote the legal right to choose to patients and help facilitate their choices. 

• Commissioned a provider to work directly with practices on their social media presence to support greater use among specific patient groups and increase awareness and understanding of general practice. 

• Commissioned a provider to optimise practice websites across our boroughs, ensuring that information is accessible and easy to understand and navigate. 

• Worked with Healthwatch colleagues to develop a better understanding of how Accessible Information Standards are delivered in general practice, leading to an increase in practices reporting understanding and tailoring more information to suit individual patient needs. 

• Introduced Interface Leads across all four acute trusts and the ICB to enhance communication and understanding between primary and secondary care colleagues. This has led to standardised principles to clarify which clinician is responsible for which diagnostic test, making things clearer for patients. We are also working on providing patients with greater information about their secondary care provider options. 

• The development of Integrated Neighbourhood Teams is helping promote the personalisation journey through seamless continuity of care for patients, so they feel there is a care plan owned by them that all professionals in their care know and understand. Read more about Integrated Neighbourhood Teams 

• Via the use of digital champions for the NHS App, we have met with hundreds of previously digitally excluded patients to work with them on how to get the best out of using the NHS App, for example with ordering repeat prescriptions easily instead of waiting for long periods on the phone. Read more about digital exclusion 

• Increased the uptake of Pharmacy First and seamless transfer of care from practices to pharmacy reducing duplication for the patients in having to explain their symptoms to multiple health professionals. Read more about Pharmacy First

• Worked with GPs on their systems for offering choice to patients and to make sure that the approaches to this are consistent throughout our GP surgeries. 

• Promoted the right to choose to local people through our website and social media and through contact with their GP surgery. 

• Supported our NHS trusts to help patients exercise their right to choose by changing their provider, which helps reduce waiting times and achieve better outcomes. 

• Worked with local communities to improve patient awareness and engagement of chronic kidney disease risk factors, healthy lifestyle information and the treatments available to keep well. “Be kind to your kidneys” awareness and well-being events were held at Tooting Market and Roehampton in Wandsworth during Autumn 2023, and more events will follow in 24/25 across all six boroughs.  

• Introduced a peer-to-peer mentoring programme for children and young people with sickle cell disease, as part of a pan-London roll out of a pilot programme in North East London. The pilot will aim to support young people by providing emotional support, improving understanding and management of the condition, help patients with the transition from children to adult services and encourage patients with sickle cell to engage in their local community to support others living with the condition. The pilot is due to begin in 2024/25. 

• Led the implementation of the Universal Care Plan across London – a digital care plan “sharing what matters to you” with everybody who cares for you – the ambulance service, GP’s, in hospital or at home. The Universal Care Plan is an NHS service that enables every Londoner to have their care and support wishes digitally shared with healthcare professionals across the capital. A care plan is created following a conversation between a healthcare professional and the person in their care. 

• A programme to support care homes to access the Universal Care Plan has seen an increase from 18% of care home who have access to almost 50% of care homes having access has supported care home residents and their families to have greater choice in decisions and plans about their care, particularly at the end of life. Work has been undertaken across care homes for older people and care homes for people with a learning disability. 

• A project piloting the use of small one-off personal health budgets/grants to support discharge for those patients medically fit to leave hospital – but where barriers in their home environment prevent this. The project was piloted in 2023/24 at St Helier hospital. Key learning from this project is captured within an evaluation report. 

• Targeted vaccinations programme for people with learning disabilities and autistic people supported by investing in community connectors. 

• Shared decision-making audit completed in primary care and findings including areas of good practice were shared with primary care networks to support continuous improvement in supporting patients with shared decision making. 

• Continue to focus on delivery of personalised care and support plans and personal health budgets to the “right to have” groups of patients – adults in receipt of continuing healthcare, children in receipt of continuing care, people who meet eligibility criteria of NHS wheelchair service will be eligible to a personal wheelchair budget and people eligible to after care services under section 117 of the mental health act. 

• A Hydration project was undertaken with care homes and is being piloted with domiciliary care and acute hospitals which uses culture change to increase fluid intake through the “But First a Drink” scheme. Training alongside the scheme promotes a wider range of choice in options for fluid intake. 

• The development and promotion of self-referral pathways to Urgent Care Response services in the community promotes choice for individuals in the community requiring urgent care. A pilot winter scheme: Care Banking, enables rapid access to low-cost items and support which can facilitate a speedier discharge from hospital, thereby giving some patients the choice of an earlier discharge. 

• The Intensive Support Service, another winter scheme, provides assessment for people in hospital with behaviours that challenge who require a Care Home placement. By developing a support plan, the person’s behaviour can be supported and Care Homes have a plan. This has opened up choice in care home placements available in this situation. 

Developing social prescribing 

• Primary care networks support, develop and deliver personalised care to local people through social prescribing link workers, health and wellbeing coaches and care coordinators roles. The roles connect people to activities, groups and services in their community and support local system priorities informed by population health management, health inequalities and local knowledge. The roles enable non-medical community-based and holistic support alongside medical treatment as part of a personalised care approach. 

• Began a pilot across Kingston and Richmond using autism social prescribers to support people referred to Your Healthcare. The autism social prescribers signpost people into the local mental health support available for people with autism and local community groups.  

• Completed an evaluation of the Battersea Youth Clinic, an innovative model delivered within a Battersea GP surgery supporting children and young people with what is important to them and addressing any unmet need that is affecting a person’s health and wellbeing. The review has informed further development of the model as well as provided shared learning across south west London.  

• NHS social prescribing link workers began referring children aged 11 to 18 to a new ‘Action For Autism’ movement therapy programme, helping them to gain confidence with social and language skills. 

• A pilot scheme at St George’s and St Helier Hospitals, which took social prescribing into hospital pain clinics has reported overwhelmingly positive results for people living with chronic pain. Findings from a Health Innovation Network South London report showed that people living with chronic pain welcomed the support.  

Making improvements to referral systems in GP surgeries and hospitals 

• We have reviewed referral management centres, clinical assessment services and referral assessment services across NHS trusts in South West London to make sure that they are able to support the new requirements and provide it in a consistent way. 

Improving inter-hospital transfers 

• We have been strengthening processes for the transfer of patients from one hospital to another, to help reduce waiting times and give people greater control over where they receive their care. 

Developing our policies and procedures 

• We have updated our policies and procedures to make sure that compliance with patient choice is included in how we monitor our contracts with hospitals and other healthcare providers. 

• We have developed a more robust provider accreditation process to help ensure compliance with patient choice. 

Cancer

Cancer is the leading cause of death across South West London and we know that as our population gets older, the chances of people getting cancer at some point in their lifetime increases. We also know that the more cancers we are able to diagnose early, the more people will survive to live with and beyond cancer. 

To support earlier diagnosis and more effective treatment, we are encouraging more people with possible cancer symptoms to come forward and to attend cancer screening appointments.  

Our ambition 

We want to save more lives in South West London, through earlier diagnosis and reducing inequalities across cancer pathways.  

For those people with symptoms suggestive of cancer, we want to make sure that we act quickly so that no one has to wait more than 28 days to receive their diagnosis, and no more than a further month to start their treatment. 

The number of people seen for an urgent referral for suspected cancer this year increased by 4% compared to the same time period 2023/24, with a total of 62,779 people from South West London seen on an urgent pathway between April 2024 and the end of January 2025. 

Our actions to achieve this included: 

Working to reduce variation and optimise care  

• Continued to tackle the variation in early diagnosis across South West London, working towards 75% of people receiving an early cancer diagnosis, particularly focusing on those with the highest need. The Lung Cancer Screening Programme (previously Targeted Lung Health Checks identifies lung tumours at an earlier stage, which helps reduce the increased rates of late-stage cancer diagnosis in our more deprived populations. 

• Since going live with a new provider in October 2023 in South West London we have delivered 24,919 lung health checks and 7044 scans. 

• This means the whole of Merton, Croydon, Sutton, and Wandsworth have had the programme rolled out and the high-risk community in Kingston has started roll out.    

Working to reduce inequalities in screening programmes and increasing uptake  

• Improved our ability to identify communities that are not being reached in screening programmes, by tracking demographic characteristics against cancer staging data, and use this information to develop targeted engagement with communities.  
   

• Our cancer screening dashboard has shown that bowel screening rates are 21% lower among the most deprived groups when compared to the least deprived groups in South West London. We have engaged with these more deprived groups, particularly focussing in Croydon, which include Asian Bangladeshi, Asian Pakistani and white eastern Europeans, and aim to launch a bowel screening campaign to coincide with Bowel Cancer Awareness month in April 2025. This campaign will also target men, who continue to be a lower uptake of bowel screening than women. 

• Worked with partners to remove inequalities in the uptake of national cancer screening programmes.  

• As part of our summer grants programme, a range of activities to raise awareness of cancer signs, symptoms and screening were developed through 63 community organisations. 

• We are utilising digital marketing and social media can play a role in increasing cervical cancer screening in women under 30 and worked alongside other London Cancer Alliance colleagues to jointly develop and deliver a campaign to coincide with the summer Olympics specifically focussed on young women who are less likely to participate in Cervical Screening. 

Working with places and primary care networks to diagnose cancer earlier  

• Continued implementation of cancer referral guidance, resulting in 84% of patients urgently referred for a lower gastrointestinal cancer investigation received Faecal Immunochemical Testing (FIT) in primary care to help assess their risk. 

• Working with GPs in Croydon to improve cancer awareness, insights into care and PCN working via a capacity building programme to improve early diagnosis  

• Proactively engaged with groups less likely to come forward with cancer symptoms and develop interventions that give people the confidence to speak to their GP about their symptoms so that we can diagnose cancer earlier. 

• We worked with a wide range of organisations reflective of our diverse communities to understand what would help support people to prepare for a GP appointment, should they have potential signs or symptoms of cancer.  We are using this feedback to develop a guide to support dialogue between reception, clinician and patient. 

• In January to March 2024, we worked on a programme to send SMS texts to patients over 18 in Croydon to enhance awareness of cancer. This encouraged them to see a GP if they have signs or symptoms of cancer as part of our Help Us Help You campaign.   

Improving diagnostic and treatment pathways  

• By working with trusts in South West London to improve cancer patient pathways, hospitals delivered consistently top quartile performance on the cancer targets, with all delivering the new faster diagnosis standard of 80%, and all exceeding the requirement to treat 70% of patients within 62 days.  

• Lung cancer diagnostics is a particular focus, and in 24/25 a new joint service to deliver the EBUS test at the new Oak Centre in the Sutton Royal Marsden Hospital in partnership with St George’s. A network approach to booking has been developed to ensure all patients in South West London with suspected lung cancer are able to access this service rapidly. 

Developing more personalised holistic care 

• Ensured that all patients across South West London are offered a consistent approach to personalised care and have the right support in place to manage their condition and aftercare. 

• Developed a patient and communities strategic forum to ensure we are involving patients and public in the co-design, oversight and scrutiny of our cancer programmes, including the co-design of an innovative, whole-system approach for cancer prehabilitation and rehabilitation. 

Accelerating innovation, spread and adoption 

• Embraced innovation to introduce new screening programmes, less invasive tests for people with cancer symptoms and increase genetic testing to identify those with a higher family risk of cancer. We have worked with the Liver network to roll out screening for HCC, which is a cancer which impacts on more deprived communities.   

Children and young people

Improving outcomes for our children and young people is a key priority for South West London and we are taking actions to improve quality of care across the system. 

Our ambition 

We want our children and young people to have the best start in life, a good education, enabling them to live well, flourish and achieve their full potential. We want to support parent and carers, at local early years settings and schools, tackling inequalities and raising education attainment. We want children to be safe, their needs and aspirations recognised and achieved, with support where required to develop independence and preparation for adulthood. 

Last year, our actions to achieve this included: 

Supporting children and young people with special educational needs and disability (SEND) to be more independent 

• Invested in three pilot intensive support services, to provide specialist therapeutic support for autistic children and young people delivered by South West London and St George’s Mental Health Trust and Croydon Health Services NHS Trust. This is part of our aim to develop a new model of care in South West London to improve specialist community neurodevelopmental service provision for autistic people and people with learning disabilities. 

• Developed our dynamic support register (DSR) process and prepared the digital platform, which we aim to launch in April 2025. The DSR will help prevent unnecessary hospital admissions and the digital platform will enable improved oversight, reporting and a more efficient process. 

• Developed an autism dashboard with a small common dataset across all our commissioned national diagnostic assessment providers.  

• Launched a new model for the south London specialist community forensic intellectual and neurodevelopmental disabilities (FIND) service. There are now three teams aligned to each of the mental health trusts in south London.  

• Began scoping the supported housing pathway and model for people with a learning disability and autistic people stepping down from adult secure services to live in the community. 

• Continued implementation of the reasonable adjustment digital flag (RADF) and associated changes within our services to help people obtain reasonable adjustments for those who need it and ensure equitable access to care. 

• Continued to implement the learning from the lives and deaths of people with a learning disability and autistic people (LeDeR Programme). Read more about the LeDeR programme 

• Clearly established a governance and accountability structure around SEND, with consistent reporting into the system from Designated Clinical Officers. Despite workforce challenges, we now have a fully staffed Designated Clinical/Medical Officer team at Place, supporting delivery of the SEND agenda through strong collaboration with local partners.  

• Made significant progress in developing the South West London SEND data dashboard, in collaboration with partners across the system. This will support oversight and assurance of statutory delivery. 

• Worked with voluntary sector partner PlayWise to co-design and pilot the Support Passport – a personalised document supporting children and young people with SEND across health, education and leisure settings. The tool has been warmly received by families and professionals and is improving transitions and consistency of care. 

• Improved the quality of health advice submitted as part of Education, Health and Care Needs Assessments (EHCNAs), supporting more effective and timely planning for children and young people. 

• Continued to increase uptake of annual health checks for people with a learning disability, using check data to support planning and improve access to care. 

• Shared a co-produced, youth-led health education film across the system, featuring young people with SEND sharing their preferred ways to access health services, how they want to be treated by healthcare professionals, and how best to communicate with them. The film supports improved engagement and understanding across services.  

• Took part in the Local Government Association SEND Peer Review in Merton in March 2025. Reviewers highlighted strong inclusive practice, trusted relationships and shared ambition across the local SEND system. Recommendations included embedding co-production, improving evidence of impact, and developing a shared definition of complexity. 

• Contributed to the national thematic review of preparation for adulthood arrangements in May 2024. Positive feedback in Wandsworth recognised strengths in strategic planning, employment, and inclusion. Areas for further development included transition to adult services and improved shared care for attention deficit hyperactivity disorder (ADHD) and mental health needs in young people aged 16–25. 

Improving oral health for children 

• We are worked with local authorities to support oral health improvement initiatives, including delivery of toothbrush packs and early years supervised brushing programmes. 

• We implemented a South West London Dental Engagement Plan which aims to improve access to primary care dental services for children and young people who do not have a dentist.    

Improving our routine childhood immunisation rates 

• We’ve continued to work with NHS England (the commissioner of immunisation programmes) to implement the National Vaccine Strategy in London by devising and implementing a South West London wide delivery plan to support London region’s ambitions.   

• The cumulative count of confirmed measles cases in London in 2024 was notably higher than in recent years and we supported the MMR campaign to drive uptake through a focussed communication and engagement plan, which targeted the areas of lower uptake.   

• Coverage of completed routine childhood immunisation schedule remains stable with almost three in four children aged five years old with completed MMR course of vaccinations in 2024. We continue to strive to achieve the World Health Organisation recommended level of 95% across all routine childhood immunisations.     

Working to improve care for childhood asthma 

• Agreed a standard asthma care plan and digital platform for children and young people across South West London. 

• Used South West London asthma data to improve the management of asthma, reduce the need for hospital care and target resources to more vulnerable groups. 

• Continued monitoring the use of asthma bags to see if they help to reduce emergency department attendance. 

• Developed a children and young people’s asthma workplan, which we are using to develop a South London Asthma Delivery Plan across South West and partner in South East London. 

• Continued embedding the Child Asthma Plan by the London Babies, Children and Young People’s team. This will help children and their care givers understand their asthma and self-manage for better outcomes. 

• Launched a pilot project in October 2024 to measure the quality of air experienced by 40 children in four primary schools in Merton. This is helping us to understand the impact of the environment on children with asthma and provide evidence that would inform the design of future asthma services. Delivered a South London Asthma Summit alongside South East London ICB colleagues to motivate, focus and drive forwards Asthma 

Learning from child deaths 

We are working towards South West London Integrated Care System becoming a learning health system where all organisations draw on areas for improvement and learning.  

Our priorities in this year included:  

• Public health/promotion in community education as it relates to closer interaction with housing on the elimination of damp and mould conditions in homes where children live to ensure homes are fit for habitation and comply with national existing housing maintenance and repair guidelines.  

• Assurance of what arrangements are in place to improve safety netting advice for parents who attend accident and emergency and urgent care treatment centres for children with a recent history of fever and temperature.  

• An assurance there have been improvements in the availability of mental health assessments to reduce referral waiting lists and improved capacity for testing of high-functioning young people who exhibit indicators of Attention Deficit Hyperactivity Disorder (ADHD)/ Attention Deficit Disorder (ADD) Autism or possible neurodiversity or other specific learning difficulties at the secondary school level, not initially identified at the primary school level. 

• A strategy to improve communication between professionals, particularly in circumstances where more than one agency/service is managing the care of the child. To encourage mechanisms for feedback and peer review to refine best practices and to address issues. 

• That services take an integrated approach to find out why some guidelines that are in place for care provision of patients, are not always being followed. To correct the anomalies that exist in those procedures that disrupt workflow, to improve the alignment of the policy to the actual real-time activity on the units in times of high activity and in compliance with national guidelines. 

• Establishing a Practice Partnership for Safeguarding Children across South West London made up of all health and care professionals supporting safeguarding for children. 

Our activity in South West London this year has included: 

• Complications with Excessive Weight (CEWs) clinics have been rolled out in St George’s Hospital. The aims of this clinic are to identify factors affecting severe obesity, treat associated complications, and consider individualised holistic plans for Children and Young People.   

• Sustaining the implementation of Mental Health Champions through Emergency Departments. 

• Supporting implementation of the Paediatric Early Warning System (PEWS). This is a tool that helps professionals to recognise and respond to any deterioration in the condition of children or young people in a healthcare environment.   

• Supporting simulation training for urgent maternal admissions and declaration of obstetric and neonatal emergencies.  

• Increasing our interactions with mothers antenatally and postnatally on safer sleep surfaces for babies and improving in communication with fathers on safer sleep messaging.  

• Leading a South West London Practice Partnership for Safeguarding Children, made up of all health and care professionals supporting safeguarding for children. 

Community care

Community health services care for people across the life stages – from the health visitors who look after new babies to district nurses providing end of life care. Staff visit people in their own homes or see them in many different settings, such as health centres, community hospitals and rehabilitation clinics. As such, they provide care when and where it is needed, preventing ill health and keeping people out of hospital. 

The crucial nature of these services has been recognised by the government, which made hospital to community care one of the big shifts central to its NHS 10-Year Plan. 

Community care teams work closely with other professionals including GPs, social workers and the voluntary sector to help people retain their independence and improve quality of life.  

These services are particularly important in bridging the gap between hospital and home, ensuring people can go home as soon as they are medically fit, making a full recovery and avoiding readmission. 

In 2024/25 we began a six-month review of community services to help us direct our resources in the right way across South West London. Through the review, we want to understand how services are currently being delivered and where there is local variation so we can meet our population’s needs. This includes looking at what could be done differently, how services are split between different providers and how digital technology is being used. 

As part of the review, we are working with Healthwatch colleagues to gather insight with a focus on engaging key service users including housebound patients, children and young people and those receiving end of life care along with their families and carers.  

Last year, our achievements included:  

• Our hydration pilot has reduced the number of emergency calls for urinary tract infections (UTIs), reduced UTIs, and increased the amount of fluid drunk by care home residents. The two-year pilot commissioned by NHS England, introduced the #butfirstadrink behavioural change and teamwork approach to improve hydration for people aged 65 and over and relieve pressure off the system.  

• We increased referrals to the two-hour Urgent Community Response service from both patients and healthcare professionals from 25,550 in 2023/24 to 26,455 (as of January CSDS data) in 2024/25, representing a 3.54% increase so far. 

• We increased the use of the Universal Care Plan by people in care homes and those with frailty and dementia – boosting take up from 66 to 147 Homes, so 81 Homes and 1826 Beds in total (48% of current target Live in the last year), increasing the number of care plans created for residents by 282.  

• Our Social Care Digital integration team have support over 90% of Care homes and over 70% of Domiciliary Care Agencies to achieve standards met on the Data Security Protection Toolkit. This is a gateway to wider integration with the NHS to better support our population holistically.    

• The team have also supported almost 88% of Care Homes to implement Digital Social Care Records in Care Homes so that records are kept digitally and not just on paper. This has progressed by over 30% in this year. 

• The Data Security and Protection Toolkit and the introduction of digital social care records has paved the way for digital integration across health and social care. We have moved from 10 Care Homes to 78 Care Homes in South West London who can now access the One London Shared Care record to better support their residents. This has helped to facilitate earlier discharge, prevented readmissions and prevented missed outpatient appointments. 

• The ground-breaking Red Bag scheme that was launched in Sutton to give care home residents going into hospital an easier stay and quicker discharge has been added to the Science Museum Group Collection in Swindon. As well as giving reassurance to patients, the Red Bag provides hospital staff with quick, up-to-date information and medication requirements, reducing the time taken to make any follow-up inquiries. 

• A winter initiative in Sutton and Merton GP practices has facilitated earlier identification of people at the end of life, provided proactive care planning which is shared on Universal Care Plans, and enhanced care where required through Doula support and emergency medication provision if needed. 

Diagnostics

Making sure that people can access diagnostic services quickly, so they can start to receive the most effective treatment as soon as possible, is hugely important in determining clinical outcomes and getting people better sooner. We are committed to providing responsive, high quality diagnostic services across South West London.  

Diagnostic services include scanning services (ultrasound, CT and MRI scans), pathology services (blood tests), physiological sciences (including audiology and echocardiography), and endoscopy services. We want to increase access to high quality, fast diagnostic services for all patients. In doing this, we want to ensure that our patients’ experiences are improved, and health inequalities are eradicated. 

Over 85% of South West London patients who need access to a diagnostic test or scan are seen within six weeks and we continue to strive to improve access.  

Demand for diagnostics services across South West London remains significant. Referrals to diagnostic services come from all types of services, including emergency care, primary care, elective and outpatient services, inpatient care, and cancer services. Our modelling predicts that by April 2025 demand for the four main diagnostic types of imaging, endoscopy, echocardiography and audiology – will increase by 30% across South West London.  

Over the last year the challenges we have faced are consistent with those set out in the 2020 independent review of NHS diagnostic services  Diagnostics: Recovery and Renewal by Professor Sir Mike Richards, including:   

The challenges we faced 

• Capacity expansion to meet current and forecast demand: High demand is causing patients to wait more than six weeks for a diagnostic test/scan.  

• Workforce: Significant challenges in recruitment and retention is increasing reliance on agency staff. Lack of sustained and consistent access to training is impacting on our ability to grow our own.  

• Equipment: Majority of the equipment we have needs replacing and we need access to new and modern technology to improve the quality of care we provide.  

• Digitalisation: Lack of a single diagnostic digital platform continues to impact on our ability to enhance connectivity and interoperability across South West London. 

• Health Inequalities: We know that people in more deprived areas have more co-morbidities and more complex health needs. Across South West London, pathways and practices vary, leading to inconsistencies in patient access to care, longer wait times or limited-service availability depending on their location. 

What we did

Increasing diagnostic service capacity 

• Better use of current capacity through improved patient booking services and expanding service provision through 6/7 day working. 

• Improving waiting list information, to ensure patients are being booked into available appointments, resulting in reduced waiting lists and higher proportion of patients seen within six weeks (South West London is the second best in London). 

• Collaborative working across our diagnostic services in South West London has enabled us to deliver an additional 1,600 echocardiography tests, 1,000 Magnetic Resonance Imaging (MRI) scans, 350 colonoscopy procedures and 150 Non-Obstetric Ultrasound Scans (NOUS). 

• By upgrading some of our technology and new machines available to us we have been able to deliver additional 6,000 MRI scans and 6,200 X-Ray tests.  

Addressing health inequalities in accessing diagnostic services 

• We have used Core20plus5 and other health inequalities data to ensure that new community diagnostic centres are in locations where they are accessible by population groups with the greatest need, including in the areas of the highest deprivation in South West London.  

• We have three fully functional CDCs, located across South West London helping reduce health inequalities by providing quicker, more accessible diagnostic tests closer to where people live, particularly in areas of deprivation, ensuring timely detection and treatment for all.  

• Through these CDCs we have delivered a total of 726,000 additional scans/tests.  

• Increased our capacity through additional equipment: (five Computerised Tomography (CT) scanners, three Magnetic Resonance Imaging (MRI) scanners, 13 Ultrasound (US) Scanners, three Endoscopy stacks and six Echocardiography machines).  

• We have established “one stop” clinical pathways to enhance patient experience whilst ensuring patients get appropriate and timely clinical care. Our “One stop” clinical pathways include: “Breathlessness” pathway in Croydon, “Abnormal Bleeding” in Women pathway at Croydon and Queen Mary’s Hospital, and a “Paediatric Asthma” pathway at Queen Mary’s Hospital.  

• We have established a “CT Pancreas” pathway which enables GPs to directly refer patients to get a scan which aids earlier cancer diagnosis.  

• We have introduced the “Trans-nasal Endoscopy pathway” which enables faster access with significantly improved patient experience of the procedure. 

• By establishing a monitoring system, we are working to further better understand groups that experience challenges in accessing services with that information being used to help us develop five-year plans to address inequalities in access.   

Workforce Development  

• We have been working through initiatives to enable South West London become an attractive place to work.  

• Through the South West London Imaging Network we have piloted an Imaging Training Academy, which has delivered over 400 hours of ultrasound training and multiple study days enabling training of 33% of the imaging network workforce.  

• We have also increased training opportunities (to the value of £265k) for endoscopists and sonographers.  

• We have enhanced training for echocardiographers by securing a practice educator post (value of £100k).   

• Work has been done to predict the workforce capacity and requirements to meet growth in demand and the expansion of diagnostic services over the next five years 

Accelerating digital transformation  

• We continue to enhance our digital connectivity and interoperability across all our trusts. 

•  We have a single Radiology Information System (RIS), which enables teams to monitor workloads and support the workforce across the trusts.  

• We have bought additional workstations (76) to enable improved image reporting.  

Releasing efficiency  

• We continue to strive for improved efficiency (£0.8m) and better value for how we deliver services through improved contractual arrangements, for both our equipment and contracts. 

Maternity and neonatal services

We are working together with women, birthing people and their families to improve our maternity services, so they become safer, more personalised and family friendly. We want services where every woman has access to information to enable her to make decisions about her care and where she and her baby can access support that is centred around their individual needs and circumstances. 

Our ambition 

We want all women and birthing people to have safe maternity care, which is personalised, kind, professional and family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred on their individual needs and circumstances so that their whole experience is positive and memorable. 

Last year, our actions to achieve this included:  

Improving safety, outcomes and experience for mothers and their babies  

• Worked with our provider trusts and their leadership teams to ensure that maternity and neonatal services have an open, compassionate, and positive safety culture. This includes working in collaboration with London Health Innovation Network to introduce a perinatal culture and leadership programme. 

• Worked closely with provider trusts to monitor and implement the action plans agreed following CQC maternity focus inspections at both St George’s and St Helier maternity units in 2023/24.   

• Reviewed the findings of the national Care Quality Commission (CQC) annual maternity survey and determine South West London actions. 

• All trusts have passed this element of Saving Babies’ Lives Version 3 in November 2024, and are working towards full compliance. Clear pathways are in place. Information is provided and discussed with women and birthing people on the plan of care to enable them to make their informed choice. 

• Built on the interventions outlined in Saving Babies Lives to reduce stillbirth, neonatal brain injury, neonatal death, and preterm birth, and implement the national maternity early warning score and the newborn early warning trigger, and track tools to improve the care of unwell mothers and babies, enabling timely escalation where needed. 

• Published our plans to reduce inequalities in women’s experience and outcomes. Read our maternity and neonatal equity and equality action plan 

• Increased education and awareness so that pregnant women are better able to detect and report when they believe fetal movements have reduced.  

• All trusts implemented actions from Saving Babies’ Lives in November 2024, to enhance the detection and management of neonatal blood sugar. Transitional Care guidelines are in place to support the effective management of babies at risk. This will improve outcomes for both mothers and their babies.  

• Implemented a standardised risk assessment to improve fetal monitoring whilst in labour. 

Improving choice, personalised care and continuity of carer for all mothers 

• Promoted access to self-care through a broad range of channels, such as social media, faith and community groups, and sports organisations. Our getUBetter app signposts and refers to local services. Further development of the diabetes book and learn platform is being planned to help improve patient experience, including ‘Sound Dr’ and self-referral to weight management programmes. 

• As part of routine practice, every woman is now being offered the choice of where to have her baby, whether at hospital, birth centre or home, and that this is discussed with her at regular periods throughout her pregnancy. Place of birth is discussed with women and informed choice is made based on their personal circumstances. 

• Continued to support vulnerable women and families, including those from the most deprived areas, and worked to identify domestic abuse or other safeguarding risks. Read more about this in Improving quality and safety. 

• Added adult and children’s safeguarding representation to the local maternity and neonatal system to ensure that learning from domestic homicide reviews, and other reviews where abuse or domestic violence may be present, are incorporated into the strengthening of safeguarding procedures within maternity units. 

• Developed personal care and support plans that record conversations about choices, giving women ownership of their plans, which are reviewed at each appointment. 

• Worked closely with seldom heard communities via our patient involvement group – maternity and neonatal voices partnership (MNVP) – and local community organisations, to further improve services for these groups. This is helping us understand the experiences of women from all our communities, especially Black, Asian and minority ethnic groups, and improve our maternity services. 

Working to enhance postnatal care 

• Continued implementation of the recommendations in the national postnatal framework to standardise the routine postnatal care that women and their babies receive in the first eight weeks after the birth.  

• Used the national postnatal assessment tool to identify gaps in current services and the local maternity and neonatal system worked with stakeholders to improve the postnatal care services and six weeks checks with GP. 

• Continued to review the infant feeding support available to women and identify key actions to increase breastfeeding rates. 

• Worked to embed our pelvic health services, bereavement services and improve access for women with mental health conditions for specialist support. 

• Developed our pelvic health services in line with national recommendations. All trusts in South West London are developing their pelvic health services in line with national recommendations, embedding evidence-based practice in perinatal care to prevent and mitigate pelvic health problems resulting from pregnancy and childbirth and improving the rate of identification of pelvic health problems antenatally and postnatally to align with other healthcare services, and are recruiting a physiotherapist lead to oversee these services. 

Enhancing learning to improve care and services  

• The findings of the national Care Quality Commission (CQC) annual maternity survey showed that people using maternity services in South West London have a positive experience, with Epsom and St Helier ranked among the top eight trusts categorised as achieved better than expected results in London. 

• Increased the number of parents using our ‘Baby Buddy’ app for maternity information. Users of the app increased by 16.7% this year compared to 2023/24. There is adult and children’s safeguarding representation on the LMNS to ensure that learning from DHRs and other reviews where abuse or domestic violence may be present are incorporated within the learning, and assurance around safeguarding procedures and DA requirements within maternity units 

Mental health, people with learning difficulties and/or autism

Mental health services are provided by a variety of organisations, including two large NHS mental health trusts, primary care and several smaller, voluntary sector or local authority-led organisations. Our main mental health service providers are:   

• South West London and St George’s NHS Mental Health Trust

• South London and Maudsley NHS Foundation Trust 

We believe that everyone has a right to good mental health. We want South West London to be the best place to live for emotional wellbeing. A place where mental health services are accessible and meet the needs of the local population, where no person feels that taking their own life is their only option and where people with serious mental illness have the same life expectancy as the general population. A place where everyone has access to early support for their emotional wellbeing and mental health, where health inequalities are eradicated and where our services work seamlessly together so that support and care are provided in the most appropriate setting.  

Last year, our actions to achieve this included:  

Working to improve recovery rates and quality of life for serious mental illness and mild to moderate mental health conditions   

• A detailed approach to physical health care for people with serious mental illness has been developed that sets out expectations, support available and the roles of different professionals while also ensuring that physical health checks for people with serious mental illness are carried out and results are acted upon.  

• We have built upon the success of social prescribing and joined up this service across South West London so that we provide consistent and effective non-clinical support to develop and maintain mental wellbeing.  

Working to improve levels of access to services across different communities   

• We have continued to develop a needs-based system for children, young people and families and worked to ensure how we provide services is both joined up and simplified.  

• Training has been revised for all health and care professionals to include a mandatory set of skills so they can recognise and understand the need for psycho-social support and are able to communicate that as well as to signpost to help.  

• Work has continued to deliver prevention activities for children and young people known to be at higher risk of developing mental health issues.  

• We have developed and delivered mental health promotion programmes based on the best available evidence.  

• An inclusive process has been developed so patients are actively involved in making decisions about their mental health treatment and are given information to help them decide.  

• We have worked to deliver the South London Listens pledges and strengthened community networks and made extra resources available.  

Work towards reducing suicide and self-harm rates  

• The ICB commissioned high-quality and evidence-based training for self-harm and suicide prevention to help frontline workers, such as those in health and social care, mental health teams, schools, and prisons, effectively engage with individuals in distress and at risk of self-harm or suicide. 

Increasing understanding of mental health issues and wellbeing amongst communities   

• NHS South West London has continued to develop an approach to prevention in our communities, drawing on work under way at the national level and drawing on the expertise in our local authority public health teams. 

People with learning disabilities and/or autism  

The NHS Long Term Plan sets out the priorities and ambitions to improving healthcare and outcomes of autistic people and people with a learning disability.    

We are committed to improving the healthcare and outcomes of people with a learning disability and autistic people across South West London.  

We want people with learning disabilities and autistic people to:  

• Have the best possible physical and mental health and access to good physical and mental healthcare, where their needs are understood, and their rights are protected.  

• Lead active and fulfilling lives and live in their own home.  

• Have the same life expectancy as the general population.   

• Have access to inclusive community services that meet their needs and that work together around the person. Where inappropriate detentions and avoidable admissions to mental health hospitals no longer happen, and people are prevented from reaching crisis point by receiving the right help at the right time in the right place.  

Last year, our actions to achieve this included:  

Working to reduce preventable admission to mental health hospitals and reducing length of stay   

• We have continued to develop the South West London key worker service for children and young people and extended it to include transition to adulthood and will continue in 2025/26 to extend to age 25. 

• We delivered the Croydon community intensive support (autism and intellectual disability) team pilot for adults, a multi-agency scheme across South London and Maudsley Mental Health Trust, Croydon Health Services and adult social care services in Croydon. We also delivered South West London and St George’s Mental Health Trust’s intensive support community pilot teams for autistic children, young people and adults across the other five South West London boroughs.  

• We will review these pilots in 2025/26, to inform the development of a new model of care across South West London which will improve community provision in place. 

• Work to develop a South West London centralised dynamic support register (DSR) – people at risk of going into mental health hospital – and implement a DSR digital platform has continued. A new digital platform is expected to launch later this year. 

Working towards improving autism diagnostic assessment and autism support   

• Began work to review and evaluate the autism post-diagnostic support pilots, which will inform future model and service developments for autism support. This work will continue in 2025/26. 

• Introduced a new model for the specialist community forensic intellectual and neurodevelopmental disabilities (FIND) service. We now have three teams aligned to each of the South London Partnership mental health trusts. We are exploring options to address the gap in community provision for a small number of autistic people. 

Improving the health and wellbeing of people with learning disabilities and autistic people   

• We have continued to work on implementing a reasonable adjustment digital flag system – and the process changes associated with it – to ensure people got the specific changes to their healthcare based on their needs. 

• Introduced a new model for the specialist community forensic intellectual and neurodevelopmental disabilities (FIND) service. We now have three teams aligned to each of the South London Partnership mental health trusts. We are exploring options to address the gap in community provision for a small number of autistic people.  

• We have developed an autism dashboard to support strategic commissioning through better understanding of specific population needs.   

• Continued to scope the supported housing pathway and model for people with a learning disability and autistic people stepping down from adult secure services to live in the community led by South London Partnership. 

Reducing mortality and preventable deaths   

• Continued to implement the learning from the lives and deaths of people with a learning disability and autistic people (LeDeR Programme). Read our latest LeDer annual reports.   

Primary care

Primary care in South West London is both innovative and responsive to our communities. Our 171 GP practices and 292 community pharmacies work hard to give people access to healthcare, support and information in the right way for them.  

Over the past year we have taken advantage of digital technology, maximising the benefits of the NHS App and new telephone systems to connect with patients and improve outcomes, helping people stay healthier for longer.   

All South West London GP practices belong to one of our 39 primary care networks, which bring them together with community, mental health, social care, pharmacy, hospital and voluntary services in their areas to better meet the needs of local people.   

Last year, our actions included: 

• Supporting primary care networks as they evolve into integrated neighbourhood teams, prioritising neighbourhoods in the most deprived areas.    

• We reviewed our borough-based training hubs to ensure the necessary support is given to primary care leaders.  

• We continued our work to end the ‘8am rush’ for appointments with better telephone systems that make it easier for patients to get through promptly, along with a range of self-referral and self-care options to avoid the need for calls to a practice. 

• Through the additional role reimbursement scheme and improved GP retention we continued to increase the primary care workforce, while providing people with access to a wider range of skilled professionals helping them manage complex and chronic conditions.  

• We continued our commitment to increase the number of GP appointments which rose from by x% (from 8,359,389 to x in the year to April 25). Numbers to be updated once full year data is available  

• We improved the connections between GPs and pharmacies so all patients in South West London can book a consultation with a local pharmacist for certain conditions.  

• We increased use of automation software to reduce the administrative burden on primary care teams, helping them concentrate on patient care.  

• We continued to roll out the NHS app as the digital front door to primary care, with 62% of South West London’s eligible population having downloaded the app. 

• We revised the risk stratification tools to include Core20plus5 analysis. This means we can identify and prioritise people who may benefit from proactive care from a range of integrated services. 

• We improved access to urgent care for patients with more options for being seen outside core hours.  

• We introduced preventative services to target long-term conditions including a directory of services around smoking, immunisations and self-management (including digital apps).  

• We supported practices to ensure all patients can use the NHS online ‘register with a GP surgery’ service. 

Pharmacy 

• We supported our community pharmacies as key partners in delivering accessible local care and taking pressure off GPs and emergency departments. 

• Through major campaigns featuring local pharmacists, we continued to promote the Pharmacy First scheme, which offers treatment for seven common conditions without the need to see a GP.  More than 95% of pharmacies are now offering the Pharmacy First service. Pharmacies are providing over 6000 appointments a month through Pharmacy First across our six boroughs. 

• By April 2025, all pharmacies signed up to offer the new Pharmacy First service will also offer the expanded blood pressure check and contraception services. 

Optometry and dentistry 

• We are reducing variation of services and improving equity of access and outcomes for people requiring eye care services by commissioning a new South West London ophthalmology pathway. 

• We held a South West London dental day in October 2024, bringing together dentists, public health experts, Healthwatch, and the voluntary sector to talk about issues including access to care, sharing data and improving oral health. 

• We worked with local authorities to support oral health improvement initiatives, including delivery of toothbrush packs and early years supervised brushing programmes. 

• We began implementation of a dental engagement plan which aims to improve access to primary care dental services for children and young people who don’t have a dentist.    

• Recognising the importance of oral health to nutrition and hydration, we worked with care homes to improve access to dental care including with end-of-life care patients. 

• We supported urgent care NHS dental hubs which operate between 8am and 2am for anyone with emergency dental problems. 

Specialised services

Specialised services support people with a range of rare and complex conditions. This may include treatments for patients with rare cancers, genetic disorders or complex medical or surgical conditions.   

Examples of specialised services include renal dialysis and transplantation, complex cancer surgery, chemotherapy and radiotherapy, cardiac surgery, improving care for patients with sickle cell disease, blood-borne virus testing, and most hospital treatment for children.    

We want all patients who receive complex treatments to have seamless, coordinated care that:  

• focusses on preventing the progression of their condition, while empowering them to stay well and improve their quality of life 

• is high quality and expert led, provided by specialised centres as close to home as possible 

• can be accessed by everyone in our population in an equitable way, working together with residents, patients, families, carers, and local communities to ensure excellent outcomes that are also cost effective. 

Last year, our actions to achieve this have included:   

Delivered better joined up working   

• Creating additional capacity in paediatric intensive care by working with the South Thames Paediatric Network.   

• Further increasing uptake of testing from 72% to 85% and creating a case for change around liver disease given the large number of new hepatitis B diagnoses whilst working together as a system to manage these patients. We have made good progress toward automation and blocking for Kingston with strong timelines for this to be implemented before the end of the fiscal year. 146,136 HIV tests performed and 175,000 Hepatitis B Surface antigen and Hepatitis C antibody tests performed across South West London his fiscal year, which has resulted in 24 new HIV diagnoses, 356 people living with Hepatitis B being linked to care and 43 new Hepatitis C diagnoses. 

• Enhanced community services for sickle cell patients by improving integration between specialist teams and community outreach. This has led to more community nursing roles and enhanced psychology input in all six boroughs. We aim to improve transition pathways, raise awareness of enhanced community services, and improve patient experience and access to local services. 

• Made the digital health record for sickle cell patients accessible across all settings of care. 

• Launched an integrated care pilot for renal services across 112 GP practices in our six boroughs. The pilot includes work to manage more care in the community, through holistic patient assessments, co-produced care plans, multi-disciplinary team-led reviews and project-led clinics, education and training, community engagement through the voluntary sector. 

High quality accessible care  

• Implementing a peer-to-peer mentoring programme for children and young people with sickle cell disease, as part of a pan-London roll out of a pilot programme that started in North East London. 18 young people have accessed the peer support programme so far. 

• Began the evaluation of pilots for a community-based sickle cell disease service and renal replacement therapy which should be complete by Oct 2025. 

• Exploring opportunities to further fund the pilot roles into the second year of the pilot programme. 

• Setting up a hyper acute unit for sickle cell patients at St George’s Hospital. This will allow patients to bypass the emergency department and be seen more quickly by specialists who understand the condition and can get them pain relief quickly. This will also reduce pressure on the emergency department. The service is due to open in April 2025. 

• Through a pilot programme we have introduced system wide roles in neurology to help provide more patients with timely access to specialist services, equitably, no matter where they live. Our aim is to improve patient outcomes and experience. The system wide roles include: 

• Epilepsy regional multi-disciplinary team coordinator to help better distribute specialised care to local hospitals. 

• Myasthenia Gravis nurse specialist to serve as a point of contact for patients, increasing access, assessment, and treatment. This is helping to avoid admissions to hospital. 

• Parkinson’s clinical network manager to help create a networked approach to Parkinson’s care. 

• Motor neurone disease care advisor to provide clinical practice, education, and pathway expertise. This is helping to reduce length of stay. 

• Functional neurological disorder care advisor to help patient access and navigate care. This is reducing ambulance callouts, emergency department attendances and length of stay. 

• Advance multiple sclerosis champion to plan, deliver and coordinate complex care for people with advanced multiple sclerosis. 

Taking responsibility for specialised services from NHS England   

• NHS England (London region) will delegate the commissioning of specialised services to ICBs from 1 April 2025. Through 2024/25, we have worked in partnership with NHS England specialised commissioning on the joint commissioning of specialised services for the South West London population. A full programme is in place to ensure a seamless transition in April 2025.  

Preventing ill health

Prevention is a key priority in our Integrated Care Partnership Strategy and in the Joint Forward Plan.    

We know that our behaviours affect our health, with some behaviours like smoking and high alcohol consumption putting us at greater risk of ill health whilst other protective factors, such as having a balanced diet, exercising and vaccinations, can reduce or prevent illnesses. 

Over the course of 2024/25, we have been busy working with our partners in the wider Integrated Care System to embed prevention in clinical pathways and to reduce the impact of risk factors such as excess weight, tobacco and alcohol. 

Working with our partners, we aim to: 

• Deepen our understanding of our population and health inequalities 

• Develop a healthy lifestyles prevention pathway 

• Protect people from communicable diseases and environmental threats 

• Increase support for the prevention and early diagnosis of chronic conditions 

Our actions to achieve this included: 

Healthy weight for adults 

• We undertook a South West London wide health needs assessment on healthy weight amongst adults. There are an estimated 550,000 adults with excess weight (overweight and obese) in South West London, comprising over half of the adult population. However, the estimated proportion of people who are inactive has decreased. Though numbers are small, there is evidence of patients who successfully reduced their excess weight to healthy weight. For each age group, the proportion of people recorded as obese are higher in the 20% most deprived population compared to the rest of the South West London. There is a higher proportion of younger people with excess weight than older groups.  This has implications for our healthy life expectancy as we will have people living for longer in poorer health. 

• Building on our health needs assessment, we have been working with our partners to improve primary prevention, early interventions and to prepare for the rollout of weight loss drugs across primary care and specialised weight management services in 2025. We undertook a survey of health care professionals in primary care on their training needs for weight management discussions to help us implement a suitable training programme.  

• Our GP practices are offered the Weight Management Enhanced Service Specification annually. This includes maintenance of an obesity register as well as incentives for referrals to tiers 2, 3 and 4 services, Type 2 Path to Remission, diabetes prevention and digital weight management programmes. Most of our GP practices participate.  

Tobacco dependency   

• We implemented the Tobacco Dependency Programme across all our hospitals in South West London. This hospital based secondary prevention programme delivers advice and personalised stop smoking services to inpatients, patients in maternity and mental health patients who want to quit smoking. The programme reached 6,000 patients in 2024/25 – around one in four of the patients who received specialist support successfully quit within 28 days. 

Alcohol and drug dependency  

• We undertook a South West London wide rapid needs assessment of alcohol misuse in South West London, focusing on health outcomes, hospital admissions, mortality rates, and current services available in the region. Hospital admissions for alcohol-related conditions have increased in South West London, particularly in Wandsworth and Croydon. Looking at mortality rates, rates of alcohol-related diseases, such as liver disease, cardiovascular disease and alcohol related cancer, we are working with our partners in local authorities and voluntary sector, to improve the support to individuals affected by alcohol misuse, including specialist treatment centres, community outreach initiatives, and hospital-based liaison services. This will involve embedding the National 10-year drug strategy, From Harm to Hope. We are also working with South East London to embed more robust early intervention and prevention programmes as part of the King’s Fund initiative, Vital 5. 

Community empowerment  

• We undertook an analysis of the different community health workers in South West London, looking to see where there is opportunity to consolidate, reduce duplication and prepare for their roles within the emerging integrated neighbourhood teams. We found 35 different types of Community Health Workers across programmes with 400 people (and growing) working within the NHS, local authorities and voluntary sector. Examples include community champions (umbrella term for health and wellbeing navigators, community ambassadors and unpaid Core20 community connectors); social prescribers, personal independence coordinators and community health and wellbeing workers.  Programmes are funded via various bodies and sources. Some community champions are unpaid and many have progressed into paid roles such as social prescribers and community health and well-being workers.  

• We have two South West London wide community link worker programmes: CoreConnectors and Community Health and Well-being Workers.  Read more about these programmes in the health inequality section. 

• Community Health and Wellbeing Workers are based on a model successfully implemented in Brazil. The model consists of individuals from a neighbourhood who are trained on a wide range of health and social care issues and then visit the households they are responsible for in their own community. Read more about Chewies in the Wandsworth Place section. 

• In 2024, we have delivered over 4,000 health and wellness checks at various events and in the community. These checks are different to standard NHS Health checks – they are open to all adults, focus on broader accessibility, particularly in Core20 populations where engagement with traditional health services is lower. It is a volunteer-led initiative with over 150 trained volunteers working alongside paid staff to deliver health checks at community locations. The checks include BMI and blood pressure measurements and type 2 diabetes risk scores and atrial fibrillation screening.   

• In Merton, Health Monitor Kiosks (available in libraries) have facilitated 7,000+ additional self-checks, significantly increasing engagement.  We have found that one in four residents had high blood pressure and 30-40% of residents with higher-than-normal BMI. 

Self-care and supporting people to manage their long-term conditions

A long-term condition (LTC) is one that cannot currently be cured but can instead be supported or managed through medication, treatment or therapies. About 500,000 people in South West London are living with a long-term condition including diabetes, respiratory disease or cardiovascular disease. Around 25% of working age adults in South West London are currently living with two or more long-term conditions.   

Through our ICP Strategy and the ICB’s Joint Forward Plan, we are committed to helping people with long-term conditions live longer in good health and reduce their requirement for hospital care. We have focused on developing services and interventions to improve personalised self-care for people with long-term conditions, and we work on embedding prevention in the clinical pathways as per the Major Conditions Strategy for the long-term conditions of diabetes, cardiovascular disease, respiratory disease, hypertension and musculosketal disease (MSK).   

We undertook a review of all the self-care programmes across South West London and are currently taking forward the recommendations. These include the need for a collective review of impact measures and governance structures to ensure quality in self-care and further review of joint working for self-care across systems and reaching out to disadvantaged groups to embed inclusiveness.   

Helping people to work or return to work  

• We worked in partnership with local authorities and the voluntary sector to develop a strategy for work and health integration to better coordinate the wide range of existing activity to support people with long-term health conditions to succeed in work. This has included incorporating Work Well initiatives and getUBetter. We have partnered with Better Working Futures to bring getUbetter to our participants. Better Working Futures – the South West London name for the government’s Work and Health Programme – is a support service that was designed to help unemployed people to start working in the South London region. They work collaboratively with participants and other services in the community to offer the best possible support for people’s personal circumstances. This collaboration is providing participants who need it with instant access to a personalised programme of support designed to help them manage muscle and joint problems. Useful links: Partnership with getUbetter | Better Working Futures. getUBetter attended a recent visit from MP Stephen Timms – Department for Work and Pensions (DWP)Minister for Social Security and Disability. The full press release will be available soon but here is what has been published so far: Minister visit to Croydon | Better Working Futures
• Further developing research, data, and digital technology in South West London which are key in empowering individuals to better self-care and improve the quality of care. For example, the GetUBetter programme has just released the comorbidities (lung health and heart health) modules which include access to information and advice 24/7, informative videos and guidance, including lived experience videos from patients, and signposting to local healthcare services if needed. All content is available in 14 languages, with audio options for improved accessibility. Other active projects to improve user experience include; a Community Pharmacy Pilot, SMS campaigns, Explainer films production, Data Analysis, Risk Stratification, GP Website updates and Online Outreach.   

• Continuing to develop digital support to help people navigate what is available to support them when diagnosed with a long-term condition, including the use of social engine marketing to divert people to the right advice and care.  

• GetUBetter: Our collaborative work with getUBetter and South West London clinical teams ensures signposting and onward referrals to local offerings are embedded into the app and are clear for users.  

• Sound Dr: South West London has procured a library of videos and video courses from Sound Dr to support various long-term conditions, we have access to these until the end of March 2027. This has been included in the local resource sections of getUBetter and we have an active project to increase utilisation across South West London. 

• Increasing the equity of access to self-care by improving visibility of what is on offer both digitally and in person, through a broad range of channels, for example, social media, faith and community groups, and sports organisations. 

Actions to support people with diabetes  

The National Institute for Health and Clinical Excellence (NICE) provides recommendations on annual care processes (CP) that adults and children with diabetes should receive, as well as three treatment targets (3TTs) that adults should achieve to reduce the risk of diabetes and complications. In South West London, we have worked to ensure that all South West London patients, at risk of or diagnosed with diabetes, have access to useful and appropriate information and that they receive the monitoring, care and treatment that is recommended by NICE (gold standard) within primary care, community, and secondary settings.  

We deliver our diabetes programme of work in 4 ways: Prevent, detect, protect and perfect.    

• Prevent: Here, we have delivered the national NHS Diabetes Prevention Programme (NDPP) across South West London. We also delivered a South West London specific pilot programme called Diabetes Decathalon, which is currently being evaluated by the Health Innovation Network. The Diabetes Prevention Decathlon (DPD) is a 10-week programme designed to address lifestyle factors contributing to the onset of Type 2 Diabetes Mellites (T2DM) codesigned by the ICB, Enable and Sweatco Ltd. to offer structured education, physical activity, peer support, and digital engagement. Initial results from 2023/24 showed 92% participation rate, an average weight loss of 2Kg per patient and a 45% increase in physical activity.     
• Detect: We have worked with our primary care and community care colleagues to deliver community led hubs, including health clinics to case find. Community Health and Wellbeing checks have also picked up undiagnosed diabetes. For pre-diabetes patients, we deliver the Healthier You Diabetes Prevention Programme. 
• Protect: We delivered the three treatment targets (3TTs) project for all patients with diabetes across South West London. This was a GP improvement programme to reduce unwanted variation of treatment targets. Meeting all three targets reduces patient risk of CVD by 75%. We developed the tools and resources and supported practices with facilitators. Thirty-six of participating practices improved eight care processes by over 11% on previous year and 11 practices had in year 3TTs improvement. We have also delivered the Early Onset Type 2 Diabetes (EOT2D) programme.
• Perfect: We continued to deliver the Diabetes ‘Book ‘n Learn’ platform, where patients diagnosed with diabetes can book onto relevant education programmes. This provides a choice of face to face, online and digital diabetes structured courses across south London including DESMOND, X-PERT, Live Well, Low Carb programme, Second Nature and HEAL-D. We have been working on a plan to expand the platform to include weight management programmes. We also deliver the National Type 2 Path to Remission Programme (formerly the Low Calorie Diet Programme). In Sutton, GP practices also proved LCS, an enhanced management of diabetes through personalised lifestyle advice and improved medication. 

Action to support people with cardiovascular disease  

• We developed and implemented a ‘multimorbidity’ model of care for cardiometabolic conditions, thereby increasing efficiency of appointments and improving patient compliance and outcomes. A pilot project has commenced, and evaluation will be done by University of Roehampton in 2025/26.  

• Similar to the Diabetes Decathalon, we delivered a cardiovascular disease Decathalon. The CVD Prevention Decathlon was a 10-week education and physical activity programme aimed at individuals who were at risk of developing CVD. Around 800 people completed the programme and the Health Innovation Network undertook an evaluation of the programme in 2024. 

Action to support people with respiratory disease  

Supporting our residents with respiratory disease has been a key action over the last year.   

• We enhanced access to diagnostics. This includes the implementation of spirometry and Fractional Exhaled Nitric Oxide (FeNO) testing in primary care settings. Additionally, funding from InHIP has substantially increased the number of patients tested at a respiratory diagnostic hub in Merton. The number of tests conducted per week rose from four-five tests between January 2023 and January 2024 to 12-13 tests per week from February 2024 to June 2024. This funding provided an additional 310 appointment slots, with up to 256 patients attending, between July 2024 and March 2025.  

• We enhanced the provision and uptake of Respiratory Rehabilitation (PR) services for four locations – Croydon, Sutton, Kingston, and Richmond – and are actively participating in the PRSAS accreditation initiative. Notable advancements include staff training in Quality Improvement (QI) processes, the implementation of customised patient satisfaction surveys, the development of operational plans for the 2024/25 period, and the launch of pilot projects focused on strength testing in Sutton.  

• The South West London Training Hub delivered education, information, and self-management support. In January 2024, the South West London Training Hub was awarded £19k to increase the number of clinicians undertaking spirometry. Sixteen spirometry module licenses were purchased, and 50% of participants completed the training. 
• In July 2024, the ICB was successful in its bid for NHSE national respiratory programme funding to support early and accurate diagnosis in respiratory. This funding is being used to improving access and capacity to support three projects:
  • Address the specific needs of Sutton’s homeless population 
  • Increase community capacity to provide spirometry testing 
  • South West London hub to deliver master classes on managing exacerbations for paediatric asthma 

Action to support people with musculoskeletal needs   

South West London has been able to deliver additional instant capacity, increase choice and personalisation, deliver system value and cash-releasing savings by utilising digital tools to provide MSK and LTCs patients with education and empowerment to better self-care and requiring less face-to-face clinical healthcare resources.

Over the last five years, we have been collaborating across partners, including: South West London APC, South West London Clinical Networks, Local Authority, academics, AHSN, patients, and a digital health technology partner, GetUBetter, to co-produce an innovative South West London digital self-management solution.

Based on an independent HIN evaluation of several Wandsworth practice audits, South West London calculates estimated MSK efficiency savings and service benefits:   

• 20% reduction in physio referrals   

• 13% less MSK GP appts   

• 66% less urgent care attendances   

• 26% less secondary care appts   

• 50% less GP prescriptions      

• Reduction of GP first appts: 7,487  

• Reduction of GP follow-up appts: 20,393 or £754,559 

• Reduction of physio referrals: 2,879 or £264,908 

• Trust Physio waiting list reduced: 771 or £70,970 

• Secondary care referrals reduced: 131, £20,916 

• Prescriptions reduced: 51,290 or £1,692,571 

• ED avoidance: 1,569 or £131,773 

• Prescriptions reduced: 51,290 or £1,181,950 

Urgent and emergency care

The NHS faced a challenging winter with significant and sustained pressure throughout. This winter, high rates of flu, Covid, RSV, and norovirus increased pressure on NHS frontline staff as healthcare services worked to manage the “quad-demic” alongside service delivery. 

Working closely with our partners across the system, we took action to support our urgent and emergency care services, supporting hospital doctors and nurses, GPs and social care colleagues to focus on those most in need of care.   

Through partnerships between 111, acute, community and mental health, primary care, social care and the voluntary sector, we want responsive urgent and emergency care services that are understood by local people and that provide more, and better, care in people’s homes, gets ambulances to people more quickly when they need them, sees people faster when they go to hospital and helps people safely leave hospital, having received the care they need.   

In line with the national urgent and emergency care recovery plan, we have made our focus improving waiting times for patients in A&E and for those waiting for ambulances in the community.    

Improving these waiting times is reliant on improving flow and efficiency in all other parts of urgent and emergency care, from how quickly a patient can access advice in primary care to how soon they can get home at the end of a hospital stay, particularly when they need community support to do so.  

Last year, our actions to achieve this included:   

Work to create a simpler and more accessible urgent and emergency care offer that patients understand   

• Appointed Dr Paul Holmes, a consultant from St George’s, and Dr Sarah Douglas, a South West London GP, to provide clinical leadership to the urgent and emergency care programme. We also appointed clinical and operational leads to support the workforce, access and discharge and flow workstreams of our two-year urgent and emergency care plan. 

• Developing and enhancing the community pharmacy offer so that people with minor ailments see their pharmacy as the place to go for advice and support. Our Pharmacy First Campaign promotes the seven key conditions and features local pharmacists. The campaign has been seen over three million times online, along with conversations taking place in low uptake communities to share information and gather insight about perceptions of Pharmacy First. We know from previous campaigns that people who see our adverts are up to four times more likely to visit a pharmacy as a result. 

• Encouraging our communities to use mental health crisis services by sharing information using a variety of channels including our community and voluntary sector relationships and networks and using social media platforms. Our Mental Health Crisis campaign ran for a 12-month period and gained 7.3 million views during this period. During key periods of operational pressure, the campaign had over 100,000 views a day. Our highest engagement rates were with content in different languages – including video content in Urdu, Tamil, Gujarati, and Arabic. 

• Making best use of the information we have through patient engagement, Healthwatch reports, and provider patient insight to ensure that we hear and act on what people are saying about our services.  

• Producing consistent and timely communications to help people understand how to access and use urgent and emergency care services. During periods of increased pressure, we ran multichannel, integrated behaviour campaigns with community engagement at the centre of these campaigns. We have promoted the NHS app to reduce pressure on primary care, Pharmacies to reduce pressure on UEC, Vaccinations in order to reduce hospital admissions, and mental health crisis support outside of A&E. This also includes promotion of 111 online during periods of industrial action, and sharing information about staying well during extreme weather alerts. 

Working to improve the patient flow through the urgent and emergency care system   

• Reviewing our staffing needs for urgent and emergency care and developing a five- year workforce plan to recruit, retain and develop staff in Urgent and Emergency Care.  

• Continued embedding same-day emergency care services to reduce the number of patients admitted to hospital. This includes:  

• Piloting the Consultant Connect admission avoidance initiative, working with London Ambulance Service and community services, such as urgent community response and virtual wards. This successfully diverted 52% of people away from emergency departments and into suitable alternatives. 

• Agreeing to establish dedicated frailty spaces at all four South West London trusts which will provide up to 70 hours of multidisciplinary care at the front door. 

• Worked with our acute and community providers to improve discharge processes in our trusts and reduce the number of patients staying longer in hospital than they need to.  

We have established discharge programmes in each trust and across all Places to build on work delivered in 2024/25.  

• Much work has been undertaken to reduce length of time people are staying in our hospitals. Whilst the average length of stay across South West London in January 2025 was 10.47 days compared to 10.11 days in January 2024.

• The programmes will continue to focus on reducing the length of stay for patients in 2025/26 and reducing the number of discharges before 1pm. 

Research and innovation 

***KLOE D3: How has the ICB facilitated, promoted and used research and innovation?*** 

Research and innovation play vital roles in improving health outcomes, enhancing care, and making services more effective. Across South West London, we have continued to support and embed research into everyday practice, helping to develop new treatments, technologies, and ways of working that benefit both patients and staff. Innovations can transform how people receive care. Research and innovation can support greater efficiencies and use of resources. 

Under the Health & Care Act (2022), all ICBs have a legal duty for research, and this involves the inclusion of research in annual reports and Joint Forward Plans, facilitating and promoting research and use of research evidence and working with people and communities on research.     

Sharing our learning from research and innovation is essential to us and we maintain that involvement and participation in research benefits the health outcomes for our population and improves the quality and efficiency of health services. Investing in healthcare research infrastructure enables innovation and generates evidence on effective prevention, diagnosis and treatment. 

Over the course of 2024, our South West London Health Research Collaborative has been working together delivering a South West London Research Delivery Plan. This aims to grow the region as a research environment. The collaborative is made up of research leads from the ICB, community, acute and mental health trusts, South London Health Innovation Network, South London Allied Research Collaboration, South London Research Delivery Network, local authorities and universities. The plan covers six workstreams:  

1. Workforce – grow, develop and support research capacity in the system and enable partners within the ICS to endorse research and benefit. This includes education and training.  

2. Needs and Priorities – identify the specific research needs in a particular area or sub-population in South West London. 

3. Participation & Involvement – taking a cross-ICS approach to increasing public participation and diversity in South West London research including research cafes, inclusivity panels, and Be Part of Research. Looking at how we communicate and promote research in South West London. Making research more visible and increasing public understanding (research literacy). 

4. Evaluation – taking the time to support South West London innovators in the evaluation of their work so that leads to longevity in what works well in South West London and sharing of lessons learned. 

5. Implementation of research findings – working with the ICB and ICP in embedding research results and evidence into improving the provision of health and care and ensuring ICP and ICB board level sight of research.  

6. Knowledge and information – improve access to people who can do rapid reviews, access to health data, population health management, NHS Research Secure Data Environment Network.  

Examples of the work that the ICB have led over 2024/25 

• Set up and development of the South West London Research Support Network. This network was set up to strengthen research capability and capacity in local communities, voluntary organisations, NHS and Local Authority staff and others.   This network meets monthly either face-to-face or online and enables people to learn from an expert and each other on different research methods.    

• Set up a network of evaluation ambassadors to support anyone across the Integrated Care System on doing evaluation (these ambassadors are a key part of the South West London Research Support Network).  

• We were successful again in securing funding from NHS England’s Research Engagement Network to support the aforementioned network and to deliver research cafes to increased public participation in open research studies. We continue to grow diversity in research by developing peer researchers (people with lived experience) and community researchers as part of our REN work.   

• Working with the South London Research Delivery Network, we are piloting research connectors programme alongside our community link workers.   

• We have collaborated in a number of successfully funded research studies, including the Welcome Trust funded study “Epistemic exclusion and patient safety participation evaluation” with King’s College London and the NHS England proof of concept study “Assessing the potential for community pharmacies to help reduce digital exclusion among older adults through online prescriptions in South West London.” Many of our staff have been co-authors on peer review publications in academic journals during 2024.   

• We were one of 12 demonstrator sites funded by NHS England to test new models of vaccination delivery. We are focusing on the innovative ways to develop workforce, including outreach.  

• We were one of six ICBs chosen to do the Health Foundation’s Accelerating Innovation initiative. This is a 12-month discovery initiative to develop practical learning for the health and care system on the different roles Integrated Care Boards (ICBs) and Health Innovation Networks (HINs) play in innovation adoption and spread. 

• We are working with our South West London universities in growing public health research and we have become a training location for public health specialty training.  We hosted maths and physics students to work on analytical studies through the SepNet scheme (SepNet is the network of maths and physics departments in South East universities with the aim of growing diversity and transferability of skills). We continue to contribute teaching to our local universities, engaging with postgraduate students on research. 

Improving quality and safety

***KLOE B1: How has the ICB facilitated improvements in the safety, effectiveness and experience of care? ***

We want high-quality, personalised, and equitable care for all, now and into the future. 

Our ambition 

We want to create a culture and environment that supports the delivery of high quality, continually improving care in which excellence in clinical care can flourish. We also believe that improving patient experience is as important as improving clinical outcomes and safety 

Last year, our actions to achieve this included: 

Safe care and system wide learning 

• Made progress in implementing initiatives in the NHS patient safety strategy to support safety improvement. Such as: 

• Implemented learning from patient safety event (LFPSE) national system  

• Implemented Level 1 and Level 2 patient safety training as part of staff mandatory training  

• Appointed patient safety partners across all South West London organisations who are mandated  

• Continued to embed Patient Safety Incidents Response Framework (PSIRF)  

• Undertaken a review on inequalities and harm  

• Taken steps to strengthen the safety culture in NHS trusts to help staff feel more able to challenge situations without repercussions. For instance, this year we have seen a few of our trusts focusing on just culture and psychological safety to include undertaking quality improvement projects aligned to this. 

• Strengthened our ICB quality governance and have system quality and safety group which brings all partners across the system with a focus on sharing learning and improvement. We have seen key outputs from our system quality group (system quality council), system patient safety steering group and PSIRF community of practice, system patient safety partners network, system patient experience group, system medicines optimisation safety and learning network and system IPC committee. 

• Continued work with provider trusts to create safer systems of care that reflect continuous learning and improvement, understanding and learning from errors and excellence and adopting best practices. 

Delivering effective care 

• Optimised use of the South West London quality dashboard, which ensures that National Institute of Clinical Excellence (NICE) clinical guidelines are reflected in how we measure outcomes.  

• Worked closely with NICE to embed their guidance at system level, this is evolving work.  

• Piloted a framework to support system learning reviews, which is helping us develop safer systems of care that reflect continuous learning and improvement and reduce unwarranted variations in clinical care.  

Experience and outcomes for patients and staff 

• Supporting our system partners to strengthen patient experience of care, use of feedback, compliments, and complaints to make service improvements that improve the quality of health and care. For example, we have established a patient experience group with representation from all our patient experience leads. The group’s focus is using insights and data to improve patient experience, implement personalised and targeted initiatives and support system wide learning and improvement.  

• We have also started a pilot to obtain experience of care for our vulnerable continuing healthcare (CHC) patients. This work is helping to make sure that groups who are under-represented or who cannot speak for themselves are heard, which will lead to services that are coordinated, inclusive and equitable.  

• In 2024/25 we have seen all our patient safety partners (PSP):
  • gain confidence in their new roles supporting patient safety activities in their organisations 
  • being involved in safety incidents reviews  
  • championing the PSP role to staff  
  • taking part in safety audits and reviews  
  • support patient safety groups and committees.   

• We have also setup a quarterly system PSP network meeting that supports all PSPs and continue to look for ways to support and enhance the role. 

Our quality statutory duties 

Safeguarding 

ICBs have several key safeguarding responsibilities to ensure the safety and welfare of children, young people, and adults at risk.  

We have executive and designated roles to represent the health community in both Safeguarding Adult Boards and Safeguarding Children’s Partnerships and sub-committees, working with police and local authority colleagues to support in the delivery of our safeguarding requirements and drive improvement.   

In addition, we ensure delivery of the NHS Safeguarding Accountability and Assurance Framework (SAAF), which outlines the roles and responsibilities of NHS staff in safeguarding children, young people, and adults at risk, and sets out key priorities to keep people safe from abuse.  

To meet our safeguarding duties this year, we have: 

• Worked with providers to ensure that all South West London commissioned organisations meet their statutory safeguarding responsibilities, with clear leadership and lines of accountability, appropriate policies and procedures, and safeguarding training so that children and adults at risk of harm are protected.  

• Ensured that the voice of the child, family and adult is central to all areas of work, learning and development, taking innovative approaches such as media to disseminate messages.  

• Supported the delivery of actions resulting from safeguarding practice reviews, Domestic Homicide Review and other cases for learning, ensuring improvements take place across the system 

• Developed assurance frameworks for embedding into all contracts, to drive up standards in safeguarding across all providers.    

• Delivered our oversight arrangements outlined in the safeguarding accountability and assurance framework (SAAF).  

• Worked with our community safety partnerships (CSPs) and provider organisations to support the reduction of serious violence within the healthcare setting and beyond. We have worked with CSPs to develop the published improvement plans, which outline the health responsibilities.   

• Improved the potential to identify victims of domestic abuse through enhanced training in primary care for both clinical and non-clinical staff and via closer working with independent domestic violence advisors working with primary care teams 

• Developed standardised safeguarding protocols for pressure ulcers, falls and medication related errors to support standardising the approach across South West London and help the decision making of front-line staff.  

• Implemented a safeguarding training strategy, strengthening our safeguarding arrangements. 

• Established a mental capacity and deprivation of liberty (DOLS) forum for to support improvements to practice, strengthen community arrangements and support children’s services in compliance. 

• Supported safeguarding partnership inspections across South West London. 

• Worked with safeguarding partnerships in the implementation of the Working Together arrangements   

• Support primary care with our named GPs ensuring strong, multi-agency working and case-based learning to support improvements in practice  

About safeguarding adults in South West London  

• Croydon Safeguarding Adults Board Annual Report   

• Merton Safeguarding Adults Board priorities, plans and reports  

• Sutton Safeguarding Adults Board  

• Kingston Safeguarding Adults Board  

• Richmond and Wandsworth Safeguarding Adults Board annual reports  

About safeguarding children in South West London: 

• Merton Safeguarding Children Partnership annual report    

• Sutton Local Safeguarding Children Partnership annual report and business plans  

• Wandsworth Safeguarding Children Partnership annual reports  

• Kingston and Richmond Safeguarding Children Partnership local safeguarding arrangements  

• Croydon Safeguarding Children Partnership annual review  

Children Looked After 

A child looked after is a child who has been in the care of their local authority for more than 24 hours. They can live with foster parents, in a children’s home, or in a residential setting.  

Many of these children may have a range of health needs both physical and mental health. The ICB has responsibility to ensure the health needs of these children are met and will work with providers of health and care to support this delivery.   

To support children looked after we have:  

• Continued to work as corporate parents with the Board and are pleased to engage directly with looked after children and care leavers, ensuring their voice and experience is heard 

• Continued work with health providers and local authorities to look at the pathways for initial health assessments and reviews to ensure that assessments and reviews are undertaken in a timely manner as per national guidance. Pathway reviews and action plans were developed for a number of areas and identifying best practice nationally will continue in 2025/26.   

• Delivered our free prescription offer for care leavers to ensure that those in most need have access to the medications they require. Work is underway to build on this program with additional support for dental and ophthalmic provision across south west London. 

• Continued work across south west London to improve the employment opportunities for care leavers, supporting their entry into working within the NHS. 

• Supported improvements in the health provision for children looked after across a range of services from mental health to physical health provision. 

All age continuing care 

All age continuing care is the collective term for services that assess and provide funding for the care of individual patients of all ages, to meet their ongoing health and care needs. This includes continuing healthcare, where eligible adults have their social care paid for by the NHS, and continuing care packages for children. 

All age continuing care brings together these services to ensure a smooth transition when people’s needs change and/or they move between eligibility of different services. We are responsible for assessing the eligibility of people for this support in South West London. 

We developed an integrated approach to continuing healthcare (CHC) across the six boroughs of South West London and commenced a transformation programme with a range of improvement priorities.  

Some of the achievements this year include:  

• Stabilised our senior leadership and clinical teams, brought all services in-house. 

• Implemented a single South West London team approach to children’s CHC. 

• Engaged and included local authorities in monitoring our transformation plan and work streams and unified our brokerage service.  

• Strengthened the contracting process for providers, restored business intelligence function, and developed an AQP (any qualified provider)/non AQP uplift process.  

• Launched a performance reporting task and finish group and introduced a scorecard across all Place teams. 

• Delivered the performance standards set and agreed with NHSE for timeliness of assessments and reducing long wait for assessment. 

• Multidisciplinary audit of 60 CHC cases showed 100% confirmation on the decisions made – provided assurance of the quality of CHC eligibility as set out in the National Framework. 

• Successful recruitment to all senior nursing posts and reduced the number and cost of all agency/interim staff. 

Data, digital, and population health management

***KLOE D3: How has the ICB facilitated, promoted and used research and innovation?*** 

We are using digital technology to transform care and improve patient outcomes across South West London. This includes promoting the health and wellbeing of our population and increasing the number of people that can live independently at home, for as long as possible. Our work focuses on five priorities: 

• Innovation 

• Personal health and care records 

• Digital infrastructure 

• Shared care records 

• Population health platform 

Population Health Management is a way of working to help the NHS understand current health and care needs, helping to predict what residents will need in the future. It involves analysing data and using that understanding to identify groups of people with the greatest need, where interventions will add most value.  

This means that we can anticipate the services and support our population may need in the future ensuring we are proactive in developing those services so that they are ready for when needed. It will also allow us to tailor care and support around individual patients, design more joined-up and sustainable health and care services and make better use of NHS resources. 

Digital technology is helping us to address long-term challenges, by offering innovative solutions for more joined up services. Our Integrated Care System provides your local NHS access to increasingly rich data, which can be used to target those communities with the greatest need.  

Taking a population health management approach is a crucial part of our plan to reduce health inequalities and improve the health and wellbeing of everyone in South West London. 

Our ambition 

***KLOE C2: How has the ICB developed its approach to population health management? ***

We are following our Population Health Management roadmap, first published in 2022, which sets out how we are working to embed these approaches across your local NHS.  

As digital technology is now a significant part of our everyday lives, we want to facilitate the analogue to digital switch, by using technology to change the way we deliver services, ensuring faster, safer, accessible support for patient self-care.  

This will also improve productivity and interoperability for our clinicians and staff for better patient outcomes. Recognising that not everyone can or wants to engage with the NHS digitally, we aim to offer a range of ways for people to access care and support. 

This year, our actions to achieve this included: 

Working to empower patients and people to take control of their own health and wellbeing in partnership with health and care professionals 

• Promoted use of the NHS app (Primary Care) and now have more than 820K people registered in South West London, including the highest percentage of 13+ age group registered. From February 2024 to February 2025, the NHS app has recorded a total of 13,339,340 logins, average 1,026m logins per month. This has improved the availability of information for both patients and clinicians at the point of care by empowering them with tools to support themselves to self-care and make informed choices about their treatment with functionality to book GP and hospital appointments, order repeat prescriptions, get test results and view personal GP records. Self Care at home has also progressed through virtual care, such as innovative Virtual Wards with a dedicated nurse led remote monitoring hub, and the use of technology in patients’ homes. 

Working collaboratively across organisational boundaries to seamlessly support individuals 

• Continued to expand our patient engagement portal (Secondary care), which integrates with the NHS App with St George’s University Hospital Trust one of the first to go live. With over 500K patients registered across South West London, they can now check their appointments and average waiting times (Kingston and Richmond piloted before successful nationally). It also helps the NHS manage and validate waiting lists and support patient-initiated follow up (PIFU). 

• Continued the implementation of our three-year digital transformation plan which includes implementation of the Cerner Millennium electronic patient record at Epsom and St Helier University Hospitals NHS Trust to align their systems with St George’s University Hospitals NHS Foundation Trust and put the organisation on a solid digital footing by 2026. 

• Collated a three year South West London Digital Transformation Investment Portfolio, with the creation of multiple working groups focusing on the collaboration and convergence of digital health and care and infrastructure improvements across the system, working towards joined-up digital platforms to enable staff seamless access to systems, patient information and clinical systems they need, wherever they are. 

• Developing a South West London Artificial Intelligence (AI) capability, including an AI Oversight group, aimed at ensuring alignment with the Pan London AI Adoption Framework and governance with system partners around AI, Robotic Process Automation (RPA) initiatives. 

• Continued work on the foundations of our data strategic plan, which describes how the NHS and local authority partners across South West London are working together to support delivery of joined up, person-centred care across our health and care system. Achievements this year include: 

• Optimising analytics and the business intelligence team and developing our community of data specialists in south west London – to develop our data capability, maximise in-house expertise and support workforce development. 

• Changing the culture of how we use data, ensuring that we have timely access to data and the appropriate tools to interrogate it. 

• Improving access to good quality data (Delivery of data environments – optimising use of data at scale) and creating robust governance for data (foundations to deliver the seven priorities for data set out in our data strategic plan for all partners)  underpinning how we work – to create a single version of truth for data across all system partners. 

Working to develop a data driven system that tackles inequalities, improves population outcomes, and drives up productivity 

• Promoted innovation that supports patients and staff, whilst addressing digital inequalities and exclusion by continuing to offer a range of ways in which people can receive care and support and interact with the NHS. 

• Completed a project to create a system-wide intelligence hub to join-up data and information more effectively, remove duplication and help deliver better patient care. 

• Joined the Association of Professional Healthcare Analysts, APHA, which has given us access to analytical peers from across the nation. This includes training opportunities, networking, and access to industry experts. This has improved our analytical skills, allowing us to use data to its best effect and help us use the intelligence and insight gained from our communities to use improve outcomes for patients. 

Working to secure transformation and learning  

***KLOE B6: How has the ICB secured transformation and learning? *** 

NHS South West London has an ambition in our Joint Forward Plan to be a learning health system and to create a safer system of care that reflects continuous learning and improvement. We can demonstrate this through: 

• The Patient Safety Incident Response Framework, PSIRF, transition: In 2023, all of the NHS organisations in South West London transitioned to work under the Patient Safety Incident Repose Framework, PSIRF. PSIRF is a learning model that supports developing and maintaining effective systems and processes for responding to, learning from and improving patient safety incidents.  

• We have commenced trust and providers site visits across South West London using a learning framework that allows providers to share what works well and where there may be areas of improvement. This framework has been successful in evaluating the safety of our services and we have rolled the framework out to our continuous improvement clinical and non-clinical leads across South West London to ‘show and tell’ the system of their improvement journey.  

• We have strengthened our system learning networks and through some of these core communities of practice, learning continues to be shared widely to improve patient safety and quality in South West London: 
  • System Patient Safety Steering Group and its Community of Practice  
  • Medicines Optimisation Safety Learning Group (MOSLIN) 
  • Continuous improvement Collaborative  
  • System Patient Safety Partners Network 

Workforce

We want to make health and care services in South West London a better place to work for all our staff. We are critically dependant on our people and the way they work. We need to work in a more integrated way, making sure that our people are supported to have more flexible careers, a better work-life balance, and that we have the right numbers of people with the right skills to meet the changing needs of our populations.  

• We want South West London to be a great place to work. A place where our people have fulfilling jobs which recognise their contribution.  

• We want everyone to be supported by great managers who respect, listen and care for them so that they in turn can do their very best every day.  

• We want to make South West London a magnet employer so that our supply outweighs our vacancies.  

• We want to be a fair, non-discriminatory system that is representative of the communities we serve. 

Last year, we have reshaped our delivery plans to deliver the both the JFP priorities (which reflect the national priorities) and the ICP strategic priorities. We have brought these together into four workforce transformation programmes:  

• Attract – our recruitment strategies, partnerships for engaging local talent, and the measures we have implemented to make South West London ICS a great place to work.   

• Retain – our efforts to ensure that once talented staff are part of our team, they find a supportive and fulfilling work environment that encourages long-term commitment and career growth within South West London.   

• Develop – our commitment to ongoing education and professional development, ensuring that our staff are not only competent but also at the forefront of healthcare innovation and best practices.   

• Transform – our initiatives aimed at reshaping our workforce structure and practices to ensure maximum efficiency, adaptability, and responsiveness to the changing healthcare landscape.   

Attract 

• We increased the promotion of the ‘350 careers in the NHS’ to our local community (including those in education) .  

• Developed a single point of information for healthcare jobs across South West London to enable and encourage South West London residents to consider careers across the ICS by improving application processes and appointing a Community Recruitment Engagement Lead to act as a ‘one stop shop’ for recruitment into the NHS for our communities. The scheme has successfully delivered multiple community engagement events, with attendees linked to current vacancies during the events.  

• Made it easier to get a job by marketing of jobs and careers in health and care in local communities. We delivered over 30 careers events, workshops, mock interviews, presentations and webinars and engaged with more than 1200 people. We created a portal for all health and care jobs in South West London in one place, and targeted people who have never worked in health and care.   

• Improved succession planning across our organisations, for example in mental health for roles affected by approaching retirement, putting succession plans in place for 50% of posts at band 7 or above.  

• Worked with further education colleges to support people currently unemployed into supported employability programmes which are aligned to work experience. The primary care project-based Work Experience programme provided a three week placement to develop essential employability skills and a work experience placement at a GP practice. Out of the 20 people, nine were offered a job through this initiative. We also provided college students the opportunity to work in the Business Intelligence team to develop a Power BI dashboard. They gained knowledge in data metrics and project management skills and as a result, one of the participants secured a paid internship at a tech company. 

• The South London Careers Hub project offered an additional 150 work experience placements across the ICB to provide opportunities to members of the local community to gain insight into a career in the NHS.   

• The Targeting Difficult to Recruit to Roles project has developed ways to improve the workforce in primary and social care. The key roles targeted by this scheme include General Practice Nurses, Care Home Nurses, Community Nurses and Health Care Support Workers (HCSW). The scheme has had particular successes so far with General Practice Nurses, with 68 placements for pre-registration nurses created to-date, and 260 Healthcare Support Workers completed training courses to help develop their careers. We’ve also supported 24 Internationally Educated Nurses to work in social care. 

• Supported care leavers to obtain employment into local health and social care roles by providing a personalised programme to help gain employment or training in local health and social care, and held four webinars on how to support people who have been in the care system or foster care to thrive in their careers during National Care Leaver’s Week. More than 25 local care leavers are being supported into apprenticeships, work experience or employment with local health and care organisations following successful workshops in all SW London boroughs. The I-CAN project supported up to 45 Care Experienced Young Adults (CEYA), aged 18-29, to pursue a career in the health sector, with a main focus on Nursing Associate Apprenticeship pathway. 

• Developed our apprenticeships and placements by making better use of the apprenticeships levy, develop apprenticeships across the system, and offer good work placements. An event was held with system partners in September 2024 with the purpose of understanding the barriers limiting the uptake of apprenticeship roles across South West London. The insights from this engagement has helped shape the work with system partners with links to apprenticeship within their respective sectors to improve uptake within employers. 

• The Community Upskilling and Job Readiness project supported local people into employment by helping adults gain specific skills to work in health and social care. We delivered community sessions and job readiness training for over 700 people, bringing learning to poorly served communities supporting access across different geographies and deprivation, people with caring responsibilities, people with disabilities, travel time and cost constraints. 

• Support local people into employment by further developing our local anchor arrangements including reducing barriers to entry and improving social mobility. 

Retain 

• Developed a South West London retention programme to support and enhance retention initiatives in NHS organisations.  

• We supported staff with the cost of living by reviewing the impact of the high cost of living on predominantly patient facing staff, particularly those in lower bands. The interim report which was informed by a cross section of 34 staff members from across the system via interviews and focus groups. As a result of the findings, food storage and reheating equipment was supplied to 20 departments based in St George’s, Your Healthcare, Croydon and SWL STG for long term use and available to just under 1000 patient facing staff members across the 20 departments. 

• In response to increased mental health related absences, we provided rapid access to mental health and wellbeing support. The South West London Mental Health Hub has three access points via three acute trusts that service the entire system. The hub offers staff, clinical assessment, counselling and onward referrals to more specialist services including the inhouse psychiatrist. There are also a group sessions for common presentations that lend themselves to group facilitation. Between April – November 2024, 1099 people were referred to the hubs. 

• The Women’s Health Project offers 1-to-1 consultations for women experiencing menopause, care packages for symptom management, and a range of resources promoted via the staff support website. The women’s health 1-to-1 consultations had 170 applications since going live in August 2024. To date, 61 consultations have been delivered with 25 staff currently on the waiting list. In addition, a menopause community has been established across the system with 250 staff on the circulation list. 

• The Men’s Health Project provides support for mental health, obesity, and MSK concerns. Male staff can access specialist seminars, cooking vlogs, exercise/stretching resources and FutiTalk (sports talk therapy group). To date, 83 staff have registered their interest, 32 members attended a FutiTalk session. Recognising that men often delay seeking help, we introduced proactive Men’s MOT sessions taking a preventative approach to health whereby 20 men attended, three serious cases flagged and two concerning cases were flagged.  

• We introduced the CapitalNurse flexible working pilot in five wards based at Kingston, SWL STG and Royal Marsden. The pilot is targeted at acute and mental health trusts and aims to support ward and unit managers to deliver flexible working in their environments to improve staff satisfaction, improve retention, reduce vacancies and reduce sickness. 

To support our ambition to make everybody feel they are included and belong:              

• our antiracist approach has been drafted and is now ready for engagement with our wider system. In addition, we are planning the big conversation on racism and have engaged 17 voluntary security organisations committed to supporting our efforts. This collaborative initiative marks a crucial step in our ongoing commitment to equity and inclusion, and we look forward to incorporating valuable feedback from all stakeholders. 

• The ‘Ask Aunty’ app that aims to support our international recruits received £250,000 in funding from NHS England and begun to roll out across London in January 2025. 

• We launched the Disability Advice Line in 2024 which aims to enhance accessibility, support reasonable adjustments, to align with the NHS Workforce Disability Standard and ultimately meet the legal duties of the Employment Act 2010. In the past 12 months, the DAL has undertaken a range of initiatives focused on increasing accessibility, improving staff training, and fostering an inclusive environment for staff. The DAL has supported more than a 100 people and hosts drop-in session every week. We have been able to claim over £30,000 from Access to Work and have built ongoing relationships. 

Develop  

• We continued to deliver the Future System Leaders Programme, open to all staff working at band 8C and above who aspire to progress to band 8D and band 9/director level roles within 12-24 months. 20 spaces was made available across the system for cohort one, and at least 60% – 70% of those spaces will be reserved for staff from Black, Asian, and ethnic minority backgrounds.   

• We launched the Inclusive Leadership Development Programme for middle managers in partnership with the University of Roehampton. The programme provides a reflective journey that aims to motivate managers to create inclusive working environments. This first cohort of 40 learners commenced in October 2024, with 35 completing the course in December 2024. A further 60 learners will be able to complete the course.  

• We mapped current training, development and talent programmes taking place across the system to determine scope and opportunity to bring them together.  

• Revised the training curricula for all health and care professionals to include a mandatory set of competencies around understanding/recognising, communicating, and signposting to psycho-social support.   

• Supported change management in primary care to equip people with the skills to embrace new technologies and innovations, for example online consultations to help guide patients through the system as quickly as possible.  

• Worked with senior leaders across the system to improve the numbers of appraisals undertaken and improve the quality of appraisal conversations, seeking to understand the aspirations of our staff and linking this to relevant resources.  

• Worked in partnership with the South West London allied health professionals council and faculty to explore possible approaches to allied health professionals educational practices to ensure that allied health professionals are supported to succeed from the very beginning of their careers.  

• Rolled out the national mandatory Oliver McGowan training programme for learning disability and autism.  

• Strengthened collaboration across health, social care, and VCSE partners, resulting in a nearly 10% increase in apprenticeship levy utilisation year to date. This has enhanced workforce development and access to training opportunities for staff across the system. 

Transform  

• Transformed workforce data to optimise service delivery, healthcare outcomes, and improve workforce planning. The programme developed a robust data system, agreed and utilised standardised data analysis across the ICB, and created decision-making dashboards to determine workforce requirements informed by finance and performance metrics.  

• Collaborated with Flair Impact to use data to develop the South West London anti-racism approach to ensure that South West London ICB and all its partners are anti-racist organisations.  

• Worked collaboratively across our trusts to address the issues surrounding the high number of Black, Asian, and Ethnic Minority staff going through the disciplinary process, by using ‘5D Review’ and increasing the mediation offering. 

• Our acute providers reviewed their existing workforce to determine opportunities for the use of different professional and staff groups and skill mix to support delivery and improve retention.   

• Community services developed a demand and capacity model across all community areas, to develop three-year forecast/projection for workforce plan to account for recruitment and retention challenges.  

• Developed and delivered a plan to address our ambitions for HR shared services.  

• Supported our trusts to reduce bank and agency spend by designing a new and consistent approach across organisations. 

• Developed a secondary agency bank as part of the national vanguard programme.   

• Improved and developed rostering practices across South West London.  

• Developed our workforce information systems and data to inform system-wide workforce planning. 

Our role as an anchor institution 

***KLOE E2: How has the ICB acted as an anchor institution within its wider system?**** 

The NHS is the largest employer in South West London, with many more employed in health and care roles in our council, voluntary and community sector and private health and care partner organisations across South West London. Our role as an anchor institute makes us best placed to help in strengthening the employment prospects and opportunities for our local communities. We are working with our partners to get those out of work or economically impacted by the pandemic and underrepresented people into good jobs and careers in the NHS and out health and care partners. 

The following programmes are supporting the ICB to deliver in our capacity as Anchor institutions across South West London to address the most challenging areas for underrepresented groups. 

Targeted engagement and informed reach to improve recruitment 

A keen focus of this work has been in being culturally mindful when linking with the community and the varied accessibility requirements of our underrepresented groups, for example Black, Asian and minority ethnic men and women, people with carer responsibilities, young people (particularly those leaving the care system), deaf and disabled people. This insight has fed into the creation of professional content and a targeted social media plan which will utilise relevant channels and will consider high impact influencers to help our communities consider jobs in health and care. 

Social mobility of our existing staff 

Last year we continued to develop insight into the current workforce, including those from our most deprived wards, to understand the existing skill set, qualifications and aspirations of staff whilst sensitively managing expectations. We will feed this learning into a programme of inclusive leadership development to increase cultural competence of managers supporting underrepresented groups. 

Social mobility for our local communities 

Our project-based work experience programme has been designed to lower barriers to entry and support local people to progress and settle into roles and careers within healthcare organisations. We are working with education providers and NHS employers to provide potential staff work experience in areas of need. The programme also supports participating NHS managers to develop coaching skills and progress their own careers. 

Increasing Access to Apprenticeships 

The SWL ICS wide apprenticeship programme has been in place for three years supporting managers to better understand apprenticeships and increased the utilisation of the levy over this period, whilst bringing partners together. More recently the ICB has developed an apprenticeship hub to bring together employers to share good practice and to tackle collective challenges, improving apprenticeship pathways, improve educational offerings, and establish a network of healthcare education providers. 

Jobs That Care School Programme. 

Jobs that Care was launched in 2019 to engage with schools in order to facilitate awareness and understanding of careers within the NHS. This Programme continues to play a vital role in supporting secondary schools across Southwest London with career advice and demonstrating the ICB’s commitment as an anchor institution within its wider system. Through this initiative, up-to-date information on the 350 diverse careers and roles within the NHS has been shared with SWL secondary schools. 

We recently supported career events in 10 local schools and engaging with over 1000 students. This has also generated a Teacher Encounter event attended by 15 school career advisers, further strengthening the vision to promote NHS career opportunities. 

Supporting our local community with pre-employment training 

We have introduced the NHS England Step into Work employability programme in South West London, designed specifically for unemployed adults to get them into entry level health and social care roles. We have worked with, further education colleges to support people currently unemployed into a supported employability programme which is aligned to work experience to build strong interview skills and job readiness. 

We have also developed accessible guidance and resources to support the overall approach. We have also worked with the Department for Working Pensions, further education colleges and the Voluntary Care Sector to support over 200 people into focussed NHS 350 careers awareness and ‘how to’ complete NHS jobs sessions and have engaged with over 1,000 people via our South West London wide careers events aimed at underrepresented groups. Many more sessions have been planned with partners across the year. 

We have made good progress on implementing the London Living Wage, which is an agreed Integrated Care Partnership action for the system in our ICP Strategy. 

We are developing an anti-racism framework and secured a shared commitment from the ICP Board to work together on this agenda. 

Through our ICP Investment Fund, we are working with partners to support our local communities to gain employment in health and care, including a focus on under-represented groups and people who experience barriers and inequalities, such as care leavers. 

Read more about our workforce in the Staff Report 

Other key achievements on the Anchor agenda 

• We have continued to develop our partnerships across health and care, the voluntary sector and other Anchor partners, such as our universities. We have incorporated social value in procurement and supported a wide range of voluntary and community sector groups who work with our diverse communities to support people experiencing health inequalities across the wider determinants of health. 

• We have made partnership commitments to supporting the green agenda as a cross-cutting theme in our Integrated Care Partnership Strategy. Our South West London NHS Green Plan sets out a comprehensive approach to sustainability and the net zero pledge. Work is underway to halve nitrous oxide wastage and procurement, further reduce desflurane usage, implement ‘Green Surgery Checklist’ principles, create recycling points for metered-dose inhalers, and further reduction in carbon emissions in our buildings. 

• We are reviewing our estates to identify opportunities to offer space to community groups across South West London, linked to the pledges we have made as part of the South London Listens programme. 

• The South West London St George’s Springfield development in Tooting includes social housing and public spaces for community use as well as employment opportunities for local people, particularly those who have experienced mental health challenges. 

Complaints

****Final figures to be updated at year end ***

Between 1 April 2024 and 31 March 2025, we received 608 formal complaints. Of these:  

• 165 related to issues for which NHS South West London was responsible for investigating and responding to  

• 282 were in relation to primary care, which means GPs, dentists, pharmacists and opticians. Complaints relating to primary care became the responsibility of NHS South West London from 1 July 2023, having previously been managed by NHS England.  

• We also received 161 complaints relating to issues which we are not directly responsible for, which were forwarded to the appropriate organisations for investigation and reply.  

Of the complaints we received in this period, five have been referred to the Parliamentary and Health Service Ombudsman.  

For those complaints that were within our remit, the most common complaints were about:  

• Continuing Healthcare (assessment for eligibility process, payment) –102 complaints  

• Mental health commissioning (access to services, availability and funding) – 23 complaints  

• General commissioning – 7 complaints  

• Primary care – 282 complaints  

• Medicines Management – 5 complaints  

• 111 or the GP out of hours service – 29 complaints   

• Evidence Based interventions (IVF & IFR) 8 complaints 

We very much value the views of patients and other people who experience the services we commission. We consider any complaint or enquiry about these services as a vital part of reviewing and, where necessary, improving them. We are putting together a ‘learning from complaints’ framework that will allow us to improve the experiences of our patients.  

Patient Advice and Liaison Services (PALS)  

Members of the Patient Advice and Liaison Service (PALS) always listen carefully to the concerns raised by patients and their loved ones, and provide advice or make recommendations, where possible, as to the best way forward for the patient or member of the public.  

While it is not always possible to resolve a concern to the service user’s satisfaction, the PALS team can give information about support services and voluntary organisations that may be able to help.  

We believe that a successful PALS service helps reduce anxiety for those who use our services and helps people navigate the health and care system, whilst also reducing the number of issues that go on to become formal complaints.  

The Complaints and PALS service also deal with a significant number of enquiries and informal concerns, from the public and MPs.  

During this period there were 955 such contacts. The most common contacts related to:  

• Vaccines – 45 contacts  

• Primary care (GPs, NHS dentists, community pharmacies) – 92 contacts  

• Continuing healthcare (assessment for eligibility process, payment) – 31 contacts  

• Redirections (inc. other NHS organisations) – 351 contacts  

• General commissioning – 8 contacts  

• Mental health commissioning (access to services, availability and funding) – 33 contacts  

• Individual funding requests (requests for funding for treatment/medication not routinely provided on the NHS) – 11 contacts  

• Assisted conception (eligibility criteria, can funding be transferred, freezing of eggs) 25 contacts  

• Medicines Management – 31 contacts  

• Compliments to the ICB – 14 contacts  

Get in touch with PALS

We very much value your views, and use your feedback to help improve healthcare for everyone in South West London. You can contact PALS Monday to Friday between 9am and 5pm:

0800 026 6082

[email protected] 

Emergency preparedness

The NHS plans for and responds to a wide range of incidents and emergencies that could affect services and patient care including anything from severe weather to an infectious disease outbreak or a major transport accident. This work is referred to as ‘Emergency Preparedness, Resilience and Response’ or EPRR. 

NHS South West London is a ‘category one’ responder which means that under the Civil Contingencies Act, the ICB must demonstrate that we can deal with these incidents while supporting our partners and maintaining services, meeting the full set of civil protection duties, including: 

• Assessing the risk of emergencies occurring and using this to inform contingency planning 

• Putting emergency plans in place  

• Putting business continuity management arrangements in place  

• Putting arrangements to make information available to the public about civil protection matters and maintaining arrangements to warn, informing and advising the public in the event of an emergency in place  

• Sharing information with other local responders to enhance coordination 

• Co-operating with other local responders to enhance coordination and efficiency 

In practice this means we have clear plans in place to allow us to continue providing core functions during a major incident, support our partners to respond to the incident and ensure we keep the public informed of any actions they should take. The ICB has been assessed against the NHSE Core Standards for EPRR as being fully compliant against a range of standards that ensure NHS organisations have policies, processes and resourcing that allow them to respond to incidents, run our ICB services against robust Business Continuity Management plans, and to facilitate the wider system response.  

The EPRR service is integrated into the South West London System Coordination Centre which has been assessed to be fully compliant with best practice guidance outlined in NHS England guidance. 

Over the past year, there have been several incidents which the ICB has responded to, these include: 

• A range of IT incidents, such as the global CrowdStrike IT outage 

• A range of Business Continuity Incidents relating to estates issues and pressure from capacity and flow in our provider trusts 

• Industrial action 

Environmental matters and sustainable development

Our plan   

The NHS nationally accounts for 4% of total UK carbon emissions, the equivalent to a small country in terms of global emissions. The national Greener NHS strategy set ambitious targets for the entire NHS to reach net zero, which are: 

• by 2040 for the emissions it controls directly (e.g. use of fossil fuels) with an ambition of 80% reduction by 2028-32 

• by 2045 for those it can influence (e.g. within supply chains) with an ambition of 80% reduction by 2036-39. 

Our Green Plan 2023-25 created the scaffolding and foundations for delivery against these targets at a system level. It created a strong commitment to net zero, emphasising the importance of collaboration and partnership in delivery. Guiding principles were established ensuring that our work was complementary to partner plans, set stretching yet feasible targets and actions, focused on behavioural change and moved towards embedding sustainability into business as usual.  

Ten workstreams underpinned delivery and the programme was expanded to collaborate with additional partners including across primary care and local authorities. The ICB plays a key coordinating role in the delivery of the NHS South West London Green Plan.  

Achievements to date  

This year, our priorities have been to strengthen partnerships across NHS organisations, primary care and local authorities, engage our workforce and unlock funding to accelerate progress.  

Highlights include: 

• Strengthening partnerships: Close working with the Greater London Authority (GLA) to host a Public Health Roundtable on Sustainability, bringing together health, public sector, and local authority leaders to explore the intersection of public health and climate action.  

• Driving adaptation planning: Following recommendations in the Mayor of London’s Climate Resilience Report, a South West London Adaptation Workshop was held for stakeholders, including trust estate teams, emergency preparedness leads, clinical colleagues and local authority public health teams.  

• Expanding sustainability training: Workforce development has been a key success, with board leadership training at gesh, the first South West London cohort of staff certified as carbon literate and funding secured to scale up primary care and staff-wide sustainability training. Plans are developed to roll out training to a further 200 staff members in 2025/26. 

• Delivering estate decarbonisation: £4.5 million funding secured via the NHS England National Energy Efficiency Fund (NEEF) to reduce emissions through LED lighting upgrades, Building Management System (BMS) improvements and enhanced sub-metering across NHS sites. 

• Boosting engagement and knowledge sharing: The ICB presented on sustainability at the Big London South Forum and regional colleagues contributed to local sustainability forums. Public health teams have been invited to NHS-led sustainability training, ensuring wider cross-sector alignment.  

It is estimated that a reduction of 3,058tCO2e savings has been set into motion through actions taken in 2024/25, recognising that we remain on the journey with regards to how we can measure success and show that we are making a difference.  

Cumulatively over the past three years we have successfully reduced the following emissions between 2021/22 and 2023/24 across a range of areas including medicines, estates, waste management and procurement. 

Emissions have been successfully reduced  

Emissions were reduced by 6,605 tCO2e (2021/22 – 2023/24) through various initiatives, equivalent to 1,540 cars off the road for an entire year.  

As a result of all our actions, the following is a breakdown of the emissions saved.  

• 6,605 tcO2e – total carbon savings across South West London 2021/22 and 2023/24 

• Cleaner air – equivalent to 1,540 cars off the road for a year 

• Desflurane – 14 tCO2e 

• Inhaler emissions – 5,342 tCO2e 

• Nitrous Oxide – 1,109 tCO2e 

• 4tCO2e electricity saved – between 2021/22 and 2023/24 in our trusts 

• 100% trusts using Rego certified renewable sources – plan to introduce additionally going forward 

• Waste 524 tCO2e reduced – between 2021/22 and 2023/24, equivalent to 116 cars, off the road for a year. 

• South West London Incineration reduced by 10% – incineration is bad for the environment and costly. 20% or less is considered good.  

Green Plan refresh for 2025-29 

A key delivery in 2024/25 is our new green plan which builds and expands on the above. The refreshed plan adopts a consistent approach for 2025-29 but reflects the needs of the programme as it has evolved. The most meaningful change is centring our vision more around Care Without Carbon, streamlining the number of workstreams, and developing targets and workplans.  Expanding on this:   

• We have considered current guidance and data available in the NHS, evolving local plans and the maturity of the South West London programme in our refresh as well as how we can better collaborate, share and work together in partnership, building on the success of our partnership working to date.  

• Central to the vision is an emphasis on delivering net zero services, empowering our staff to make the changes they want to see, building net zero considerations into everything we do, and continuing to build links and effective working relationships with partners. Our actions will give focus to areas of greatest impact, such as high-intensity carbon pathways.  

• Our vision builds on our strengths, whilst also recognising the challenges faced by the NHS particularly around productivity. As explored in the case for change, net zero is strategically aligned to the Government’s three missions 1) analogue to digital, 2) hospital to home, 3) treatment to prevention – as effective quality care is greener care.  

• Investing in decarbonisation not only helps us meet our net zero commitments but also delivers financial returns through long-term operational savings, energy efficiency and reduced waste.  

This plan is organised into eight workstreams and three cross cutting themes. These themes align to national guidance, are adapted for local needs and reference workstreams of our partners such as local authorities and the Greater London Authority (GLA). Each workstream has a specific work plan within outlining specific actions and targets. 
 
The workstreams are:  

• Workforce, leadership and training  

• Net zero clinical pathways  

• Digital transformation  

• Medicines  

• Travel and transport 

• states, waste and food  

• Supply chain, circular economy, procurement and single use items, and adaptation 

The cross-cutting themes are:  

• Primary care: as it cuts across all workstreams and requires dedicated attention 

• Place: where transformation is delivered and there is alignment with local authority colleagues 

• Data and monitoring: using an evidence base is integral to delivering change. Ensuring that we monitor the financial co-benefits of the green agenda  

• We have also taken the opportunity to review our governance systems and processes to ensure they remain fit for purpose and continue to align with London and local system partners including local authorities, health providers and voluntary sector. We oversee the South West London NHS sustainability strategy, with a South West London Green Plan Delivery Group ensuring implementation. The quarterly Sustainability Forum engages stakeholders from NHS trusts, primary care, councils and voluntary sectors. 

Climate-related risks are managed via existing business continuity planning and risk management structures. Our new green plan recognises the further development of adaptation planning as a key priority to improve consideration of climate-related risks and risk management across the system.  

Ambition for 2025-26 

We are fortunate to have such innovative and passionate staff that care about this agenda in South West London and want to make a difference. We want to continue to build the support in to enable them to deliver for the NHS, patients and the public. Central to this is our vision to place the concept of “Care without Carbon” at the centre of everything we do. To do this, we need to continue working with colleagues across the NHS and with our partners in local authorities, universities, the voluntary sector and at a pan London level with the GLA and London Councils.  

Additional information on our green activities (such as planned activities, risks and issues and carbon baselines) can be accessed in the Green Plan 2025/26-2028/29. More detailed information around historical performance is also available in our six-monthly reports to the ICB Board. 

Capital investment

*****Final figures to be updated for year end  ******

We have a financial duty to ensure that the system’s allocated NHS capital budget is not overspent. We have worked in collaboration with SWL NHS partners to follow a risk-based approach to prioritise expenditure within the capital budget for NHS trusts to ensure value for money and that our services and environments are safe and fit-for-purpose for patients, staff and the public.   

• In 2024/25, a budget of £141.5m was allocated to South West London for NHS trusts. With the transfer of £50.9m of capital receipts from asset sales into future years to reinvest in the Tolworth Hospital site redevelopment and additional allocations from NHSE for lease accounting and IT schemes, the revised budget for NHS trusts was £122.6m. The reported position at month 12 was [£112.5m] due to changes against plan following lease negotiations. The budget was largely invested in the maintenance and other critical replacement investment in estates, IT and medical equipment and supported the operational delivery within our trusts.  

• A £2.6m budget was allocated from NHS England for the investment in primary care for replacement IT and maintenance of GP practices. The reported position in month 12 as [£10.9m]. 

• These budgets were further supplemented in-year by additional national funds from NHS England secured through bidding processes (£43.3m for trusts and £8.3m for primary care). Funding contributed towards:  

• Implementing a new electronic patient record for Epsom and St Helier Hospitals to support the trust’s journey towards digitisation (to be completed in 2026/27).  

• Redeveloping the Barnes Hospital site in conjunction with the Department of Education to support mental health services in the community (to be completed in 2026/27). 

• Building a new community and primary care centre in New Addington to support services outside the acute hospital setting and primary care services in an area of high deprivation (to be completed in 2026/27). 

• Investing in energy efficiency schemes across trusts, including the installation of LED lighting and sub-meters to better manage energy consumption.  

• Accelerating critical IT infrastructure projects in primary care.  

• Working in partnership with Croydon Council to support the development of a new branch site for general practice in Coulsdon (to be completed in 2026/27).   

• Planning for a new Specialist Emergency Care Hospital in Sutton was paused in-year, following the Government’s announcement in January 2025 that the scheme was part of Wave 2 of the New Hospitals Programme, whereby construction would not start until 2032 to 2034. 

• In 2025/26, we will continue to support the system to invest in the maintenance of its buildings and in the replacement of ageing equipment, ensuring patients are kept safe and that day-to-day operations continue.  In line with our new South West London NHS Infrastructure Strategy, finalised during 2024/25, we will also continue to support the utilisation and modernisation of the existing NHS estate, digitisation of the NHS and our net zero targets. 

Estates 

Our vision, in line with the London estates strategy, is for all South West Londoners, regardless of their background or where they live have access to high quality health services in high quality facilities.  

Modernising and making full use of our healthcare infrastructure will also help deliver NHS services in the most efficient and cost-effective way and help us deliver to reduce our carbon footprint.  

In 2024/2025, we have made progress in many areas and continue to plan for the future needs of local people so that we can make the most of the facilities that we have. 

We developed a 10-year South West London NHS Infrastructure Strategy which sets out our ambitious collective vision to improve our infrastructure and to evolve health infrastructure planning across the estates, digital, workforce and green agendas.  

• Smarter, better health and care infrastructure – centring our infrastructure on the needs of the user, enabling access to joined-up care, making use of digital technology, supporting our workforce.  

• Stronger, greener buildings – supporting a net zero and energy efficient estate, having safe, resilient and flexible estate.  

• Fairer, efficient use of resources – tackling health inequalities, driving out value for money across health and public sector estate, ensuring that the existing infrastructure and new investments are financially sustainable. 

We conducted a significant review of our estates data to take stock of the current estate alongside existing local trust and Place strategies. It identified infrastructure challenges across our health and care system but were not too dissimilar to other health systems such as: significant estates and IT backlog maintenance needs in our hospitals, areas of inefficient use of our estate, disjointed digital infrastructure, cyber security risk, capacity issues in primary care contextualised by a lack of funding for primary care over several years, the scope to improve the environmental sustainability of our sites and services, and people capacity and capability issues.  

The review also identified that the scale of investment that would be required to address all of these issues is not affordable so we need to prioritise our capital, revenue and people resources to keep our services, staff and patients safe, but also strive to support strategic and transformative change to address financial sustainability, efficiency and productivity, health inequalities and patient outcomes. The scale of the backlog in our trusts is such that we will need to be more innovative in how we work together now to free up resources in the medium to long term. 

Engaging people and communities

***KLOE A7 – How has the ICB involved its local population in decisions that affect them? **

Working collaboratively with people and communities is central to what we do in South West London. Listening to feedback from communities and co-designing our projects not only makes us more accountable for the services we provide, but also ensures people have opportunities to shape and improve them.   

Understanding the needs of our communities, particularly those that experience health inequalities, as well as people’s experience of the services we provide, is essential to improve healthcare and prevent illness.   

In this section we describe: 

• Our engagement strategy and legal duty  

• Examples of engagement work across our six boroughs  

• The six different ways we engaged communities last year   

• The infrastructure that supports our engagement 

• Working with our Healthwatches and the voluntary, community and social enterprise (VCSE) sector 

Our engagement strategy and legal duty 

Our people and communities strategy supports us to ensure the voice of people and communities is central to all levels of our work – and that we have inclusive ways of reaching and listening to our diverse populations. Through our work we aim to: 

• Reduce health inequalities by better understanding the needs and aspirations of our local people and communities and responding to them in how we plan and deliver services.   

• Plan how local people and communities will be involved early – at the start of any work looking to change how services are delivered.  

• Work with community leaders to strengthen our understanding of our communities and their experiences.   

Read our engagement strategy 

The NHS has legal duties to make arrangements to involve the public in its decision-making, set out in the Health and Care Act 2022. We are rightly required to make arrangements to involve patients and the public in planning services, developing, and considering proposals for changes in the way services are provided and decisions to be made that affect how those services operate.  

Building relationships with communities and talking with them openly about service changes ensures we meet our legal duties. Understanding people’s experiences is vital to designing healthcare which meets people’s needs. The level of engagement we carry out is based on the scale of any proposed change, and how significant it is likely to be. 

We work closely with Health Overview and Scrutiny Committees in our borough councils to plan engagement activities. They ensure local people’s needs are central to decision making. 

Examples of engagement work across our six boroughs  

We work hard to make sure that what we learn from our engagement with local people has an impact on decision making and the way health and care services are delivered across South West London. Some examples from our work last year include:  

• In Croydon, Local Community Partnership events are held once every two months in each of Croydon’s six localities. These are led by 13 Co-Chairs involving local people and communities in determining local priorities and inviting local residents to contribute to making change in their local communities. Over 1,100 VCSE staff from 679 organisations have taken part in these solution-focused engagement activities. Locally owned Community Plans have had input from nearly 2,000 people living in Croydon and community development workers have been working at a street level to reach out to communities that are seldom heard to enable inclusive input to the plans. Linked to the Health and Wellbeing Board priorities, each locality gathers insights on mental wellbeing, supporting residents around cost of living, community safety as well as specific support for children and young people and supporting our older populations. Cross cutting all themes is identifying ways to tackle inequalities and intergenerational activities. Insight collected from the partnerships is reported directly to the Health and Wellbeing Board, shaping the Joint Local Health and Wellbeing Strategy 2024-2029 and Croydon’s Health and Care Plan 2024. 
• One of our GPs, working as part of Selsdon Medical Practice, in Croydon, informed us that he was retiring in April 2025 and would be selling the building he worked from in Mitchley Road. This meant that the space in the main Selsdon site needed to be reconfigured to allow for additional capacity. We worked with the practice to inform patients and stakeholders and held a number of sessions so that patients had the opportunity to feedback on plans and ask any questions they had about the change. We also worked with the practice to identify patients who may have additional accessibility needs – such as those with a serious mental illness or a learning disability – as well as those who did not speak English as a first language. These patients received bespoke information with practice staff having one to one conversations to make sure that they were aware of the changes to access in the future. 
• We wanted to understand people’s experiences of the current Merton community physiotherapy (musculoskeletal / MSK) to feed into the design of a new service. We hosted feedback sessions at the Merton Health and Care Community Voice Forum and the Merton Practice Leads forum to conduct surveys with existing patients to gather data on people’s experiences. Feedback informed the service design – helping to address the key issues like waiting times, accessibility and supporting people with care personalised to individual needs.   
• In Merton and Wandsworth, 10 workshops were held with over 140 Pakistani, Indian, Bangladeshi, Black African and Caribbean women who shared their experiences and barriers in accessing women’s health and fertility services. These discussions have fed into local South West London plans for better education and awareness sessions running in the upcoming year. 
• We engaged with over 420 children, young people and their families or carers in Merton and Wandsworth who are disproportionately impacted by health inequalities.  Working with 12 local VCSE organisations and groups who ran over 30 activities including family activities, intergenerational work, play sessions and focus groups to hear about physical activity, the local environment and the wider determinants of health such as money, housing, local environment that impacts on both physical and mental wellbeing. The insight was further discussed at both our Merton and Wandsworth community voice forums and has influenced the Wandsworth Health and Wellbeing Board strategy. 
• In Sutton we are engaging as part of a review of pathways to support the emotional wellbeing of children and young people with special educational needs and disabilities and neurodiversity. Following a review of nearly 20 engagement reports across South West London, we are working with families and children to understand more about the experience of current pathways and the challenges they face when accessing and navigating services. 
• In the summer of 2024 we worked in Sutton with the Carshalton Fields surgery to support its successful merger with another practice (Wallington Family Practice). We worked very closely with the practice manager to develop clear communications messages to let people know why this would be happening, the benefits it would bring and when it would take place. We also supported them to hold an in-person event so people could ask questions and discuss any concerns and developed FAQs which were put on their website. We worked closely with the Patient Participation Group to hold conversations with those patients registered as housebound or vulnerable to ensure they were aware of what was happening and to answer any questions.  
• Through our core20plus programme – which aims to reach communities impacted by health inequalities across South West London – Kingston Voluntary Action has worked in partnership with local groups to deliver health checks and talks to over 224 people from diverse communities. Many of these sessions enabled people with English as a second language to understand what support was available from the NHS and to share their views about their health and wellbeing. 
   

• We are working with Richmond Council, Richmond Carers Centre and other community partners to better recognise and support unpaid carers of all ages by creating a Carers Charter. We are engaging with carers to understand what is important to them from the Richmond carers strategy. These insights will inform a Charter that truly reflects the needs and desires of unpaid carers in Richmond. The final charter due later in 2025 will set out priorities that NHS organisations, Richmond Council, and the local voluntary sector can pledge to work towards, so our unpaid carers are supported in the way that is valued for them.   

The six different ways we engaged communities last year   

We deliver a wide range of engagement opportunities and activities to seek insight and feedback from our different communities, with a focus on those who experience health inequalities.  

We have six ways of engaging with communities: 

• Community led approaches  

• ICB Listening events  

• Working collaboratively with our people, communities and partners   

• Focus groups, interviews and events  

• Digital and online engagement   

• Communications and engagement campaigns  

Community-led approaches   

We take a bottom-up approach to working with our communities, empowering local people from the outset. We tailor our approach to the specific needs of each community we work with, ensuring long term sustainable networks between health, care and voluntary organisations whilst supporting local people’s health and wellbeing.     

A key element to enabling this way of working is maintaining our relationships and links to community leaders and voluntary sector organisations. For each borough we have mapped out the key communities we need to reach in order to understand more about those who experience health inequalities. For each population we have mapped how to reach them whether this be through local forums, community groups, social media, our relationships with community leaders, or newsletters.

Relationships are key to understanding our local populations. Our aim is to ensure we have regular, meaningful interactions with key community leaders throughout the year – to find out what really matters to the people they connect with, share opportunities for them to be involved, and feedback about the difference their insight has made.  

We also extend our reach by working in partnership with our voluntary, community and social enterprise (VCSE) organisations – we know that we gather richer insights and hear voices we wouldn’t otherwise due to the connections and trust our VCSE partners have with local people and communities.   

This year we have provided a number of grant funding opportunities for our local communities in collaboration with our VCSE South West London Alliance through our Childhood Immunisations Fund, Winter Engagement Fund and community grants for anti-racism work. 

In summer 2024, with a rise in measles cases we aimed to increase awareness about childhood immunisations and influence plans to deliver vaccines – including MMR, whooping cough and flu. We worked with community organisations to engage parents and carers and understand their views and concerns. 36 organisations were funded to host activities and engage with our communities between July and September 2024 which reached over 3,800 people. The programme engaged with diverse communities, providing information in an easy read and in 20 languages including Polish, Urdu, Arabic and Tamil. Read the insight report. 

Our Winter Engagement Fund distributed 115 grants to local community and voluntary sector organisations that can reach people who are likely to experience unequal access to healthcare and communities with the greatest health needs. The small grants scheme supported community leaders to bring communities together to share information during the winter months about our local health campaigns on:  

• NHS app – reducing pressure on primary care  

• Pharmacy – reducing pressure on urgent care services  

• Vaccinations and immunisations – reducing hospital admissions  

The engagement not only provided guidance and advice about local health services but also created opportunities to gather valuable feedback on what matters to local communities. Insight on challenges accessing urgent care and barriers communities experience are due to be discussed by the Urgent and Emergency Care Board to help us adapt and improve our services to better meet our communities’ needs – including a focus on languages and translation.

This winter around 350 activities and events took place, reaching 10,000 residents across South West London. Funded organisations included Wandsworth’s Baked Bean Charity, which hosted a series of Zumba sessions for adults with learning disabilities and the Togetherness Community Centre’s Caribbean Social Club in Merton funding hot lunches for the over 65s. Watch our short film here. 

Our South West London Joint Forward Plan includes equality, diversity and inclusion as a cross-cutting theme which is underpinned by our work as a system in how we proactively take an anti-racist approach. Hearing from our local communities is essential to this and local organisations have been running focus groups, holding one-to-one interviews and events to help engage on how our anti-racism approach is developed.

We are working with Kingston Race and Equalities Council to distribute grants to 20 community and voluntary organisations who are able to reach our most marginalised and disadvantaged communities. These organisations have the trusted relationships to make sure our anti-racist approach is co-designed with our local people and communities and that our next steps have meaningful impact for our most diverse communities. 

ICB Listening events 

We want to have a continuous conversation with local people about what matters to them. This year we engaged regularly through borough-based community networks. In the coming year we will be widening the membership of these forums in ‘listening events’. At regular points throughout the year we will be synthesising what we have heard at a borough level, the important issues to local people, and testing them back at these events so that people to let us know what resonates with them and the people they connect with, and tell us what is missing and what we should look into further. The forums which met this year include: 

• Croydon Local Community Partnerships  

• Merton Health and Care Community Voice Forum 

• Wandsworth Thinking Partners 

• Richmond Community Voices  

Working collaboratively with our people, communities and partners   

The Integrated Care System brings health and care organisations closer together than ever before – so collective resources can be used to meet people’s needs most effectively. There is an even greater focus on working with voluntary and community organisations and our six Healthwatch organisations across South West London. We have a united ambition to foster our existing relationships with local people and work with our diverse people and communities across our six boroughs, so we can make a bigger collective impact by collaborating on projects of work.  

In January 2025, we collaborated with more than 80 of our voluntary sector, community and Healthwatch partners who joined us for our South West London listening event to help us understand what matters most to our communities about the Government and NHS England’s 10 Year Health Plan.

During table discussions participants discussed the three shifts of the plan – prevention, community care and digital services – discussing their fears and hopes for the future. We also asked representatives to share with us ‘what matters most to your communities’ – by showing us which area was most important to their Place communities in a ‘dotmocracy’ exercise. See more information and watch our film. 

We have been working closely with our South West London Healthwatch organisations who have conducted an in-depth piece of work around Accessible Information Standards in collaboration with voluntary sector organisations. NHS England’s Accessible Information Standard (AIS) requires that health and care providers effectively meet the communication needs of patients and carers with disabilities.

South West London Healthwatch engaged 144 patients and carers, along with 82 GP practice staff, to assess their experiences and identify key challenges in implementing the Standard. To address the issues raised, recommendations include increasing AIS awareness, expanding accessible communication resources, and evaluating the effectiveness of new BSL services.  

To support our work around one of the three shifts, from hospital to community, we have commissioned local Healthwatch organisations, coordinated through our South West London lead, to conduct some targeted engagement with service users around community services. The work seeks to understand the experiences of services for those who are housebound; those experiencing end of life care, and parents and carers of children’s community services. Each Healthwatch is adopting a bespoke approach to delivering this piece of work.

The common areas that are being covered include understanding more about the importance of consistent carers, how well services were integrated and worked together, the extent to which services were tailored to their needs including accessibility and cultural needs, and if services supported their independence.

The methodological approaches include: surveys of parents of children under five, those who have experienced bereavement, and people who receive care from community nursing; in-depth interviews with frail service users; and a workshop for physically disabled and isolated people.  

Focus groups, interviews and events  

We often bring together small groups of people to hear about particular health topics or to hear from specific communities to help inform our local work and help shape local health and care services. Sometimes it will be more appropriate to talk to people on a one-to-one basis and this is often used to complement insight gathered from a focus group or survey.

We aim to speak to specific communities based on what our local data and insight tells us about who is or isn’t accessing services, people who have poorer experiences of services and those with poorer health and wellbeing outcomes – aiming to make sure we hear from people that are representative of the population in South West London.  

We used a layered approach to engagement in Kingston and Richmond when we were looking to understand more about families’ experiences of children’s therapy. Improving therapy services for children (0-18) is a key priority for our Kingston and Richmond Places. To support this, we took a mixed methodological approach to hear from families who access existing services to understand what is working well and where they thought it could be improved.

We offered one in person workshop in each borough, three online workshops at different times of the day, individual conversations for those who could not make the planned sessions, and met with our Kingston parent and carer forum. Through this feedback we were able to understand which elements of the service were most welcomed, such as the importance of early years support and how communication could be improved between therapists and families for children who receive their therapy in schools. The sessions also allowed clinical colleagues to discuss with families the evidence base and best practice for how therapy should be delivered. 

We have been working with Croydon BME Forum to understand and support Black neurodivergent individuals and families in Croydon and develop priority actions around the specific neurodevelopmental needs of Black communities in Croydon. A baseline survey was completed by more than 100 people to help shape plans for five online discussion events which were attended by 60-75 people per session, and a conference attended by 150 people. We are looking at how we can best support children and adults with neurodiverse conditions working with our partners in education and the local authority.   

In Merton, we have been working with Martin Way Church Shelter and Faith in Action to understand the experiences of health and care of people experiencing homelessness in the borough. The shelter provides people with a hot meal and a bed for the night. We held in depth one-to-one interviews with people who attend the shelter with the support of a Polish translator. Through this feedback we were able to understand some of the barriers they face in accessing health and care, including language and digital access.  

We held two online workshops with our Wandsworth community voice forum, Wandsworth Thinking Partners where local VCSE organisations helped to shape priorities for the Wandsworth Local Health & Wellbeing Strategy 2024-2029. In the workshops, we ran a number of focus groups making sure our approach was inclusive to meet the needs of our larger organisations and also making sure our smaller grassroot groups felt heard. The insight, views and experiences will feed into decision making for the delivery and development of local priorities. 

Digital and online engagement   

We use a range of different digital methods and platforms to engage with South West London residents. We know these methods don’t work for everyone, but they are important tools to enable us to reach a large audience, and people who might not attend in-person events. We use an online engagement platform to help conduct surveys to ask a number of questions to local people and digital marketing helps increase response rates. Our websites and monthly e-bulletins to local residents and stakeholders help us advertise all upcoming engagement opportunities and the impact of insights shared.  

This year, across South West London, we are planning an in-depth piece of engagement to understand what local people feel about our approach to healthy weight. The work will focus on finding out more about their views on weight loss drugs, specialist weight management services, and lifestyle interventions. We will be gathering insights primarily through an online survey aimed at people who have experience of weight loss interventions as well as those who qualify but have not taken up such offers.

We want to understand people’s perceptions of the current services, if open to weight loss medications, how and where they would like to receive them and what wrap around support is required. The feedback will inform our delivery model, service pathway and communication about services. Our plan is for the survey to be online and sent to service users via the providers as well using targeted promotion through social media. People will be offered the option of discussing their experiences on a one-to-one basis or in an online focus group.  

Communications and engagement campaigns  

We use a community engagement centred approach to sharing information and raising awareness of services, working through the wide-reaching networks built by our borough engagement leads, as well as their strong links and relationships with community leaders and voluntary sector organisations.   

We work with groups and individuals to share information which is most relevant, or of most interest – and feedback back insights to help develop our messaging.   

Building on our community engagement, we also share information through many other public facing channels and ask our trusted partners to share materials on our behalf too. For example, through websites, social media channels, staff communications networks and community and stakeholder newsletters. We also use paid marketing – such as radio adverts, outdoor advertising and digital advertising. This is how we ensure information is reaching individuals through lots of different routes.   

Our approach to communications and engagement campaigns is based on this ‘integrated approach’ where we adapt our consistent messages and materials to suit each targeted audience. This means bespoke communications for our diverse communities, around geographies, age, ethnicity, but also for staff and for different digital platforms. We also use a behavioural science approach so we can truly understand our audience and engage with them in the right way. Our aim being to make sure that people can make good choices with accurate information.   

During winter 2024/25 we have run a range of priority campaigns – promoting Pharmacy First, the NHS app and promoting vaccines and immunisations. Here is a summary of some of the campaigns:   

• NHS App for primary care access – highly targeted local advertising has been promoting the NHS App. Adverts encourage people to order repeat prescriptions, switch on notifications and manage primary care appointments, alongside wider messaging about the app.    

• Pharmacy First – paid online advertising promoting pharmacy services and the support they offer has been running since October. People are up to four times more likely to visit a pharmacy once they’ve seen one of the borough-specific adverts. This campaign has been seen over 3.7 million times. 

• Vaccinations and Immunisations – our campaign was seen 8.4 million times on and offline, targeting areas of low uptake. We developed new materials which featured members of the community, from Croydon BME forum, asking questions about vaccinations of a local pharmacist. 

Our grant programmes underpin our campaigns and provide outreach and engagement in local communities, for further information see our Winter Engagement Fund in the ‘community-led approaches’ section. 

The infrastructure that supports our engagement 

A key element of making community engagement central to decision making is ensuring the voice of people and communities has impact at strategic decision-making forums. Our decision-making framework is described as our governance and we use a range of different ways to ensure there is a strong presence for people and communities and their views.  

Representation at decision making forums  

In all the key meetings where decisions are made, members are required to consider patient and public engagement and communications activity. This includes our Integrated Care Board and Integrated Care Partnership which meet in public.

Active consideration of the voice of our people and communities is a requirement of our constitution and implemented by our submission templates for papers. Our Integrated Care Board constitution states: “The Board will receive reports which provide an overview of the engagement activities across the Integrated Care Board – noting the communities it has reached, impact that it has made, decisions it has influenced and any lessons learned”.  

Our Executive Director of Stakeholder and Partnership Engagement and Communications sits on our Board and has responsibility for coordinating our engagement activity to maximise its impact as a key system priority. This is so that it influences priorities and decision-making.

We fund two strategic posts, a South West London VCSE director to support the collaborative working across six boroughs and an executive officer post for South West London Healthwatch to support our six local Healthwatches’ partnership working. Both people in these roles further enable a strong voice for people and communities in decision making forums – they are members of the Integrated Care Board and many other programme steering groups.  

People and communities are also central at our borough Place Committees, championed by all partners sitting round the table – including Healthwatch, VCSE representatives and Health and Wellbeing Board Chairs. When considering priorities and service transformation plans lived experience and insights from the community focus discussions and are key to agreeing the way forward.   

We also work with a number of patient or public partner champions who are involved in our local decision making on our committees and meetings either at the borough or South West London level. A patient or public champion partner is often someone with lived experience who gets involved to represent their own views or works with local networks e.g. our Maternity Voices Partnerships to advocate and make sure their voices are heard.  

South West London People and Communities Engagement Group  

We have a South West London People and Communities Engagement Group which works collaboratively with partners to review engagement plans and activities, with membership from across the partnership including medical directors and programme directors from our provider organisations. After each meeting, we report to the Integrated Care Board through our Chief Executive’s update and reports are published on our website.    

Network of communication and engagement professionals  

We have professional communities in each of our six boroughs that bring together local authorities, NHS trusts, our borough engagement leads, the voluntary sector and Healthwatch. Through these networks we bring together insights and coordinate engagement activity at Place level so we can gain a more comprehensive view of the views and experiences of our local people and communities.   

The South West London Bank of Engagement Insight  

Through working with these colleagues from local organisations across our six places, we have collated insight reports from across South West London and uploaded them onto our website. This means we can effectively share the insight that already exists. With a reduced ICB engagement resource we can pool our collective knowledge amongst local partners, and ensure we aren’t wasting people’s time by different organisations asking the same communities the same questions.  

This ‘insight bank’ helps us to ensure views of local people influence the decisions we make as an ICB – for example, the collection of 180 reports helped inform plans across ICB teams – including the SWL Digital Strategy – and the refresh of our Joint Forward Plan. The report on insights from the previous year provides an easily accessible and strong baseline of what we know for different subject areas and with different population groups.   

Visit the Bank of Engagement Insights 

Working with our Healthwatches and the voluntary, community and social enterprise (VCSE) sector 

Healthwatch  

We have always worked closely with our six Healthwatches. As independent statutory bodies, they help us hear people’s feedback and improve standards of care and their insight from people and communities has influenced what we do and how we run NHS services   

This year they have worked collectively to raise awareness about the impact of the lack of dental access on our communities. Supported by our South West London lead, our local Healthwatch organisations collaborated to bring a presentation to the South West London Dentistry Day, contributing insights from national datasets as well as patient views about the impact of costly dental experiences and low availability of NHS dentists. This presentation helped bring focused insights about the needs and experiences of local people to encourage and gain commitments to improvements. 

Voluntary, community and social enterprise (VCSE) sector 

Our voluntary and community partners hold the key to supporting us to deliver more community-led approaches, increase diversity of participation and to build trust through continuous conversations.   

For example, five GP practices in Battersea are working with community health and wellbeing workers to visit people in their homes to provide advice and connect them to NHS, council and voluntary and community services and support. The workers focus on every aspect of life that can influence health, including housing, employment, social isolation and financial pressures, linking people with the help they need. This engagement helps with the early detection of illness, prevention and better management of people’s health and wellbeing.   

In May 2024, we launched the South West London Research Support Network to help support local people and organisations to get involved with research and engagement with their communities.  Read more about how we’re addressing health inequalities.   

The seven Network Cafés have welcomed over 200 participants, including community leaders, NHS staff, academics, local authority staff and students who come together to learn practical skills such as bid writing and evaluation to strengthen community involvement and improve diversity in health and care research.  We also have new Evaluation Ambassadors, a group supporting organisations to embed evaluation expertise across sectors, making research and improvement efforts more meaningful, measurable and actionable.  

Without the efforts of both local Healthwatches and voluntary and community sector partners this year, our reach would be narrower and insights less rich. Recognising the importance of both their roles, we continue to invest in posts which support collaborative working across our six boroughs.   

Statement from Alyssa Chase-Vilchez, Executive Officer, South West Healthwatch organisations and Healthwatch representative to the South West London Integrated Care System 

Healthwatch are independent organisations that champion the voices of patients, carers, and our wider communities. Six Healthwatch organisations (Healthwatch Croydon, Kingston upon Thames, Merton, Richmond upon Thames, Sutton, and Wandsworth) are located within the borders of the South West London Integrated Care System (ICS).   

In 2024-25, South West London Healthwatch continued to collaborate closely with the ICB engagement team to ensure that our residents influence decisions about their health and care. 

First, we worked together to create a culture of engagement throughout the ICB, advocating that commissioners listen to patients when developing new strategies and making changes to services. We also provided direct feedback on engagement plans to enhance their effectiveness.  

Second, the ICB engagement team has facilitated our ability to share learnings with the appropriate stakeholders. Through their support, for example, we brought evidence showing that dental commissioning is not meeting local demand, and highlighted the economic, physical and mental health consequences. Our evidence, combined with the efforts of other colleagues also advocating for improved dentistry, has increased momentum to improve dental services. 

Finally, the ICB engagement team keep us informed about planned service changes, ensuring that patient and carer needs remain at the forefront. For instance, in response to a national proposal to shift health services from hospital into the community, the engagement team commissioned us to speak with patients and carers to understand how we can improve existing community services across South West London. This work will directly inform the delivery of this evolving strategy. 

Ultimately, our collaboration with the ICB engagement team enables us to better harness the power of people’s voices, and to make real change for our residents. This in turn helps us build trust with our communities and promotes a democratic approach to our health.  

Statement from Sara Milocco, South West London Voluntary and Community Sector (VCSE) Alliance Director 

The VCSE (Voluntary, Community, and Social Enterprise) sector is vital to South West London, serving as a key partner to the NHS. With over 5,500 VCSE organisations, they play an essential role in delivering personalised, holistic support services that meet local needs and improve community wellbeing. They reach communities that often don’t engage with mainstream services, helping to ease the strain on healthcare systems through preventative care and innovative solutions. 

The South West London VCSE Alliance has been positioning itself in the last two years to be the link between local voluntary and community sector organisations and other partners within our ICS and help transform the health and care services for local people.  

We are successfully working in partnership and have established grant funding mechanisms that enable South West London to connect with small local grassroots organisations, supporting initiatives focused on prevention and early intervention, through the Childhood Immunisation grants, Winter Engagement Fund and community grants to support our anti-racism work. The grant programme attracted the interest of other partners and was replicated with HPV and general cancer awareness grant programmes working with the Cancer Collaborative. 

We have worked closely this year on mental health, with our two VCSE mental health representatives working closely with South West London St George’s in the design of the South West London Mental Health Provider Collaborative – and how this can help us to better deliver community-based interventions that are accessible, less stigmatising, and tailored to specific populations. There’s clear commitment to explore a longer-term funding model, more effective communication with providers as well as championing the VCSE sector as equal partners. 

We paved the way for more local VCSE organisations to embrace apprenticeships and worked together on promoting digital inclusion and shaping the South West London Data Strategy 2025-2028 and digital inclusion approach. Our VCSE Digital representative was involved in several projects to help the NHS address concerns from our communities such as fear, mistrust, skill gaps and language barriers. As part this we collaborated with the Long-Term Conditions team to distribute small digital inclusion grants to VCSE organisations to help gain feedback in the development and design of the BetterU app – a self-management app which helps people manage musculoskeletal injuries and conditions like back pain. 

We remain committed to our collaborative partnership with South West London, working to further embed the VCSE expertise and knowledge to create future opportunities as part of the South West London VCSE Alliance. We look forward to continuing to address health inequalities, fostering a strong partnership with the VCSE sector and driving a significant shift towards prevention. 

Overview of our key performance issues and risks

When we review this chapter and look back over our performance over the past year, it is important to identify the key risks our organisation has dealt with, and how we have managed and attempted to mitigate then. These are described below: 

Delivering access to care – NHS Constitution Standards 

A key issue which we have worked hard as a system to manage over the last year is the number of people waiting for care which can result in a delay to their treatment. This means that on occasion hospitals are not able to meet important national and local performance standards – for example this year we have faced challenges in access to primary care, and access to children and young peoples’ mental health services. We continue to perform well, relative to other ICSs, on delivery of cancer waiting times and waiting times for planned care in our acute hospitals. 

Meeting national standards for access to services, regardless of where they live in South West London or their background, is the foundation of providing high quality healthcare services. We have strong measures in place and will continue to work hard to maintain and prioritise high quality care across South West London.    

Actions we have taken to help manage this risk in 2024/25 

• Hospitals track activity each week, in particular focusing on patients who have been waiting a long time and compare this to expected activity levels as part of our elective recovery governance process. 

• Hospitals have been checking that their list of patients is always accurate and they prioritise patients waiting for surgery based on criteria and recommendations from the Royal College of Surgeons. This is helping us to make sure we are prioritising and scheduling patients efficiently. 

• Plans are underway to deliver the national targets around elective recovery including an increase in elective work and delivery of targets around advice and guidance and patient-initiated follow-up to ensure that we can prioritise our most urgent patients. 

• We have held regular system-wide meetings to monitor and manage performance against the performance standards and to ensure action is taken where problems are identified. 

• Where we know we have challenges in long waits we have plans in place at a specialty level to address this, for example by ensuring that there is additional capacity made available. 

• Quality and service delivery are reviewed bi-monthly at our Quality and Oversight Committee meetings, and meetings are held fortnightly between hospital recovery leads and our performance team to help manage long waiting patients. 

• Introduced data quality improvement meetings to specifically help reduce coding and data quality errors around long-waiting patients. 

• Long, medium and short-term operational and clinical opportunities are being explored and implemented as part of recovery to ensure improved and sustained achievement of constitutional standards. 

Read more about our performance against key performance standards and our performance throughout the year

Urgent and emergency care 

Urgent and emergency care services are of key importance to our local communities, and we are working hard to prioritise delivering high-quality urgent and emergency care services across South West London. Urgent and emergency care services include NHS 111, services provided in the four emergency departments across our boroughs, urgent primary care services and urgent admissions into hospital. It is important that we continue to work hard to meet national targets and minimise delays to patient care. 

The risks around the pressures in urgent and emergency care have consequences for the rest of our health and care system. We have worked hard over the past year to maintain our focus on patients being discharged promptly from hospital when appropriate, reducing waiting times to receive urgent and emergency care, and work to minimise the handover time for patients from the ambulance service.  

Actions we have taken to help manage this risk in 2023/24 

• We have continued to strengthen system-wide governance through the Urgent and Emergency Care (UEC) Board and four local Delivery Boards, ensuring a coordinated approach across South West London. 

• These boards provide oversight on performance, patient pathways, and system-wide interdependencies, including links with workforce and primary care. 

• To manage seasonal pressures, we have implemented a winter plan for 2024/25, investing in hospital, community, local authority, and voluntary sector services to increase capacity between November 2024 and February 2025. 

• We have developed a high-level dashboard to monitor patient flow and length of stay, ensuring national performance standards are met. Monthly reporting to the UEC Board provides detailed insight into system pressures, including patients waiting in ED for over 12 hours for both physical and mental health care. Action plans approved by the UEC Board are actively monitored for impact. 

• We continue to focus on reducing ambulance handover delays and improving hospital flow by working closely with ambulance services and emergency departments. Strengthening early discharge planning remains a priority to free up hospital capacity and minimise delays in admissions. 

Read more about how we’ve developed urgent and emergency care services this year

Failure to modernise and fully utilise our estates 

We need to modernise and make full use of our estate, or we will risk not being able to deliver NHS services in the most efficient and cost-effective way.  

Investment in our estate means we can spend more of our money on frontline services for patients rather than increasingly expensive backlog maintenance bills. Poor estate also means we cannot make fast enough progress towards a net zero carbon footprint, and can also delay us delivering integrated care in community settings as we have committed to in our Joint Forward Plan NHS SW London.   

Our vision, in line with the London estates strategy, is for all South West Londoners, regardless of their background or where they live, to have access to high quality health services in high quality facilities. 

We have made progress in many areas this year and continue to plan for the future needs of local people so that we can make the most of the facilities that we have. 

Actions we have taken to help manage this risk in 2024/25 

• We have developed and approved a South West London NHS Estates and Infrastructure Strategy, which provides a framework for maximising estate use, minimising the carbon footprint, and meeting local needs. 

• This strategy ensures a coordinated and sustainable approach to estate planning across the system. 

• As part of our financial recovery workstream, we are working with providers and Places to identify opportunities to exit under-utilised buildings and consolidate estates where appropriate, helping to reduce costs and improve efficiency. 

• To better understand the future needs of primary care estates, we have undertaken a comprehensive data collation exercise, which has allowed us to prioritise estate requirements, maximise use, reduce vacant spaces and explore digital solutions in place of costly large-scale developments. 

• We continue to review void and vacant space across our estate in partnership with NHS Property Services and Community Health Partnership, ensuring that under-utilised space is repurposed wherever possible.  

• Queen Mary’s Hospital, where we are collaborating with NHS Property Services and the PFI provider to address void space within contractual obligations and national policies. 

• We have embedded critical infrastructure investment criteria into all capital prioritisation processes to ensure that ageing estates do not negatively impact patient care. Additionally, we continue to seek funding opportunities to transform services and de-carbonise the estate, including through the New Hospital Programme, the public sector de-carbonisation scheme, and other capital funds. 

• Finally, we are working closely with NHSE to develop the ICS estates strategy, ensuring a system-wide approach to estate management that aligns with national objectives. 

Read more about how we’ve invested money this year to develop NHS estates

Financial sustainability 

South West London remains a financially challenged system. Each part of our NHS system has worked together to minimise spend and deliver a financial position that has been agreed with NHSE. We continue to work hard on delivering a stretching financial recovery plan for the coming year, including programmes that will deliver on: efficiency measures, productivity improvements, workforce planning, better preventative care and co-ordination, digital health solutions and stronger budgetary control and financial governance.  

Further to this there is additional risk that the ongoing changes to the NHS financial frameworks, due to the creation of new population-based allocations (including specialised services), means the ICB/ICS will find it challenging to deliver its strategy and the objectives of the Long-Term Plan due to the constraints of the financial envelope. 

Healthcare services need to be delivered efficiently and effectively so that investments can be made to support the local population’s health and wellbeing. Over the last few years and in response to the pandemic, additional investments have been made which have increased the cost base of the system. As well as this, costs are increasing through high levels of inflation and the impact of industrial action. 

The system has identified opportunities to reduce costs, but these will be challenging to realise, in terms of capacity to deliver, speed and maintaining our focus on operational delivery. Our system leaders have focused this past year and continue to prioritise this coming year, working hard to live within our financial means as the best way to address the changing healthcare needs of our local population. 

Actions we have taken to help manage this risk in 2024/25 

• We have undertaken a planning and budget-setting process to ensure resources are prioritised appropriately, aligning activity, workforce, and financial planning to support financial balance while minimising running costs. Each organisation has developed a savings programme, which is overseen by both individual organisations and the South West London ICB Finance and Planning Committee. 

• We continue to report the financial position monthly through budget holders, Senior Management Team meetings (including Place leads), and the Finance & Planning Committee to the ICB Board. The ICB Board reviews the financial position at each meeting, with quarterly NHSE assurance meetings providing further oversight. Additionally, the Chief Financial Officer attends regional ICB meetings to ensure that financial assumptions and approaches align with regional and national strategies. 

• Recognising the ongoing financial challenges across NHS providers in South West London, we have established a Missions Board (replacing the Financial Recovery Board) to oversee the service transformation required to deliver the savings programme and financial recovery plan. This Board reports to the ICB Finance and Planning Committee and ensures a system-wide approach to financial sustainability. 

• In 2023/24, we undertook a detailed analysis of financial opportunities, consolidating these into a high-level financial recovery plan. For 2024/25, we have reviewed and refined our workstreams, focusing on workforce, system infrastructure, elective services, and improving urgent and emergency care pathways. Alongside this, we are conducting further modelling to understand how best to deliver services within a financially sustainable framework. 

• As part of NHSE’s updated requirements, all ICBs and NHS partners must develop plans to ensure core services can be delivered within a reducing financial envelope by 2025/26. We are actively working with NHS partners to achieve this, building on our financial recovery plan and incorporating further analysis provided by NHSE to support long-term financial sustainability. 

Read more about our financial performance this year

Workforce capacity wellbeing and availability 

In common with the rest of the NHS, our South West London NHS workforce numbers and the skills we need undoubtedly remain a challenge, but we have made incremental improvements this year. As a whole, our South West London system has reduced staff turnover and staff sickness, has less temporary and more permanent members of staff, and has taken action around health and wellbeing initiatives to work harder to retain the excellent staff we have across South West London. Industrial action impacts the most on our patients, but also on our workforce who have worked extremely hard to keep patients safe during the protracted periods of strike action. 

Actions we have taken to help manage this risk in 2024/25 

• We have embedded the Mayor’s Skills Academy Programme within the South West London system, working closely with the social care sector to improve domestic supply by attracting more local people into the NHS 

• Recruitment and retention committees are in place across provider organisations to monitor workforce pressures and ensure effective solutions are in place. Regular workforce reports continue to be reviewed at provider boards and the ICB People Committee 

• Identifying key workforce challenges and actions to improve recruitment, retention, and staff wellbeing. 

• Trusts have continued local, national, and international recruitment campaigns and have adopted fast-track recruitment processes to streamline hiring. Following last year’s operational planning round, Trust HR Directors have worked together to agree on priorities for workforce supply and retention, including reviewing pay enhancements, bank/agency use, and reward systems. 

• To support staff health and wellbeing, we have established the South West London Health and Wellbeing Hub, providing a centralised support system for NHS staff. This is funded through the ICP investment fund, but ongoing funding beyond March 2025 remains uncertain and will need review. In addition, financial wellbeing support has been made a priority across all Trusts to ensure staff receive the necessary resources to manage cost-of-living challenges. 

• We continue to support mental health and wellbeing through regular meetings with staff counsellors and provider health and wellbeing leads. While mental health SDF funding is due to end, the remaining funding has been allocated across South West London NHS organisations 

• To ensure continued workforce wellbeing support, Occupational Health and specialist services remain in place across all provider organisations. 

• A South West London workforce report, incorporating input from NHSE workforce teams and the ICB Workforce team, is regularly presented to the People Board and the ICB Board. This report now includes both health and social care workforce data, ensuring a more comprehensive workforce strategy. 

• We have launched a skill mix review, led by our Chief Nurse, focusing on: 

• Strengthening safer nursing staffing across South West London 

• Reducing high-cost resourcing  

• Ensuring professional nursing roles focus more on patient care 

• Additionally, we continue to work in partnership with trade union representatives to ensure a collaborative approach to workforce planning, recruitment, and retention. 

Read more about how we’re supporting and developing our workforce

System quality oversight  

Maintaining and improving the quality and safety of healthcare services in South West London is of the highest importance to us. We are working to make our quality monitoring processes as robust as possible so that we can address any potential issues in this area. 

The progress we have made over these 12 months has strengthened our quality governance at both at system and Place level. We will continue to work to further strengthen our governance, and further develop our relationships with our providers to foster an open culture of sharing and learning. 

We are working hard to ensure that we recruit to vacancies in the ICB quality directorate to make sure we can capture and understand quality risks across provider services and continuing healthcare. A key focus for us has been to ensure the quality of key pathways across South West London including children and young people, mental health, maternity services and urgent and emergency care.  

Actions we have taken to help manage this risk in 2024/25 

• Our Quality Directorate continues to identify, assess, and monitor risks across the system, ensuring that plans are in place to mitigate any potential adverse impacts on the quality and safety of services. 

• The ICB’s review of its quality governance and assurance processes has strengthened early risk identification and escalation, ensuring adequate systems and processes are in place. The ICB now regularly monitors quality risks through the Quality Operational Management Group, the System Quality Council, Place Quality Group meetings, and the ICB Quality and Performance Oversight Committee. 

• Providers continue to report and provide assurance through internal governance routes and quality committees, escalating severe risks to their Board Assurance Framework (BAF). 

• All South West London providers have now successfully transitioned to the Patient Safety Incident Response Framework (PSIRF), and independent providers remain on track to implement this framework. 

• Regular South West London Chief Nurse meetings continue to be held bi-weekly with the ICB Chief Nursing Officer, where escalations and mitigations are discussed at both organisational and system levels. 

• Through regional Joint Scrutiny and Oversight Group meetings, we continue to share intelligence with the Care Quality Commission (CQC), NHS England, and other regulators, ensuring a coordinated approach to identifying and addressing provider concerns. 

• Providers and local authorities are now in a phase of readiness for the new CQC single assessment regulatory framework, and all South West London local authorities have undergone peer reviews in preparation for upcoming CQC inspections. 

• In addition, we have strengthened integration between the contracts and commissioning teams to ensure quality and safeguarding outcomes are embedded into provider contracts, supporting long-term service improvement and patient safety. 

You can read more about our approach to quality oversight this year

Interruption to clinical and operational systems as a result of a cyber-attack 

We know the risk of cyber-attacks on NHS and public sector services is increasing. A cyber-attack is an unauthorised attempt to gain access to our computer systems or networks, this could be those belonging to our provider trusts or any of our shared services. Cyber-attacks can mean data breaches, disruption to local services and impacts on patient care. There are often financial consequences and potential reductions in public trust in health and care services. 

Over the last year we have made good progress last year with our partners to increase the number of cyber defences and response tools we have at our disposal. However, we know we need to remain vigilant and to continually evolve our defences. We will continue to work hard to ensure that services and patients are better protected against cyber threats. 

NHS South West London co-ordinates the cyber security assurance across our ICS, with cyber security accountability remaining with each individual organisation. 

Actions we have taken to help manage this risk in 2024/25 

• We have completed an ICS-wide cyber assessment to establish a comprehensive security baseline across providers and primary care IT systems. This assessment has provided a clear risk position, enabling us to prioritise mitigation efforts. 

• To strengthen governance and collaboration, we have worked closely with providers to develop a coordinated approach to cyber risk management. This includes the establishment of formal governance structures, which have helped shape a draft cyber roadmap of activities designed to enhance cyber resilience across South West London. 

• To further embed cyber leadership across the system, we have appointed a dedicated ICS-wide cyber lead to oversee the implementation of risk reduction strategies and support system-wide cyber security improvements. 

• Our NHS providers continue to own and manage local cyber risks, ensuring they meet annual IT Health Check requirements and complete the NHS Data Security Protection Toolkit (DSPT). The ICS supports these local efforts while also promoting a joined-up approach to cyber security, which helps improve efficiency, reduce service frictions, and achieve cost savings. 

• In partnership with NHS England and the National Cyber Security Centre (NCSC), we continue to receive cyber monitoring and incident response support, particularly for devices in the shared NHS tenant and Health and Social Care Network (HSCN). National agencies also support security assessments, audits, technical remediation services, and funding opportunities to help address local security risks. 

• As part of our ongoing cyber resilience strategy, we have completed a Multi-Factor Authentication (MFA) review across participating organisations to strengthen system access security. We have also conducted an ICS-wide cyber incident simulation/tabletop exercise, ensuring that organisations are well prepared to respond to potential cyber threats. 

• To support consistent cyber security practices, we have developed key cyber policies, which have been shared with provider organisations for review and adoption. 

Read more about our approach to cyber security

Read more about our approach to risk management in our governance statement