1 Contents
NHS Sussex Winter Plan: update
2.0 NHS Sussex Winter Plan – Additional Demand Impacts
3.0 Our delivery plan: progress
3.1. Discharge, including rapid improvement workstream actions
3.2 Out of hospital urgent care rapid improvement programme
3.3 Improvements in ambulance performance
3.4 Improvements in 111 performance
3.5 Acute Hospital Urgent Care Services
3.9 Infection Prevention and Control
3.10 Seasonal vaccination programme
3.13 Planned Care Recovery Programme
3.14 Public Health – East Sussex
NHS Sussex Winter Plan: update
1.0 Introduction
This report provides a summary review of the impact of the Sussex Winter Plan on urgent and emergency care services, together with planned care. The report highlights the impacts of the Sussex wide and East Sussex specific elements of the plan as set out in the paper presented to the Health and Overview Committee in December 2022 and covers the period to January 2023.
Delivery of the Sussex Winter Plan has been overseen by a weekly Winter Board, chaired by the NHS Sussex Chief Executive and attended by NHS Provider Chief Executive Officers, System Executives and Local Authority colleagues, ensuring that strategic leadership decisions required in response to any emerging issues or risks, have been taken in a joined-up way. This has ensured that we have taken into consideration the needs of our entire population and the needs of staff working across both health and care.
2.0 NHS Sussex Winter Plan – Additional Demand Impacts
The Sussex Winter Plan was informed by detailed capacity and demand modelling with evidence-based assumptions related to seasonal urgent and emergency demand trends, the forecast impact of further Covid-19 waves, and seasonal flu related demand. However, this Winter has been impacted by additional factors that have materially impacted on the local health and social care system as follows:
· Whilst a further Covid-19 wave over winter was modelled within the system winter plan, a further wave impacted slightly earlier than modelled and a peak of 288 acute hospital beds occupied by Covid-19 positive patients was observed on 26 December, compared with a peak of the previous wave of 308 on 12 October.
· Whilst it was anticipated that the flu season this winter would be worse than pre-pandemic levels, actual prevalence and subsequent impact on acute hospital admissions was greater than modelled with a sharp increase in cases and a peak observed on 29 December when there were 157 acute hospital beds across Sussex occupied by patients with flu, compared with a peak of 23 in early December of the previous year, 2021 – see figure 1.
Figure 1: Sussex Acute Hospital Flu General and Acute bed occupancy
· Nationally there was significant surge in paediatric demand in December 2022, which was driven by an increase in Group A Streptococcus prevalence and high-profile national media coverage. This surge in activity impacted services across all primary, urgent and emergency care services. There was a 46% increase in Paediatric A&E attendances in December across Sussex and 58% increase at ESHT. Across Sussex we ensured increased capacity in our Paediatric Emergency Departments and Urgent Treatment Centres, and rapidly mobilised Paediatric Acute Respiratory Infection Hubs across the county.
· In addition to the above factors the system had to respond to industrial action with a GMB strike impacting on ambulance services on the 21 December and 11 January, and an RCN strike impacting NHS providers on the 17 and 18 January with further industrial action planned over the course of the remainder of the winter period. System and provider agreed plans were effective in managing the additional risks identified.
The above additional demand factors coalesced at the same time to significantly impact on our health and social care system and urgent and emergency care services with the peak consolidated impact observed during the Christmas and New Year holiday period.
As a result of these additional risk factors the Sussex health and care system declared a system Business Continuity Incident (BCI) on 16 December, which was then further escalated to a system wide Critical Incident on the 30 December running until 6 January when the system was able to de-escalate back to BCI. The system was then subsequently able to de-escalate on 23 January following review of the system position and significant improvement observed in relation to ambulance handover delays and long waits in A&E.
3.0 Our delivery
plan: progress
3.1. Discharge, including rapid improvement workstream actions
Most patients in East Sussex continue to be discharged home without the need of further support. However, for the small proportion of patients who might need social care, rehabilitation services or longer term residential or nursing care to support their discharge, the health and care system has collaborated to develop and implement full plans to support people over the winter period. This has included additional health, social care and voluntary sector capacity[1] to support people to be discharged to their own home; additional bedded capacity for people who are ready for discharge and need further assessment for their longer-term care needs; a range of measures aimed at improving the workforce capacity in the care market; and additional support for carers. Enhanced work with our district and borough councils is also supporting discharge pathways for more vulnerable and complex patients who are homeless or have housing difficulties.
Our priority in East Sussex continues to be to discharge people home wherever safe and practical to do so, this is our Home First pathway. The plans outlined above that we have implemented have included additional clinical and domiciliary care capacity to support this preferred discharge pathway.
Within the context of the wide range of additional capacity and support in East Sussex, there has been a sustained reduction in the numbers of patients who are assessed as medically ready for discharge and are waiting to be discharged. This additional capacity includes an additional 86 Discharge to Assess beds in Care Homes, an additional 910 hours of home care per week and additional capacity from the voluntary sector to support patient discharge, alongside additional workforce to support patient discharge across the health and care sector. The sustained reduction in patients waiting to be discharged is as follows. In East Sussex, the mean number of patients who are medically ready for discharge has reduced from 229 (over the 7 day period ending 14 October 2022) to 162 (for the 7 day period ending 17 February 2023). Within East Sussex Healthcare NHS Trust, there was a mean of 145 waiting during the same October 2022 period, reducing to 87 during the same February 2023 period.
3.2 Out of hospital urgent care rapid improvement programme
The focus of the out of
hospital urgent care workstream has been to improve ambulance
response times by improving join up and input from alternative
services to best support our patients.
A key development has been the Admissions Avoidance Single Point of Access (AASPA). This went live on the 14 December. It provides a single 24/7 telephone number for South East Coast Ambulance Service (SECAmb) for professionals. It is a clinically led service where SECAmb crews are able to discuss a patient’s condition, determine the right service for the patient and once clinically referred, have the confidence to leave the patient safely at home where clinically appropriate to do so, allowing the crew to get back on the road. It connects crews into alternative services such as Urgent Community Response services and reduces the number of patients being conveyed to hospital.
The ambition is to expand this service to become the single access point for all admissions avoidance contacts from health care professionals, including GPs, across Sussex. This means that for some people for whom other services can best meet their needs, do not need to be taken to hospital for assessment or admission.
We have been developing a range of expanded out of hospital services that can respond quickly to support people in the community and are working to integrate this work with our Virtual Wards and other clinical decision-making functions so we can optimise access to clinical advice across pathways.
The Admissions Avoidance Single Point of Access is already starting to have a positive impact with ambulance and community teams working closely to optimise use of these alternative pathways which will have a positive impact on our system as a whole. It reduces demand on the ambulance service and potentially lost hours waiting to transfer patients into acute hospitals; it reduces the number of people, and length of time for people, waiting to be seen in our Emergency Departments; and most importantly our patients who are better able to receive the right care, in the right place at the right time. This service has also helped ensure as many ambulance crews as possible remain on the road during periods of industrial action.
3.3 Improvements in ambulance performance
Overall, there has been continued high demand and the ambulance service has not consistently been able to meet its national response time targets. In January SECAmb Cat 1 mean response time was 9 mins 55 secs compared to an England mean of 11 mins and 0 secs and was ranked 5th out of 11 providers. Cat 2 mean response times were 23 mins and 53 seconds compared to an England mean of 32 mins and 6 secs and was ranked 2nd out of 11 providers. Developments such as the rollout of the Admissions Avoidance Single Point of Access are a positive development, and we expect to see performance improvements. We are also working with Surrey Heartlands ICB who is the lead commissioner of the service, to oversee the implementation of CQC actions which will have a positive impact.
Ambulance handover delays continue to be an area of key focus across our system and the acute hospital sites have worked closely with SECAmb on improvement plans to ensure no delays. Since September 2022 all our sites have shown common cause variation impacted by national ambulance strikes and there remains a sustained trajectory of improvement as illustrated figure 2 below:
Figure 2: Sussex 100 Day Trend >30 min Ambulance Handover Delays
3.4 Improvements in 111 performance
Following significant pressure and increases in call volumes experienced nationally, which saw call abandonment rates approach 50% in December, activity has now reduced to closer to seasonal norms and the abandonment rate has been reduced to between 9% and 15%. Clinical contact rates within the Clinical Assessment Service have been maintained in the region of 50% ensuring that patients can talk to a clinician when they need to. Where call handlers reach an initial disposition of either Emergency Department (ED) or for ambulance dispatch, clinicians continue to validate these calls to ensure either an Emergency Department or ambulance are appropriate with over 50% of people able to be directed to a more appropriate service for them.
Recruitment and training are ongoing to achieve the target establishment for call handlers and deliver the required improvements to move towards achieving 95% of calls being answered in 60 seconds and to reduce call abandonment rate to <5%. Trajectories for attainment are being agreed through contract management mechanisms. In the interim, additional capacity has been secured from VOCARE, a national provider of urgent and out of hours services commissioned by NHS England, as a temporary arrangement which has been in place from December and will remain until March 2023 at least, whilst recruitment is ongoing and to meet the immediate need.
We continue to ensure improvement actions and targets are robustly overseen through agreed contractual and governance mechanisms.
3.5 Acute Hospital Urgent Care Services
Following a challenging period over Christmas and New Year due to increased demand in particular relating to increased numbers of patients requiring support in hospital for Flu and Covid, the Emergency Departments at East Sussex Healthcare NHS Trust and University Hospitals Sussex NHS Foundation Trust have seen an improvement in performance during January and February 2023.
Our plans to improve flow to our co-located and stand-alone Urgent Treatment Centres have included increased face to face GP appointments in Eastbourne accessible through the Eastbourne Urgent Treatment Centre and additional clinical workforce at Lewes Urgent Treatment Centre. These measures further improve the capacity of these services available to local people, therefore freeing up more time for the emergency medics to treat the seriously unwell.
At University Hospitals Sussex there has been a particular focus on reducing the number of patients who are medically ready for discharge (MRDs) to improve flow in the A&E departments through maximising the use of existing and additional community and adult social care capacity and the number of MRD patients at Princess Royal Hospital and Royal Sussex County Hospital have reduced over the Winter period.
Our local hospitals have continued to operate flexibly to support flow through their organisations by responding to varying levels of demand through opening additional escalation areas to increase the amount of bedded capacity available, ensuring access and support is available for the population of East Sussex.
3.6 Out of hospital pathways
Community based falls response
In line with national guidance, Sussex has delivered a community-based falls response services for people who have fallen at home, including in care homes. Implementing a community-based falls service aims to free up emergency ambulance capacity to respond to higher acuity incidents.
Development and enhancements within falls response services through the winter workstream include:
· Integration of community-based falls response services within Sussex Urgent Community Response (UCR), which operates 7 days a week
· Community First Responders – deployed to both level one falls and concern for welfare referrals; ensuring dedicated clinical oversight from ambulance service and Urgent Community Response.
· Equipment provision – provision of Raizer2™ chairs to support falls response across organisations and enable Urgent Community immediate response for non-injured fallers, reducing ambulance call outs and conveyances
· Adopting the Association of Ambulance Chief Executives’ (AACE) Falls Governance Framework as a minimum national standard as part of pathways
In addition to this we have undertaken targeted actions to support avoidance of conveyance from care homes where people can be better supported in the community and remain in their own environment. A range of interventions have supported this work, including collaborative work with care homes to support those with the highest 20% rates of unplanned ambulance conveyances; enhancements to access advanced clinical decision-making support for care homes; optimisation of Enhanced Health in Care Homes, Infection Prevention Control, and quality support provision to care homes. We have also undertaken promotional sessions across Sussex led by ambulance crew ‘champions’ for promoting use and access of Urgent Community Response services and ensured training resources and information in place and easily accessible for care homes.
Virtual Wards
A key part of the system Winter Plan was the roll out of the nationally recognised virtual ward model across the Sussex system. Virtual wards allow some patients, who would otherwise be in hospital, to receive the acute care, monitoring and treatment they need at the place they call home (including care homes) safely and conveniently. The model was successfully launched in Sussex, as planned, in December 2022 and there are now 98 virtual wards beds open across the system, with 23 of these open to East Sussex residents. Up to 26 January, 260 patients have benefited from the new service. There are plans in place to significantly increase the use of virtual wards across Sussex during the course of 2023 and ahead of next Winter. There has been very positive patient feedback on this service as shown in the patients quotes below:
“I thought the virtual ward was marvellous. It saved a bed and allowed me to stay at home with my wife which is my main priority. I thought it was fantastic.”
“I felt I was involved with the whole process all along including why the treatment was going to be stopped.”
“A fantastic service! I can’t sing their praises enough – from the paramedic who referred me in, to the nurse who comes to see me, and everyone involved in virtual wards. Benefit number one: The relief of being able to stay in my own home; benefit two: I haven’t taken up a hospital bed for someone in a worse condition than me; benefit three: I can see it saving the NHS millions!”
Examples of other pathways
In addition, our Urgent Treatment Centres and Minor Injury Units continue to support patients where their condition is best suited to these settings. Our remote GP service, LIVI, has enabled patients to be reviewed and treated remotely where appropriate, therefore freeing up capacity for those with more urgent of complex needs to be seen by our Emergency Departments. Our Same Day Emergency Care services have also been enhanced through improved pathways between SECAmb and clinical services, removing the need to go via the Emergency Department; these services have also increased their medical workforce capacity to support demand for their services over the winter period.
Our work with our district and borough councils and local voluntary and community sector continues to enable support to people who are homeless or have housing difficulties and those who may need help with more complex needs and people who need help with welfare benefits advice. Our Safe Spaces in Eastbourne and Hastings town centres continue to operate on Saturday nights to support and advise vulnerable people as part of the night-time economy who may otherwise require support from an Emergency Department.
3.7 Increasing primary care capacity and improving care for people who are high risk of hospital admissions
Additional winter funds were made available, weighted for areas of high deprivation, to increase capacity during the winter months. In total, about £800k was made available initially to bring in additional clinicians, offer specialist clinics, and generally increase access to GP services. This has resulted in approximately 39,000 additional appointments.
This winter, in addition to the expected general increased in demand, our services experienced a significant increase in Group A Streptococcus and other respiratory presentations throughout December and into January. To meet this increase in demand respiratory assessment hubs were stood up across Sussex in December and have continued into the new year. In East Sussex these were at Hampden Park in Eastbourne; Beaconsfield Road Surgery in Hastings; and St Leonards Medical Centre, all of which offered a combination of virtual and physical appointments. As of 2 February 2023, 1,266 additional face to face appointments had been attended out of 1,831 offered (67%).
Patients were able to book into these appointments via their GP or through the Urgent Treatment Centres, who provided additional support out of hours for patients experiencing respiratory problems. Initially these appointments were open only to paediatric cases, but as the impact spread into the adult population the hubs were opened up to all ages.
Some of the additional winter funds have been used by two Primary Care Networks in East Sussex – Bexhill and Victoria– who are testing new models of care for people who are at high risk of hospital admission. These are focussed on proactive care plans for people who are frail and have multiple long-term conditions, with the aim of better supporting these individuals to stay well. This is an approach which has been trialled successfully in other systems and in other parts of the country. Should these pilots prove successful further roll out of the approach will be considered.
3.8 Mental Health
Our plans over winter have ensured a particular focus on supporting people with mental health needs in the right place for them; reducing the number of patients having to receive inpatient support outside of the county; and reducing delays in supporting patients to be discharged from inpatient services. There has been a significant amount of work undertaken with Sussex Partnership NHS Foundation Trust to support this, as well as across the wider system. Key actions have included an increased use of Havens (dedicated, mental health crisis assessment facilities that provide support and assessment for adults 24 hours a day), enhancing community support to reduce the number of people attending Emergency Departments with a mental health issue and reducing the number of Sussex residents cared for inappropriately in out-of-county inpatient beds has been reduced to zero.
As part of our system discharge plans we have also invested in initiatives over winter to reduce the length of time patients are waiting to be discharged from mental health inpatient settings and to support children and young people who attend our Emergency Departments with a mental health need.
3.9 Infection Prevention and Control
This winter has seen an increase across viral outbreaks and secondary bacterial infections such as COVID 19, Influenza, Norovirus and Group A Streptococcus (GAS). The Sussex Integrated Care System have a dedicated Infection Prevention Team that supports all NHS and social care providers with maintaining high standards of infection prevention to maintain high quality and safe services.
The Sussex Infection Prevention Team have implemented the following measures:
· System infection prevention cell meeting weekly to ensure local adoption of national guidance which is applied in a standardised approach across all providers
· Specialist infection prevention support across Sussex to provide outbreak management across health and social care providers.
· Established infection prevention governance monitoring and reporting.
· Daily Covid-19 monitoring.
· Development of an updated Sussex ICS Seasonal Infection Prevention Surge Plan.
· NHS support to social care providers via local authority Public Health teams.
· Development of Sussex Clinical and operational GAS cell to support the provision of additional services and clinical management of an increase in suspected infections
· Provision of additional specialist training for new infection risks identified.
· Mutual aid support across Infection Prevention Control teams such as personal protective equipment (PPE).
3.10 Seasonal vaccination programme
The autumn/winter Covid-19 and flu campaigns started in September 2022 and in Sussex these were delivered across a network of 64 GP-led vaccination sites, Community Pharmacies and Vaccination Centres; 21 of these being in East Sussex. The focus for this campaign was to offer the vaccine to residents in a care home for older adults and staff working in those homes, frontline health and social care workers, adults 50 years and over, persons aged 5-49 in an identified clinical risk group, persons aged 5-49 who are household contacts of people with immunosuppression and persons aged 16-49 who are carers.
Further to a statement issued by the Joint Committee for Vaccination and Immunisation (JCVI), the Covid-19 vaccination campaigns ceased on 12 February, with the influenza campaign also ending on 31 March. However, the evergreen offer for Covid-19 vaccination (vaccines for individuals aged 5 years and over and yet to complete their primary course) continues predominantly through mobile vaccination units. In East Sussex this activity will focus on providing vaccinations to care homes, care settings, housebound patients and their carers, homeless and insecurely housed persons. There will be opportunistic vaccinations in GP practices, signposting and engagement work with targeted groups, children’s vaccinations in schools and mobile vaccination units to target our population focus areas. These include, but are not limited to, immunosuppressed patients and their household contacts, patients with learning disabilities and mental health needs, pregnant persons, BAME groups, Gypsy, Roma and Traveller Communities, young men aged 16+, LGBTQIA and TNB people and Refugees and people seeking asylum. An after-action review process is on-going, and this will shape plans for the next campaigns. For Covid-19 this is likely to be in the spring and will focus on those who are most vulnerable to Covid-19.
Tables 1 and 2 highlight uptake across both vaccination campaigns as of 15 February 2023.
Please note the following:
· some cohorts are not comparable as the cohort definitions changed from Autumn 2021 campaign to Autumn 2022
· the total number eligible in each cohort changed between campaigns
Table 1: Covid-19 Vaccination uptake East Sussex Autumn 2022
|
Cohort |
Uptake |
|
1. Care Home Residents & Residential Care Workers |
3,194 (85.6%) |
|
2. Healthcare Workers |
17,428 (51.8%) |
|
3. Social Care Workers |
4,739 (48.3%) |
|
4. Aged 80+ |
31,956 (88.3%) |
|
5. Aged 75-79 |
27,441 (88%) |
|
6. Aged 70-74 |
27,232 (86.9%) |
|
7. Aged 65-69 |
25,330 (82.1%) |
|
8. At Risk |
31,667 (50.8%) |
|
9. 12-15 At Risk |
53 (31%) |
|
10. 12-17 Household contacts of immunosuppressed |
66 (5.5%) |
|
11. 5-11 At Risk |
171 (29.4%) |
|
12. Aged 60-64 |
13,035 (69.8%) |
|
13. Aged 55-59 |
12,709 (59.2%) |
|
14. Aged 50-54 |
10,072 (49.4%) |
Table 2: Influenza Vaccination uptake East Sussex Autumn 2022
|
Cohort |
Uptake (%) |
|
Aged 65 and over |
79.9 |
|
Aged 50-64 |
46.3 |
|
Aged 6 months to 50 years in risk groups |
36.8 |
|
Pregnant women |
39.4 |
|
Aged 2-3 |
46.4 |
|
Aged 4-10 |
41.7 |
3.11 Workforce
Workforce capacity over winter is an identified risk within our system plan and this has been further exacerbated by the current industrial action affecting our providers and ambulance services.
The following measures are in place to ensure that the workforce issues arising from industrial action are addressed:
· The sharing of risks and issues at the weekly System Chief People Officer meetings across all our organisations
· Shared intelligence about local derogations and liaison arrangements with strike committees
· Sharing of real-time information about staff numbers participating in industrial action and services affected and regular communication with the Regional Operations Centre to support the smooth management of services across strike days.
At the same time, measures put in place earlier in the winter continue to be implemented and further developed. These include:
· Robust safe staffing escalation processes in place within each provider.
· System wide mutual aid systems and processes to enable the sharing of workforce across providers to maintain safe staffing levels and service provision. An enhanced staff sharing Memorandum of Understanding to support planned and unplanned staff sharing across system partners is in an advanced stage of development.
· A programme steering group has established to oversee implementation of a collaborative Sussex Health and Care system international recruitment approach and a shared staff bank pilot for Healthcare Assistants. This will include a harmonisation exercise to review bandings and other terms and conditions, as well as the development, pastoral and accommodation support offers available for international recruits.
· A Sussex Health and Care system Retention Lead has been in place since January 2023 to develop an ICS retention plan, building on existing retention activities being undertaken by system partners. A Retention Community of Practice is being established to be launched in February 2023.
· Assessment of staffing levels daily, and implementation of local response actions to meet shortfalls in capacity.
· New roles and ways of working are being implemented, for example the virtual ward programme.
· As a system we are a vanguard nationally in a violence reduction and prevention programme to keep colleagues safe in the workplace. Level 3 and Level 4 Violence Prevention training modules are to be piloted in Sussex later this year with 45 fully funded places offered to partners across the Sussex health and care sector.
· Our workforce vaccination programme commenced in September to support protection of colleagues from contracting flu and covid infection in support of our sickness absence position.
3.13 Planned Care Recovery Programme
The Sussex Planned Care Recovery plan has focussed on improving access to services for patients and reducing waiting time by maximising existing capacity across the system and transforming how care is provided. While winter pressures and industrial action have led to some cancellations of planned care, every effort is made to rebook those patients who are affected at the earliest opportunity.
Across the five Community Diagnostic Centres (CDC) in Sussex, an additional 77,157 diagnostic tests have been delivered since April 2022, with 19,464 of those undertaken at the Bexhill CDC (which is delivering 143% above plan). This additional diagnostic capacity provides patients faster access to tests, supporting decision making for treatment plans. This also gives the acute hospital providers more internal capacity to diagnose emergency inpatients, to support their treatment plans and aid earlier discharging.
The Sussex health and care system remains on track to eliminate waits of 78 weeks or longer for planned care treatment by April 2023. This is being delivered by partners across the healthcare system offering alternative sites and choice to patients, including in the independent sector where insufficient NHS capacity is available. East Sussex Healthcare NHS Trust has remained one of the top performing Trusts nationally consistently reporting very low numbers of patients waiting over 78 weeks for treatment.
Sussex health and care partners continue to focus on improving productivity in order to maximise delivery of planned care, delivering theatre utilisation of 79% (third highest ICB in England) and day case rates at 82.7% (highest ranked ICB in England). The Sussex Orthopaedic Treatment Centre (SOTC) is also one of eight centres nationally selected for ‘centre of excellence’ accreditation by NHS England, which will benefit the Sussex population who require elective orthopaedic treatment.
3.14 Public Health – East Sussex
Joint work with Public Health in East Sussex continues as part of winter plan implementation. This includes maximising uptake of Covid-19 and Flu vaccinations across the whole population and reducing health inequalities and transmission of Flu and Covid-19, with outreach engagement for groups with the lowest uptake and in the areas of highest deprivation. The East Sussex Energy Partnership (ESEP) has continued to deliver its fuel poverty reduction programme actions, including the ‘Keep Warm and Well in East Sussex’ communications campaign, aiming to ensure a consistent and co-ordinated approach to the delivery of interventions to tackle health and wellbeing issues related to cold homes, particularly for vulnerable groups. Alongside this, we have continued to offer the East Sussex Warm Home Check service, offering advice, home visit assessments, provision of small preventative measures and coordination/ installation of major heating and insulation measures (subject to sourcing of external funding) for eligible low-income households. An emergency temporary heating scheme and advance cold weather community messaging system (coldAlert) continues to be delivered.
The Public Health protection team and the ICB infection control teams have continued to work closely together providing support to the East Sussex care provider market with infection prevention control support.
4.0 Summary
There has been robust working across the health and care system as we implemented our winter plans and responded to the additional demand and specific circumstances including industrial action over this winter period and the surges in demand such as Group A Streptococcus. Sussex health and care partners continue to work together to ensure that patients continue to receive the best possible care.
Whilst there has been high demand across all services the system continues to oversee plans to ensure these are collectively addressed and local people have access to safe service provision in a way that best meets their needs.