1 Table of Contents
NHS Sussex Winter Plan: update
2.1. Discharge, including rapid improvement workstream actions
2.2. Out of hospital urgent care rapid improvement programme
2.3. Improvements in ambulance performance
2.4 Improvements in 111 performance
2.5 Acute Hospital Urgent Care Services
2.6 Acute Hospital Emergency Care Services
2.10 Infection Prevention and Control
2.12 Planned Care Recovery Programme
2.13 Public Health – East Sussex
3.0 Learning from the Winter Plan and Actions Taken
3.1 Winter Plan Review and Feedback
NHS Sussex Winter Plan: update
1.0 Introduction
This report provides an update on, and evaluation of, the impact of the NHS Sussex Winter Plan. It identifies learning to be taken forward to further enhance planning for Winter 2023/24. It builds on the report submitted to the HOSC in March 2023, updating this where relevant and reflecting on further learning from this period.
It includes:
· Performance and recovery of services (elective and non-elective)
· Workforce pressures and staff wellbeing
· The effects of industrial action
· An overview of how well the discharge and admission avoidance programmes have been working.
· An outline of key performance measures for the system:
§ Bed occupancy rates
§ Emergency Department waiting times and waiting times to be admitted to hospital
§ Number of admissions for Covid-19 and seasonal flu
§ Ambulance handover times.
As previously reported, the delivery of the Sussex Winter Plan was 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 Directors of Social Care. They ensured that strategic leadership decisions required in response to emerging issues or risks through the Winter were taken in a joined-up way and considered the needs of our population and the needs of staff working across both health and care.
2.0 Our
delivery plan:
2.1. Discharge, including rapid improvement workstream actions
As previously reported most patients in East Sussex continue to be discharged home from hospital 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 collaborated to develop and implement full plans to support people over the winter period. This included additional health, social care and voluntary sector capacity[1] to support people to return home; additional bedded capacity for people who were 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 also supported 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 that we implemented included additional clinical and domiciliary care capacity to support this.
Within the context of the wide range of additional capacity and support in East Sussex during the winter period, there was a sustained reduction in the numbers of patients who were assessed as medically ready for discharge and awaiting discharge. An additional 910 homecare hours per week and an additional 86 Discharge to Assess beds in Care Homes were secured for the winter and through Quarter 4 drawing on additional national funding to support extra capacity in health and social care to improve discharge flow. Alongside this, a range of additional health and social care workforce was secured to support discharge flow across a range of services. A weekend discharge team was mobilised alongside key additional workforce to identify patients more rapidly for intermediate care services earlier in their pathway, which directly led to improvements in rates of weekend discharges. Other schemes including increasing utilisation of Voluntary Sector capacity to support discharge alongside Personal Health Grants were mobilised to improve system flow, patient support and experience. The East Sussex system partners agreed key actions for our Discharge Transformation Plan and are working across Sussex as part of the Discharge Frontrunner Programme building upon initiatives and schemes that commenced through the winter period. The Discharge Transformation Plan continues to be focused on improving pathways to discharge across health and social care, including VCSE support, support for vulnerable people and streamlined patient assessment.
2.2. Out of hospital urgent care rapid improvement programme
The focus of the out of
hospital urgent care workstream was to improve ambulance response
times by improving join up and input from alternative services to
best support our patients.
As previously reported a key development has been the introduction of the Admissions Avoidance Single Point of Access (AASPA). This went live on 14 December 2022. 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, they do not need to be taken to hospital for assessment or admission.
SECAmb continue to work closely with our community providers to optimise use of alternative pathways through the AASPA and have established daily touchpoints to ensure appropriate cases are supported into Urgent Community Response services. This will inform the rollout of an automated CAD portal to stream cases direct to community teams over the next 2-3 months. SECAmb have now recruited some additional resource through funding provided by ICBs within their footprint, to further accelerate and promote these pathways.
The continued development of the AASPA is a recognised priority in the NHS Sussex 2023/24 Shared Delivery Plan (SDP) and will be taken forward as a priority workstream within the NHS Sussex Urgent and Emergency Care Delivery Programme.
2.3. Improvements in ambulance performance
Overall, there continued to be high demand and the ambulance service was not consistently been able to meet its national response time targets.
Cat 1 and Cat 2 mean response times – April 2023
|
|
England |
SECAmb |
Ranking (out of 11 providers) |
|
Cat 1 mean response |
8 mins 7 secs |
8 mins 22 secs |
7th |
|
Cat 2 mean response |
28 mins 35 secs |
24 mins 43 secs |
4th |
Developments such as the rollout of the pan-Sussex Admissions Avoidance Single Point of Access, the funding of additional SECAmb resource to embed change and close working between SECAmb and community teams have been positive, and we expect to see performance improvements as the utilisation of alternative community pathways to reduce avoidable dispatch and conveyance increases. NHS Sussex has recently taken over as lead commissioner of the service from NHS Surrey Heartlands and will oversee the implementation of CQC actions which will contribute further to service improvement.
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.
Bank holiday weekends put significant pressure on hospitals and ambulance services, and this is seen in an increase in waiting times for ambulances to handover their patients to Emergency Departments in May 2023 due to three bank holiday weekends in quick succession. Bank holiday weekends put pressure on services due to a number of factors:
· Increased population due to an increase in holiday makers in the county
· Extended periods of time where a patient cannot access their GP and therefore access alternative health services which may include Emergency Departments
· Reduced discharging from acute and community hospitals at weekends.
Responding over bank holidays is included as part of our planning to ensure good access to services are in place.
The charts below build on the information previously provide to the East Sussex HOSC and provide an update to the end of the winter period and beyond.
Sussex wide ambulance performance position
Conquest General Hospital
Eastbourne District General Hospital
Royal Sussex County Hospital
2.4 Improvements in 111 performance
As reported in the March meeting, 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 15.44% and 18.65% between January to March. Clinical contact rates within the Clinical Assessment Service have exceeded 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 45% 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 2022, 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.
2.5 Acute Hospital Urgent Care Services
As previously reported our plans to improve flow to our co-located and stand-alone Urgent Treatment Centres (UTCs) 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 improved the capacity of these services available to local people, therefore freeing up more time for the emergency medics to treat the seriously unwell. East Sussex patients also access the Urgent Treatment Centre at the Royal Sussex County Hospital where they have access to General Practitioners for minor illness treatment and Emergency Nurse Practitioners for minor injuries.
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.
2.6 Acute Hospital Emergency Care Services
The winter pressures on Emergency Departments were considerable. Services to support admission avoidance, redirection away from hospital and alternatives to hospital were fully utilised to ensure best support available for local people.
The Sussex system leadership, informed by the system Chief Operating Officers, Chief Medical Officers and Chief Nursing Officers, agreed a focused set of a clinical risk system metrics to be used over the Winter period to safely manage risk and inform the response to any required system escalations or significant issues identified in order to ensure rapid focus and response. This was well managed over the winter period.
These measures are:
1. Number of ambulance handover delays >60 minutes
2. Number of patients in the ED >12 hours
3. Number of patients receiving care in Emergency Department corridors
4. Number of super surge beds open (non-bedded areas used for inpatients).
The above metrics and associated triggers were used in addition to the existing system agreed escalation framework and continue to be the principal measure of escalation and pressure levels across the system.
The framework was developed to identify site and acute hospital-based escalation triggers for each of the 4 key acute metrics. The triggers were calibrated in a consistent way across all acute sites using historic activity data and are aligned to the variation in normal A&E demand observed at each site.
The response to these triggers is defined within action cards that have been developed for each organisation which describe the actions required to support de-escalation.
2.6.1 Length of stay in the Emergency Departments
The length of stay for patients within the Emergency Departments was impacted by a number of factors such as Covid-19, Influenza and Industrial Action. The performance is reflected in the graphs below. The impact has reduced since its peak in December 2022.
East Sussex Healthcare NHS Trust saw no patients wait over 12 hours in the Emergency Department from the time a decision to admit them to hospital was made.
East Sussex patients are also seen in the Emergency Department at the Royal Sussex County Hospital which is part of University Hospitals Sussex NHS Foundation Trust. The Royal Sussex County Hospital does have higher numbers of patients within Emergency Departments before decisions are made to admit or discharge them. They have developed an urgent care improvement programme which looks to address the barriers to good flow through the emergency departments across University Hospitals Sussex, supporting patients within the hospitals.
2.6.2 Hospital Occupancy
Hospital occupancy across Sussex continues to be high. Whilst there was a slight decrease in January and February 2023, March 2023 saw a slight incline. Robust capacity modelling supports the system response to this to ensure people can access the support and care they need.
2.7 Out of hospital pathways
2.7.1 Virtual Wards
Virtual wards provide an alternative for 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 in December 2022 and maximum capacity achieved has been 112 against 107 plan in April, with 37 of these open to East Sussex residents. Up to 11 May 2023, 1,364 patients have benefited from the new service in East Sussex including general, frailty, respiratory and heart failure virtual wards supporting admission avoidance and timely discharge. During the course of 2023 and ahead of next Winter Virtual Wards will grow further to a total planned Sussex capacity of 146 by March 2024 (56 in East Sussex). There continues to be very positive patient feedback on this service and further case studies will promote the use of the service this year.
2.7.2 Examples of other pathways
As previously reported, our Urgent Treatment Centres and Minor Injury Units (MIUs) 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 (SDEC) services have also been enhanced through improved pathways between SECAmb and clinical services, removing the need to go via the Emergency Department; these services 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.
2.8 Increasing primary care capacity and improving care for people who are high risk of hospital admissions
In the last report to HOSC the additional support to practices over winter was described, utilising additional funding , 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 across East Sussex. This resulted in approximately 39,000 additional appointments in General Practice; and in addition, 2,145 Face to Face and 5,051 virtual additional appointments offered to patients through Acute Respiratory Hubs between December 2022 and March 2023. This has now been independently evaluated by the Kent Surrey Academic Science Network, and draft finding confirm that this demonstrated value for money and was welcomed by staff and patients. The full report will be available in July 2023 and will directly inform planning for winter 2023-2024.
On 9 May 2023 NHS England and the Department of Health and Social Care issued their “Plan for Recovering Access to Primary Care” (PCRP). The plan builds on the Fuller Stocktake report and forms part of the Government’s commitment to improve access to general practice outlined in its Autumn statement. The PCRP focusses specifically on the aspects of the Fuller Stocktake report that concern “tackling the 8am rush”, with the stated aim of “reducing the pressure on General Practice” to allow it to stabilise and thus engage with the broader transformation agenda around themes such as Integrated Community Teams, as well as ensuring short- and medium-term improvements in patient experience and satisfaction. Its publication is timely given the programme of change set out in the system’s Shared Delivery Plan (SDP). The ask for all systems is to produce a “System Level Access Recovery Plan” which will define our short medium, and long term activities to improve the patient experience of accessing primary care, and will be presented to the NHS Sussex Board in Autumn 2023, with a further update to be provided in February/March 2024.
2.9 Mental Health
The plans for mental health services over winter 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. Whilst mental health pressures have continued beyond the peak winter period the sustained reduction in patients receiving their inpatient care outside of Sussex has continued. The number of patients being assessed as requiring acute psychiatric admission over winter has been on a reducing trend although patients have waited longer for admission than is ideal. The root cause of the challenge in accessing timely inpatient mental health care is one of flow, rather than demand, primarily due to the number of patients whose onward care from hospital is delayed.
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) especially to provide an alternative to waiting in an Emergency Department, the promotion of the Sussex Mental Health Line and Staying Well Cafes, the development of a Section 136 support service in Eastbourne & Worthing and the Blue Light Triage service in north West Sussex.
The highest number of total non-SPFT beds utilised was 103 (81 SPFT commissioned acute Independent Sector beds in Sussex and 22 out of area placements) on 14 September 2022 which reduced to 0 in November 2022. There have been small numbers of Out of Area Placements used since that date and the current number of Out of Area Placements is two (May 2023).
As part of our system discharge plans, we 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. We are concluding a review into crisis pathways, and this will make recommendations for early implement to support further improvement ahead of next winter.
2.10 Infection Prevention and Control
This winter saw an increase across viral outbreaks and secondary bacterial infections such as COVID 19, Influenza, Norovirus and Group A Streptococcus (GAS). The Sussex Health and 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.
2.10.1 Covid Admissions
2.10.2 Influenza Admissions
Influenza affected bed availability during December and January with a high number of admissions across all hospitals in Sussex. This significantly reduced from February onwards.
2.11 Workforce
Over winter, workforce was an identified risk within our system plan and this was further exacerbated by the industrial action affecting our providers and ambulance services.
The following measures continue to be 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.
Periods of industrial action have affected all aspects of the health and social care system this year. So far in 2023 there have been 28 days of industrial action affecting healthcare providers in Sussex from a number of healthcare workers unions, plus education and transport workers unions.
NHS Sussex has managed a co-ordinated Sussex response to every period of industrial action to date that has had an expected impact on healthcare. Throughout each period of industrial action a battle rhythm of command and control meetings are set run to ensure a coordinated response, Incident Coordination Centres are established, virtually or physically, and collaborative working with system partners is coordinated by NHS Sussex to ensure robust planning for service delivery across all industrial action days and management of the actions that need to take place to mitigate any risks that emerge during the action.
This is coordinated through the Sussex Incident Control Centre (SxOC) which operates 08:00-18:00 seven days a week. During periods of Industrial Action, the SxOC opening times are extended to match South East Regional Operating Centre opening hours. Health organisations across Sussex also have similar incident control arrangements in place, with a robust and well-tested on-call mechanism managing the response out of hours.
System partners work together to develop plans to identify and mitigate the potential risks associated with the industrial action, ensuring the system is in the best place possible entering into periods of action.
The key impact of industrial action on the system is the addition of significant operational pressures on an already pressured system and workforce, and the knock-on effect of the rescheduling of elective care, which is only undertaken when absolutely necessary to ensure patient safety. To mitigate this staff and rotas are aligned to prioritise critical areas, agency and bank staff are brought in where available to provide cover, and elective care appointments are re-booked as soon as possible to avoid delays to care.
System-wide debriefs, co-ordinated by NHS Sussex, are undertaken after each period of industrial action and identified learning is shared and used to inform planning for future periods of action.
2.12 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.
The 22/23 delivery plans, enhanced with winter oversight, supported East Sussex Hospitals to deliver key elective milestones as set out in the NHS planning guidance. As of 31 March 2023: no patients waited over 78 weeks for routine elective treatment (capacity or complex reasons), 77.5% received a cancer diagnosis within 28 days against the national standard of 75%, which is twelve months ahead of the national requirement to deliver the Faster Diagnosis Standard.
Across the five Community Diagnostic Centres (CDC) in Sussex, an additional 101,444 diagnostic tests have been delivered during 2022/23, against a plan of 80,280, with 25,750 of those undertaken at the Bexhill CDC (which was 146% above plan). This additional diagnostic capacity provides patients faster access to tests, in a community setting, 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 has submitted a delivery plan approved by NHSE for 2023/24. This is being delivered by partners across the healthcare system and builds on the plans that have been implemented during 2022/23. This year we will further increase access to services with a commitment to offer alternative sites and choice to patients, including in the independent sector where insufficient NHS capacity is available.
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). As a minimum we will increase productivity to 85%.
2.13 Public Health – East Sussex
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.
3.0 Learning from the Winter Plan and Actions Taken
3.1 Winter Plan Review and Feedback
In April 2023, system partners were asked for their feedback as to how we had performed against our given aims. Respondents were asked to answer four simple questions:
1. What were our high-level achievements?
2. What have we learnt?
3. What are our outstanding priorities?
4. What is our Forward Delivery Approach?
Responses were received from across the Sussex system, including NHS Sussex Place Based Operational Executives, Acute Providers, Clinical Leads, Community Providers, Mental Health and Local Authorities.
3.2 Top Themes:
• Strategic Vision
• To develop and align place-based models for integrated health and care within overarching NHS Sussex strategy.
• To evaluate outcomes and focus on most impactful as priorities for the future.
• Develop a decision-making forum to develop and implement plans to support NHS Sussex Strategy.
• Continue with Sussex Discharge Frontrunner Programme
• Winter Planning
• To have a dedicated System winter clinical lead.
• To use a coordinated approach to winter planning, in particular discharge.
• To achieve clarity on recurring funding and budgets as early in the year as possible.
• To develop models now for next winter.
• Planning
• To balance central guidance vs local risk and longer-term planning for surge periods.
• For Operational Exec Groups (OPEX) continue to plan/ mitigate operational pressure across the system including industrial action.
• To consider resource to provide consistent comparable system wide evaluation of schemes.
• Pathway Redesign
• To establish a cross ICB Task and Finish Group to support continued SECAmb delivery and pathways optimisation.
• Digital Integration
• A dashboard of system impact to be utilised to ensure data-driven approach and ongoing monitoring against initiatives.
• Collaboration
• To continue to reduce organisation barriers to improve integrated working.
• To maintain cross service and multi system engagement.
Learning from evaluation of seasonal plans is routinely incorporated in future planning where it is within the gift of NHS Sussex. The learning has been widely shared across all the partners within the Integrated Care System.
NHS Sussex has also taken part in a nationally led review of Winter 2022/23. It is likely that this will influence the shape of national priorities for Winter 2023/24.
4.0 Summary
In summary the operating model implemented by the system for winter has enabled the system to effectively respond to and manage periods of significant exceptional pressure and elevated system risk as a whole system.
The winter operating model meeting cadence enabled the system to respond in an agile way with the model and system escalation framework being rapidly adapted and further developed in response to live learning and the specific issues and risks identified. However, there is a need to consider how clinical input into the system Urgent and Emergency Care surge planning and delivery/oversight infrastructure can be further strengthened ahead of next winter as part of the System Operations Centre function’s further development.
The approach to system capacity and demand modelling to inform surge planning and risk mitigations needs to be further developed to provide a more accurate assessment of the impact of deployed capacity schemes and there is a need to strengthen the alignment with internal provider capacity and demand models.