East Sussex Health Overview and Scrutiny Committee (HOSC)
Sussex System Winter Plan 2023-24
November 2023
1. Introduction – Winter 2023/24
This report provides a summary of the Sussex System Winter Plan that spans the period from November 2023 to April 2024. The report highlights the Sussex wide and East Sussex specific elements of the Plan and aims to provide assurance to the HOSC that the health and social care needs of the local population will be met over the winter period.
The Sussex System Winter Plan is a whole system health and social care plan, recognising the interdependencies of the system to meet the needs of the local population. It is an annual national planning requirement and provides assurance that the system and partners have the necessary measures in place to deliver health and care for the local population.
Over the past year, the Sussex system, similar to other systems across the country, has continued to see sustained high demand on urgent and emergency care services. While performance over the summer months has demonstrated an improvement relative to 12 months ago, the system is not yet achieving consistent delivery of the A&E 4-hour standard in emergency departments at the target level set by NHS England (NHSE) for this year (76%).
These challenges will continue over the winter months and will be compounded by additional factors such as seasonally driven increases in illness (acute respiratory, flu, Covid, norovirus etc), cold weather and the ongoing impact from the cost-of-living crisis which constrains the ability of the most vulnerable in our population to keep themselves well.
Consequently, as in previous years, the purpose of the Winter Plan is to develop a comprehensive and aligned system approach to ensure that the Sussex system:
· Continues to maintain and improve the quality and safety of services.
· Ensures timely access to services for the entire population, supported by a clinical risk-based focus at times of surge in demand.
· Focuses on the most vulnerable and at risk; and
· Takes forward learning from previous winter planning 22/23 including;
- To have dedicated System winter clinical leadership;
- 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; and
- To develop models early in the year for the next Winter.
2. Sussex system approach to developing the Winter Plan
The Sussex system approach to developing the Winter Plan was driven by two key influences:
This year a guidance letter from NHSE ‘PRN00645 Delivering operational resilience across the NHS this winter’ was issued on 27 July 2023 with a number of key requirements and expectations:
· To conduct a demand and capacity analysis, as the basis for the Winter Plan, underpinned by robust planning assumptions.
· To clarify and agree within the system the key roles and responsibilities for managing the winter effort.
· Implementation of a System Co-ordination Centre (SCC); and
· To adopt the revised Operational Pressures Escalation (OPEL) Framework
Further details of the Sussex approach to these four requirements are set out in Section 9 – Plan Delivery of this report.
In addition to the guidance letter, NHSE issued a number of specific requirements for all trusts and provider organisations relating to:
· Improving and protecting the wellbeing of the workforce;
· Protecting the public and healthcare workforce from flu and other infectious diseases; and
· Ensuring there is an established pathway for identifying patients at risk of Covid and flu in those that are immunosuppressed.
To provide assurance over delivery of the national requirements and expectations, the system completed a narrative and numerical return which was submitted in September 2023. While there is some degree of overlap with the content of the NHSE return, this does not negate the need for a separate system plan which articulates the specific areas of focus in Sussex and how partners will work together to deliver it.
In addition to the national requirements, the Sussex system considers what specific priorities or areas of focus are required to best meet the needs of the local population (based on locally observed demand and capacity) and the governance arrangements required to ensure all parts of the system work together to best mitigate the risks for the entire population. This requires bringing together actions and intelligence at neighbourhood, place and system level, prioritising the areas of focus and ensuring response and delivery mechanisms are in place that reduce duplication and maximise impact without adding unnecessary burden on operational and clinical teams.
Each year, the Sussex system undertakes a learning exercise post winter to ensure that the system follows a cycle of continuous improvement. Key areas of focus for improvement this year include:
· looking at how to reduce duplication of asks, particularly those that fall to clinical or operational teams for delivery;
· ensuring a small number of data driven areas of focus for consistency of approach; and
· building on the clinical risk-based approach initiated last year.
3. Developing the Sussex System Winter Plan
The plan incorporates the requirements set out within the NHSE guidance letter and describes the focus on three key priority workstreams:
· Demand management
· Admissions avoidance; and
· Hospital Flow
These workstreams are underpinned by a series of cross cutting workstreams relating to:
· Critical clinical pathways (frailty and respiratory)
· Workforce
· Infection Prevention and Control (IPC)
· Clinical Leadership
· Voluntary, Community and Social Enterprise sector (VCSE)
· Partnership working with local authorities; and
· Communications.
Contributors to the Plan include:
· NHS Sussex ICB
· East Sussex Healthcare NHS Trust (ESHT)
· Queen Victoria Hospital (QVH)
· Sussex and Surrey and Sussex Healthcare Trust (SASH)
· Sussex Community NHS Foundation Trust (SCFT)
· Sussex Partnership NHS Foundation Trust (SPFT)
· University Hospitals Sussex NHS Foundation Trust (UHSx)
· South East Coast Ambulance Service NHS Foundation Trust (SECAmb)
· Local Authorities
· Primary care; and
· The VCSE Sector.
4. Data and information focus
The Sussex system has taken a data driven approach to developing the Winter Plan to ensure that system resource is targeted to the areas of greatest need or where the greatest impact will be achieved. As part of the work undertaken by the NHS Sussex Urgent and Emergency Care (UEC) Programme Board, a comprehensive review of urgent care data has been undertaken.
Key headlines from the analysis include:
· People over 65 account for a proportionally higher number of Emergency Department (ED) attendances and non-elective admissions.
· Deprivation has a significant influence on ED attendances and non-electiveadmissions and to bring rates of attendance and admission in line with those of the least deprived quintile would result in c.22k fewer ED attendances in Sussex, and c.10,000 fewer admissions per year.
· The rate of ED attendances for Mental Health Disorders, Psychosocial issues and behaviour change is significantly higher in Sussex than for peers. NHS Sussex is 39th out of the 42 Integrated Care Boards (ICB) in England on this measure.
· In Sussex there are fewer staff working in emergency care settings (Urgent Treatment Centres, Minor Injury Units, Walk in Centres and EDs) than peer ICBs and the England average, however, Sussex has a higher number of staff than the peer average in NHS organisations overall.
· In Sussex, a higher number of primary care appointments are undertaken than in peer ICBs (when adjusted for population size), but fewer face to face and same day appointments than the national average.
· Sussex has lower activity for 111 calls and online compared to the equivalent national rates, however, 999 call volumes are higher.
· Sussex has higher levels of ambulance conveyances to ED and lower levels of Hear and Treat (treatment of conditions by 999 and 111 staff over the phone) than the England average.
· Sussex has fewer available overnight beds than both ICB peers and the England average but has seen a significant increase in long length of stay and has one of the highest number of patients who no longer meet the criteria to reside (NCTR) (in both acute and community settings).
This analysis provided some clear areas to focus on in the Winter Plan including: the older population, population in areas of deprivation, individuals requiring Mental Health support, the need to right-size emergency care, workforce, optimising use of primary care capacity, optimising use of 111 and 999 services, reducing rates of conveyance, and addressing challenges relating to discharge and length of stay.
Development of the Winter Plan was underpinned by demand and capacity modelling. In line with the NHS England Winter Priorities, a demand and capacity analysis has been undertaken as the basis for developing the Winter Plan to inform planning assumptions.
NHS Sussex demand and capacity modelling has continuously been updated via provider BI intelligence to ensure the modelling tool is as accurate as possible. The model includes assumptions in relation to Covid, Flu and Respiratory Syncytial Virus (RSV). Industrial action introduced an added level of complexity in modelling capacity. The model sets out baseline bed capacity, surge capacity and super surge capacity (only opened in extremis). This has been offset by expected demand which typically results in a bed deficit at the start of each winter planning round. The impact of the planned areas of focus within the Winter Plan have been quantified and this has been overlayed in order to mitigate the remaining bed deficit.
Work was undertaken to quantify the impact of schemes in the priority areas of focus including the benefit of any investment through the Better Care Fund (BCF) or application of national funds and this has been reflected in the demand and capacity model in order to ensure that the forecast position is understood and agreed by all system partners. This will continue to be developed and refined over Winter and is reflected in the Winter Plan.
The demand and capacity model is used to ensure that all system partners are clear on the levels of performance across a key range of metrics such as length of stay, bed occupancy, Not meeting Criteria to Reside (NCtR), admissions and daily discharges by pathway. This in turn will ensure the system is managed in a proactive way, with early intervention when these metrics deviate from plan.
5. Priority Areas of Focus
As set out in the previous section, analysis of key data sets has provided a good indication of where the Sussex system needs to focus efforts this winter:
Effective demand management will ensure that patients are directed first time to the service most appropriate for their needs and helps ensure that capacity for direct patient/clinician interactions is protected for those most at risk.
The Sussex System Winter Plan includes communications around encouraging the use of 111 to ensure patients are directed first time to the service which best meets their needs. In parallel, work is being undertaken with SECAmb to ensure that call response times and call backs are being sufficiently timely to build public confidence in the service.
A revised operating model has been proposed by SECAmb that sets out the impact of the removal of non-recurrent funding received in 2022/23 and 2023/24. Call handling capacity has further been challenged following the move of SECAmb’s emergency operations/111 centre to Medway with current establishment at 80% of funded level. However, recruitment plans are in place to recover this position by January 2024, with the shortfall partially being filled by overtime in the interim.
Commissioners continue to work with SECAmb and finance leads across Kent, Medway & Sussex to fully articulate the cost pressure, potential system impact and make recommendations to allow NHS 111 to continue to protect wider systems and minimize clinical risk.
Primary care, in line with all other health services, is under significant operational pressure. Close working will be required with system partners to ensure limited capacity is optimised to best support the population over winter.
Primary Care Networks (PCNs) already provide support to care home patients through the Enhanced Health in Care Homes (EHCH), which is one of the required services PCNs provide under the Directed Enhanced Service (DES). All practices in the ICB are also signed up to the Frailty and End of Life Care Locally Commissioned Services (LCS) ensuring they can identify and optimise the care of people with complex needs and long-term conditions outside residential care settings.
In addition, workstreams have been developed and task and finish groups started to support the delivery of key actions from the primary care recovery plan including:
· Use of the Apex Demand and Capacity Platform mobilised in all practices by October 2023, which will enable practices and NHS Sussex to monitor any changes in demand and provide suggestions of possible activity to enable change via the SHREWD platform.
· Maximising use of underutilised Primary Care Enhanced Access (EA) Capacity (additional evening and weekend GP access arranged by PCNs), particularly to ensure coverage over the Christmas and New Year period.
· Advance Primary Care (APC) Roles to enable practices to focus on quality.
· Agree model with PCNs and GP Federations for Local Hubs that will be stood up as surge capacity (subject to funding). The model will include sites, patient communications, and referral pathways into and support from secondary care.
· Preparation of fast-track approval process for additional primary care capacity, should funds become available. This will enable rapid mobilisation based upon last year’s successful model.
· The common conditions/Pharmacy First scheme that will enable pharmacists to supply prescription-only medicines, including antibiotics and antivirals, where clinically appropriate, to treat seven common health conditions (sinusitis, sore throat, earache, infected insect bite, impetigo, shingles, and uncomplicated urinary tract infections in women) without the need to visit a GP. This scheme is permitted under the national Patient Group Directions (PGDs) legal framework.
· Further support in the expansion of the contraceptive service and the hypertension case-finding service. Negotiations are still under way nationally with input from Community Pharmacy England.
· Vaccination of those over the age of 65 and in areas of deprivation. In response to a new Covid-19 variant, flu and Covid vaccination started in September. This will ensure adequate protection over the winter months for vulnerable patients in Sussex. Frontline health and social care workers are also included in the eligible cohorts for both vaccinations.
Current flu and covid vaccine uptake in East Sussex is 49.0% with Sussex at 51.6% and National at 46.9%. We continue to have a number of sites operating in East Sussex including community pharmacies and local GP sites, who will be continuing to offer vaccinations to their eligible populations.
It is well known that a small number of individuals make particularly frequent use of health care resources. This can be for a number of reasons including complex health needs and/or psychosocial needs. A High Intensity Users programme is a priority area of focus for this winter. This involves targeted patient level work with individuals to better understand their support needs, linking where appropriate to personalised health budgets, social prescribing, VCSE support and linking with wider local authority services. Patients who access the service have reported a greater sense of control over their daily lives, satisfaction with their current housing, financial stability, and improved physical and emotional health among other reported outcomes. Many of the patients supported are from areas of deprivation, are disabled and are vulnerable due to their housing situation.
This builds on the very successful impact VCSE high intensity user service that uses a psychosocial and longer-term approach to target Brighton and Hove frequent users of emergency services at University Hospitals Sussex (RSCH and PRH). The service has been expanded to include East Sussex, operating Monday to Friday; 9am till 5pm. The service provides support for up to nine months, although many patients are involved with the service for a shorter period.
As the service has not been operating very long in East Sussex the data is limited. The service saw 13 new referrals within the first three months of operation, 31% of who reside in Core20[1] areas of Multiple Deprivation. In 2022/23 the same model in Brighton and Hove, reported a 68% reduction in ambulance conveyances, 61% reduction in ED attendances and 74% reduction in non-elective admissions (NELs). Additionally, the individual impact on service users, family and friends is significant. A pilot is being established in West Sussex.
A focus on admissions avoidance will ensure patients are treated in the most suitable environment for their needs. In many cases this will be in their normal place of residence, supported by carers, family, and friends. Minimising the number of admissions to those patients who can only be treated in an inpatient setting reduces bed occupancy and the risk of delayed discharge and better supports the individuals.
The Sussex system mobilised an admissions avoidance single point of access (AASPA) as part of the 22/23 Winter Plan. This was considered best practice by NHSE and was subsequently included as a requirement for all ICBs in the 23/24 National Winter planning requirements. This continues to be a priority for the system with the strategic ambition to expand the function to become the single point of access for all healthcare professionals, and to develop the service as a strategic component of the NHS Sussex integrated community model.
To support winter 2023/24, priority focus is being applied to:
· Increasing access to senior clinical decision makers to ensure those contacting the AASPA (paramedics etc) are supported to make decisions which support patients to receive the right care in the place most appropriate for their needs.
· Development of technical enablers to increase capacity and resilience of the function and improving access to patient records to support clinical decision-making; and
· Building capacity and clinical pathways which link with same day emergency care (SDEC), Urgent community response (UCR), Enhanced Care for Care Homes and virtual wards (VW).
The virtual ward programme has transitioned from being an ICB led programme into a provider led programme, led by SCFT. This ensures that those closest to delivery of the service are supported to take ownership of service design, and use direct knowledge of resource requirements, service transformation opportunities, and provider to provider relationships to optimise the opportunities for service improvement.
A stocktake of current services in Sussex has been undertaken, recognising that Sussex benchmarks low nationally on the overall number of virtual ward beds, to support the system to expand capacity in an optimal way, utilising resources, and meeting population needs. It is the focus will include maximising opportunities in Admissions Avoidance and link to cross-cutting areas of clinical focus including Frailty and Respiratory.
Urgent Community Response (UCR) services across Sussex are a core part of admissions avoidance, operating to support both the AASPA and virtual wards. In addition, daily touchpoint calls are in place with SECAmb to identify category 3 and 4 patients from SECAmb’s ambulance dispatch queue, and where clinically appropriate, referring direct to UCR to reduce demand on the ambulance service and improve the speed of response. The ICB has funded SECAmb pathway champions to embed and promote this service within the ambulance provider.
Work done in relation to the “ECHO” PEoLC co-ordination service in the southern area of West Sussex has highlighted the significant impact that effective management of end-of-life care for patients can have both on the patients themselves and inpatient capacity. As a consequence of this work, case for change principles have been agreed for a potential future development of a centralised PEoLC coordination function across Sussex.
In the meantime, quick wins are being considered in advance of winter 23/24 to support patients in the community including:
· The potential in Brighton & Hove and East Sussex to replicate the Hospice led admission avoidance scheme that has been in place in West Sussex since 2020, is being explored. An overview of the scheme has been shared with hospices in East Sussex as part of assessing the feasibility of implementing something similar locally and this will inform future plans
· Improving interface between hospices and care homes to establish clear descriptors of the support they offer to care homes to support admissions avoidance pathways.
Improvements in hospital flow (acute, community and mental health) will have a number of benefits, including freeing up capacity to meet demand, supporting patients to receive timely access to care (admitted or non-admitted), and reducing the likelihood of cancelling elective activity. Helping people to get home from hospital quickly is important, not just for our patients, but also for our system as a whole to ensure our hospitals have enough available beds to admit people who require an emergency admission. Our acute, community and social care teams already work closely together to facilitate discharge. However, there are opportunities to optimise this further by improving our systems and processes. Improvements in flow will be delivered through the following:
Site-based flow improvement plans are in place for both acute Trusts (ESHT and UHSx) to support consistent delivery improved performance against the 4-hour standard. The plans if delivered will see the trusts deliver 4 hr performance of 71% and 69% respectively over the winter period. This is a significant improvement on the previous year, where performance of 66% and 61% was seen in Q3 and Q4 respectively. The impact of this would be more timely care for those patients who present at EDs across Sussex.
The Mental Health Crisis Improvement Plan, agreed by the system in early July, aims to:
· reduce mental health ED attendances by 20% by March 2025 (equivalent to 327 attendances being diverted away from ED each month)
· eliminate over 72 hour waits in ED for a mental health concern by October 2023, and eliminate over 24 hour waits by July 2024
· Reduce the average time waiting for a mental health bed by 20% by March 2024
· reduce the average length of stay in a mental health by 21.5% by September 2024 and;
· reduce the number of patients detained under section.136 who are conveyed to ED by 20% by September 2024 (49 fewer each month).
Both SCFT and ESHT have bed optimisation plans in place that are designed to reduce length of stay in community beds through a combination of focussed efforts around patients experiencing long length of stay; strengthened clinical leadership to support timely decision making; use of bed managers and discharge support assistants; and improved Multidisciplinary Team (MDT) working. Work is also underway to review intermediate care capacity and support is being aligned from the national BCF team to enable optimisation within the system.
Delivering the comprehensive discharge improvement plans which have been agreed between system partners will reduce the number of people in hospital who “do not meet the criteria to reside” (NCTR patients) from 477 to 320 (a reduction of 157) and will release the equivalent number of beds. These are people who no longer medically need to be in an acute hospital bed. This will improve capacity and reduce the risk to patients of de-conditioning. This will enable patients to move to the most appropriate place of residence for their needs at the earliest opportunity.
The roll out of Transfer of Care Hubs (TOCH) is a core part of the Winter Plan and part of the 23/24 National Winter planning requirements. The key aims of the hubs are to reduce discharge delays and free up hospital capacity ahead of winter by improving patient flow and to provide more help and support for patients and those that care for them, so their wellbeing and conditions can be managed at home and in the community. Implementation of the core requirements of the NHSE national model involves delivering 9 priorities, including improved links with hospital staff and onward care staff, early discharge planning, and 7-day delivery.
Care Hubs have been in development since quarter 1, with the Sussex system ahead of the national requirement for their establishment.
East Sussex is currently implementing a Care Transfer Hub and has appointed a Hub lead. Implementation involves delivering against the core requirements set out in a national model that identifies 9 priorities (NHSE guidance). This includes improved links with hospital staff and onward care staff, early discharge planning and 7-day delivery. Other priorities relate to governance and leadership of the hub and discharge operations.
There are two sites in East Sussex (Conquest Hospital and Eastbourne District General Hospital) co-locating with multi-agency partners. Hub functions serve the whole of East Sussex (i.e., for all East Sussex residents regardless of which hospital they attend within or outside of the county). Hubs once in full effect will improve patient flow and management of flow with effective and timely escalation, and multi-agency leadership to ensure patients have the care and support they need in the most appropriate setting at the right time. The key aims of the hubs are to reduce discharge delays and free up hospital capacity ahead of winter by improving patient flow and to provide more help and support for patients and those that care for them so their wellbeing and conditions can be managed at home and in the community.
6. Cross cutting clinical pathways
There are a number of cross cutting clinical workstreams which form a core part of the Winter Plan. Data has shown that over 65’s and individuals who suffer deprivation are disproportionately driving urgent care demand in the Sussex system. Two specialties which feature high numbers of patients from these groups are Frailty and Respiratory illness.
Two tests of change are planned for winter 23/24 to develop more proactive and effective management of patients with frailty both in and out of hospital settings:
(1) Across Brighton & Hove and West Sussex geographies, UHSx & SCFT are working collaboratively to develop out of hospital urgent frailty response pathways supporting admissions avoidance and early supported discharge, with access to senior clinical (medical) decision makers to refer patients to the most appropriate pathways including frailty SDEC and virtual wards. The focus is on immediate interventions that will have an impact this winter and identify opportunities for rapid pan-Sussex expansion of clinical best practice models to support frail patients. The Brighton & Hove model will go live from November. The West Sussex model has been approved to proceed and recruitment is underway to appoint Consultant Geriatricians to support senior clinical decision making.
(2) In East Sussex, focus is on in-hospital frailty pathways, building on the ESHT established frailty programme and taking learning to identify opportunities for rapid pan-Sussex expansion of clinical best practice models to support frail patients.
Collectively, these test areas will provide the system with evidence to support targeted early rollout of positive in and out of hospital intervention across Sussex and inform the longer-term Frailty Strategy. Additionally, work is underway to understand the population health indicators that will allow identification of frailty cohorts, including consideration for falls prediction datasets to provide opportunities for further targeting of at-risk patients.
The UEC Clinical Reference Group has been tasked with bringing together groups of clinicians around acute hospital sites who will work together over the winter months to share information about service demand and consider how service delivery across primary, secondary and community services can be optimised to best meet demand and manage clinical risk locally. This will start with consideration of how the Sussex system will optimise delivery of respiratory services over Winter 23/24 by re-framing current services and capacity, to both proactively manage respiratory patients at risk of deterioration and admission, and to respond to any respiratory surge.
Effective clinical leadership is key to Sussex designing and delivering a winter plan which improves the quality and safety of services and focuses on patient needs. The majority of priority areas and cross cutting workstreams are designed and delivered through relevant Shared Delivery Plan (SDP) workstreams, all of which are supported by clinical reference groups. This has ensured there is clinical engagement and leadership included in the design and delivery of the Winter plan.
Senior clinical roles are being established to provide robust clinical leadership in response to “real time” operational issues which if not effectively addressed could increase risk of clinical harm.
In addition, three clinically led “Pod” teams are being established, one of which will serve ESHT. They will consist of a small group of named senior clinical and care professionals from across all partners who will provide strategic leadership. By having a consistent team in place across winter, will enable the Pod team to oversee improve patient outcomes and experience.
RSV is the major cause of lung infections in children, commonly causing bronchiolitis and cases with complications can develop into pneumonia. Infants in the first year of life are more likely to experience severe infections requiring hospitalisation because their airways are smaller. In the UK RSV epidemics generally start in October and last for four to five months, peaking in December. Actions being undertaken to manage the increased RSV prevalence during Winter include:
· Revised modelling data for an RSV and childhood illness surge based on trend analysis from the regional team and the ICS BI team
· Overview of Paediatrics capacity across the region and plan in place to manage Paediatric Critical Care capacity in the event of a surge
· Plans developed by acute trusts to proactively mitigate risks ahead of winter
· Paediatric Operational Pressures Escalation Levels (POPEL) and Escalation Status for the Sussex system in place
· Escalation process for mutual aid and key contacts; and
· Key risks and mitigations identified in the Sussex system.
ICBs and Operational Delivery Networks (ODNs) will work in partnership to co-ordinate, implement and oversee robust winter and surge planning, including mitigations to manage the impact of surges in paediatric respiratory infections on Children and Young People (CYP) services. This will include mutual aid arrangements at regional and national level, particularly for Level 3 paediatric intensive care unit (PICU) bed provision and for children on long term ventilation. Critical surge planning is in place for both adults and children across the acute Trust sites should there be a requirement to expand critical care capacity.
7. Other cross-cutting pathways
There are several other cross-cutting pathways which will form a core part of the system winter plan.
Maintaining workforce capacity and resilience across Sussex will be key to the delivery of safe and high-quality services over the course of winter. Multiple periods of industrial action this year and continued high demand has impacted on staff morale, and it is recognised that many staff are fatigued going into the winter period. This needs to be considered by all partners as part of our winter planning so that staff can be supported to deliver the care that will be required during this period. Key areas of focus within the Winter plan to support the workforce are as follows:
A Workforce and Wellbeing task and finish group is reviewing the Sussex system wellbeing offer aiming to provide consistency within this offer across health and care providers. Presently all NHS providers have in place cost of living provisions, Occupational Health services and Employee Assistance programmes.
It is recognised that proactive and quick access to mental health support is paramount, given 21% of sickness absence during December 2022 was categorised as anxiety, stress, or depression. The ICB is working through the appropriate support to have consistency in place with the funding provided including the continuous roll out of Mental Health First Aid training.
Additional staffing requirements are being modelled, specifically with acute providers with regards to any planned capacity increases above those within the operating plan for 2023/24. Recruitment of staff within organisations remains a key focus with vacancy rates reducing across the system.
Challenges remain in recruiting to nursing vacancies particularly within mental health services. There is a significant risk with regards to industrial action taking place in the system during the winter period, both during any action and also before and after, in managing patient pathways. There currently are no planned strikes, but a series of strikes have taken place throughout 2023. Temporary staffing is a key focus within the system in building supply with staff banks and reducing reliance on agency workers. The system is now part of the South East Temporary Staffing Collaborative, working in partnership and sharing good temporary staffing management practice.
Seasonal illnesses play a significant role in driving the surges in demand which health care services experience over winter periods. NHS Sussex has developed a governance and reporting structure. The following areas will be delivered during Winter 2023 and reviewed by NHS Sussex’s Antimicrobial Resistance (AMR) / Health-associated infections (HCAI) programme board:
· Development of a Winter Infection Prevention plan to support learning from 2022/23 to include development of respiratory hubs, point of care testing, laboratory capacity, measles prevention
· Development of IPC winter surge plan for winter viral illnesses which includes national guidance implementation, risk assessment and provider actions to support patient flow across providers
· Review of healthcare providers’ policies including outbreak as part of Sussex ICB attendance at Provider IPC Committees
· Delivery of training provision across all health and social providers including a Link Practitioner development day and Winter preparedness training which includes UK Health Security Agency (UKHSA) 'Think Flu' campaign
· Sussex ICB Infection Prevention Specialist Team to provide expert advice to health and social care settings
· Attendance at bi-weekly regional NHSE IPC meetings to support with horizon scanning and regional escalation as required
· Daily review of Infection Prevention bed closures and outbreak situation to support patient flow.
The VCSE sector plays a key role in supporting the delivery of safe, high-quality services over winter. Schemes, typically commissioned at Place, are delivered by local organisations such as Care for the Carers, British Red Cross and Imago and organisations that support informal carers, and these organisations play a key role in supporting areas such as discharge and admissions avoidance, delivering ‘take home and settle’ type schemes or other initiatives to support vulnerable members of our community to stay well at home over the winter period.
As part of the development of the Sussex System Winter Plan, the system worked together to enhance the service capacity over winter, share intelligence regarding what works well and engaged with the VCSE to understand what more could be done to optimise their support and use their community knowledge to best meet the needs of those most at risk over the winter period.
Helpforce, a charity with a mission to accelerate the growth and impact of volunteering in health and care, are also playing a key role in the workforce workstream of our Discharge Improvement Plan, with an initial focus on East Sussex.
In East Sussex the British Red Cross Assisted Discharge Service, Home from Hospital and Carers Crisis Response service supports people to enable a timely return home from hospital to settle and stay well at home preventing early re-admission.
Work with local authorities at Place is key to successful development and delivery of the Winter Plan and critical to the focus on the impact of deprivation in managing demand over the winter period.
Consequently, the current cost of living crisis poses a particular risk to those already living in or at risk of deprivation and the system is working closely with local authority partners to understand the risks and mitigations which could be delivered through the winter plan and through the use of the BCF. General information on the Cost-of-Living services and information is included in the place-based directory of service which is made available to all NHS providers.
Local authorities also play a role in many of the initiatives which feature in the winter plan priorities of Admissions Avoidance, Hospital flow and Demand management and consequently collaborative development of the winter plan is key. This has been achieved through place-based conversations and governance, and also through local authority membership of the workstreams as reflected in earlier sections.
In East Sussex, additional assessment capacity and care capacity (Discharge to Assess beds and home care) remain in place to continue to improve how local people are discharged from hospital in a timely way and to the most appropriate setting. East Sussex County Council continue to recruit to reduce the number of social work vacancies, to maximise support for local people over the winter.
As a system, the priority is to ensure that the recovery of planned and cancer care services is maintained, by securing capacity across Sussex which will not be impacted by emergency admissions. This will include work to agree standardised clinical pathways across Sussex to enable patients to be treated at any appropriate clinical site across the system, using mutual aid between NHS providers and use of the independent sector where necessary, and development of a single Patient Treatment List (PTL) for Sussex managed proactively, using digital technology (SHREWD) to provide contemporaneous demand and capacity data.
This will help the Sussex system to continue with the elective recovery plan to diagnose and treat both the most clinically urgent and those that have waited the longest. There is a Planned and Cancer Escalation Framework which sets out the underpinning principles, key triggers, and actions at each stage of escalation to protect the continuity of planned care and cancer services.
A coordinated system wide communications and engagement plan has been developed with system partners to ensure clear communications are in place to support operational delivery over the winter period. This includes global approaches to key messages for the public, partners, and staff, as well as targeted and focused approaches based on data and insight. The plan will bring together activity over the Winter period, covering Flu and Covid-19 vaccinations, preventative advice and support to key audience groups such as respiratory advice for children and young people, urgent and emergency care pathway, and reputation management and stakeholder management during the key months of winter.
Planning will focus on addressing health inequalities, and the known challenges and barriers present within our population. Insight will shape communications activity and ensure that work considers the whole population.
8. Plan delivery
NHSE’s Winter Planning letter sets out clear roles and responsibilities for all system partners. In signing off the final Sussex System Winter plan in November, all system partners will be asked to agree to undertake the roles and responsibilities as articulated in the letter. All delivery boards with programmes of work related to the Winter Plan will be asked to reflect on these roles and responsibilities ensuring alignment with the national guidance is maintained.
NHS Sussex established a Systems Operation Centre (SOC) in October 2022 in order to coordinate and lead the management of operational pressures across the system. The system was considered ahead of the curve in its early adoption of this approach, and this led to a national requirement for all systems to adopt a similar approach and set up System Coordination Centres (SCCs).
In Sussex a Task and Finish Group was set up with system partners to consider how best to achieve the requirements articulated by NHSE. The Group considered how the required functionality could be delivered by working smarter together to review real time data and respond to early warning triggers by taking appropriate actions in a coordinated way, draw on Business Informatics, SHREWD and provider organisation sitrep data and undertake effective application of the OPEL framework. The ICB received additional funding from NHSE to support the developments in SHREWD which will lead to improved access to real time information which will allow decisions to be made to support appropriate and timely actions to relieve system pressures.
In addition to the management of the day-to-day pressures, the group considered periods where extraordinary action may be required (industrial action, bad weather, respiratory surge, management of the Christmas period) and how the system would work in lockstep to mitigate pressures over these periods.
9. Implications
The resourcing of the Sussex Co-ordination Centre (SCC) to allow the delivery of the new SCC standards will need to be considered by the NHS Sussex following completion of the full impact assessment.
No specific legal implications have been identified in relation to this paper.
The paper describes how NHS Sussex is complying with national requirements in respect of planning for winter and core roles and responsibilities, as well as drawing on existing system surge plans and learning from previous years.
The winter plan has a risk register which describes the risks to safety and quality over winter. All risks have been assessed and mitigations are being defined.
The risk register describes the quality and safety implications. A specific focus, as part of the Winter Plan, will be on ensuring that quality and patient outcomes are maintained and improved.
An Equalities and Health Impact Assessment (EHIA) checklist has been completed. As outlined in the body of this report, there is a high degree of correlation between deprivation and ED attendances and admissions. Continual challenge needs to be applied to ensure that this is being taken into consideration, along with any other health inequalities when planning resource allocation to support delivery of the Winter Plan.
Public representatives are involved in the ratification of surge plans. Engagement work is underway via Healthwatch, the voluntary sector and GPs.
The Sussex System Winter Plan describes the application of the BCF, including the National Discharge Funding, which has been developed by partners and approved by the three Health and Wellbeing Boards in Sussex.
10. Conclusion
The Winter Plan sets out the mechanisms through which the Sussex system will remain sighted on the key issues, respond in an agile way to pressures and ensure that system leadership remains aligned on the key actions that are undertaken. The Winter Plan was formally approved and signed off in early November 2023. Work programmes are being mobilised around key areas of focus, determined by analysis of the drivers of urgent care demand in the Sussex System. The plan is an iterative process and will continue to be added to during the Winter period.
The HOSC is recommended to note the approach taken to the development of the Sussex system winter plan to successfully mitigate identified risks this winter.
[1] The most deprived 20% of the national population as identified by the national Index of Multiple Deprivation (IMD). The IMD has seven domains with indicators accounting for a wide range of social determinants of health.