DRAFT East Sussex Health and Wellbeing Board

Shared Delivery Plan milestones – 2023/24 progress summary


The report provides a summary overview of joint work on the eight milestones in year 1 (2023/24) of the 5-year Sussex Shared Delivery Plan (SDP) that are specific to the East Sussex Health and Wellbeing Board. Noting that some of the milestones form part of a long-term delivery process, as well as an accompanying summary narrative for each a milestone rating has been given about progress status[1] relative to our expectations in June 2023 when the SDP was agreed. This is as follows:


Green: milestone has been progressing well against delivery objectives and will be built on in 2024/25


Amber: milestone progressing but will be subject to change or further refinement in 2024/25


Red: progress has been challenging and a full review of objectives for 2024/25 is recommended 


Overall, the progress made with delivering our objectives across our SDP milestones in 2023/24, will shape the ongoing critical milestones for 2024/25 that will be a focus for our shared work to improve health and integrated care for the population of East Sussex. Planning for 2024/25 is underway through our oversight board and programme structures and will be finalised during March and April 2024. Some milestones will be a continuation of shared priorities for transformational change over the medium term, building on the activity and progress in 2023/24.



What we will do (2023/24)

(East Sussex HWB SDP milestone)

What we will achieve



Red Amber



Building on the Universal Healthcare initiative and other local programmes, we will have a joined-up approach to planning and delivering health, care, and wellbeing in Hastings, with clear evidence of integrated approaches to improving outcomes for local communities.

A planning and delivery approach agreed by Place leadership board.

March 2024





To support the planning and delivery approach Public Health and business intelligence leads have collaborated to develop intelligence profiles for each of the 16 ICT footprints in East Sussex. These have now been finalised and are the profiles for the 5 East Sussex ICT footprints, including Hastings, are published on our East Sussex Joint Strategic Needs Assessment (JSNA) website ICT Profiles | (eastsussexjsna.org.uk).  They consist of an initial understanding of population health and service needs in each ICT footprint, and will serve as a tool to support local planning about priorities and focus specific to each ICT as they develop.  Themed insight packs have also been developed covering a number of topics that will be of interest to ICTs and their populations, based on existing local information and good practice.

A strategic planning session took place in Hastings, as the ‘community frontrunner’ site in East Sussex with Hastings Borough Council, Hastings Voluntary Action, Hastings Community Network, Hastings Primary Care Network, East Sussex County Council, NHS Sussex Integrated Care Board, East Sussex Healthcare NHS Trust.  As part of exploring a joined-up approach to planning and delivering health, care, and wellbeing through establishing an Integrated Community Team (ICT) in Hastings, the session identified some specific shared themes in the Hastings context that the local ICT service model could helpfully focus on. These are:

·         People who use services very intensively and who are often known to more than one team.

·         People who are ‘on the edge’ of this who, with the right proactive model of care and support intervention, can be prevented from tipping into very intensive use. For example, people with care or housing needs who are socially isolated, or people with complex needs and issues who are being seen by voluntary organisations, where a well-timed and coordinated early intervention would help avoid or delay things getting worse.

Based on this, a further session with key frontline service and team leads in March 2024 will begin the local co-design of the Hastings ICT, focussed on an integrated service model for these groups and taking in functions across planning and multi-disciplinary team working, as part of developing the broader ICT core offer. This will include designing the approach to organisational development, joint training and relationship building needed to support a ‘team of teams’ approach, as well as how an information-sharing platform can help teams to rapidly mobilise support to prevent situations getting worse.


A second twelve-month phase of the Hastings Universal Healthcare programme investment commenced in September 2023, to further test and evaluate seven prototype initiatives at a larger scale. This will better understand their potential impact on population health outcomes and inequalities and their contribution to priorities set out within our SDP, and this is due to complete in September 2024.


A key focus is one of the broader themes that emerged during the initial phase of Universal Healthcare; the role of the VCSE sector in improving access to health and care and reducing demand for primary care. The output of this community of practice will be a co-designed proof-of-concept model for a point of access to health and wellbeing support in the community. This will be tested within the local development of Integrated Community Teams (ICT), and will inform the co-design of the ICT model in Hastings and ICTs generally. This is of particular note in relation to how people can best access services, ensure data-driven working, secure meaningful engagement by partners and community members, and co-create and test innovations. A first workshop has taken place with VCSE partners to explore what is working well, current limitations and what a successful model of access would look like. More broadly, as part of the evaluation due to report in September 2024, each of the Universal Healthcare prototype initiatives will report and feed into ICT development the following during 2024/25:


·         The impact of further testing (activity metrics, case studies etc)

·         The learning that has been developed around the stakeholders, resources, systems, and processes needed to deliver the model/approach effectively

·         Recommendations on how the model/approach could be adopted in other pieces of work/parts of the system.

The findings and recommendations of the Universal Healthcare prototype initiatives evaluation will feed into the implementation of the agreed pan-Sussex ICT core offer, and proposed service model for all ICTs during 2024/25, as part of the ICT development tailored to the local challenges and strengths in Hastings.



Service models will be developed and approved for scaling up across the county and an implementation timetable with key milestones agreed.

Service models will be approved by Place leadership board.

March 2024




A core offer for Integrated Community Teams (ICTs) has been developed through collaboration at Place and Sussex level. This describes the principles, functions, outcomes and proposed integrated service model that all ICTs in Sussex will deliver, in addition to a tailored approach to local challenges and strengths in each footprint based on intelligence and insight about local communities. Once this has been agreed in March 2024, it will be taken through our Place-based partnership and individual organisation governance for formal endorsement and implementation plans will be drafted.


In conjunction with the first phase of learning activity that has taken place under the Universal Healthcare to inform the seven learning prototype initiatives, our East Sussex Community Oversight Board has undertaken an initial high-level review of our strengths, weaknesses and opportunities in relation to the proposed purpose and functions of ICTs, to ensure that legacy learning and evidence from implementing integrated planning and delivery in our communities has been factored into programme design. Other key community-facing plans and programmes have also been reviewed to understand how they can underpin ICT development. This includes using data-driven population health management to drive work with ‘hyper-local’ community support targeted at vulnerable people within populations, local community network support, asset-based community development focussed on our most deprived Wards in East Sussex, and social prescribing.


This is shaping a draft in-year programme milestone plan to support phase 1 implementation of all five ICTs in East Sussex during 2024/25, to deliver the ICT core offer building on progress made in East Sussex with integrated care and existing multi-disciplinary team-working, and current learning through Universal Healthcare and other projects. The milestone plan will ensure the key existing programmes focussed on community networks, asset-based community development and social prescribing, and the collective resources available to support this, are connected with the ICT core model through strategic oversight at Place level as implementation progresses.



A comprehensive stakeholder engagement process will take place to help us explore how we can improve health outcomes in cardiovascular disease (CVD), respiratory disease, mental health, and frailty and healthy ageing as significant drivers of poor health and early death in our population.


Improvement plans approved by Place leadership board.

March 2024





An Improving Health Outcomes in East Sussex planning workshop took place and was attended by 73 people from stakeholder organisations across the system. The workshop covered service mapping, action planning and prioritisation through dedicated sessions on CVD, respiratory disease, mental health and frailty and healthy ageing. Workshop summaries were then produced for each of the four condition areas, setting out the suggested actions and next steps which were shared with participants and tested more widely with stakeholders, including programme oversight boards for connected areas of delivery, for further feedback. The whole-system health outcomes improvement action plan for 2024/25 will be finalised, along with supporting governance and delivery arrangements for each area, for approval by our East Sussex Health Outcomes Improvement Oversight Board in April.



Aligned to our discharge workstream, we will develop our integrated hospital discharge model, implement the 2023-24 hospital discharge capacity plan, and deliver the improvements aligned with the discharge frontrunner programme.

More people will be able to be discharged safely to a community setting.

March 2024





The overarching principles and Home First model will be finalised and agreed during Q4 2023/24. This builds on existing integrated approaches across health and social care, housing and the voluntary and community sector including discharge approaches to home and to bedded care.


Hospital discharge capacity plans for 2023/24, included continued enhanced domiciliary care, bedded care that has been flexed in response to system pressure, improved use of VCSE services and improved embedding of housing as part of discharge pathways. Other improvements aligned with the hospital discharge frontrunner programme include:


·         Reduction in delays experienced by patients who have waiting in hospital over 21 days (17% reduction in numbers of patients waiting over 21 days, 196 to 162, and 17% reduction in associated occupied bed days - January 2024 compared to March 2023).

·         Introduction of ‘Rhythm of the Day and Week’ as a planning process to support multi-agency discharge planning, review and escalation arrangements 

·         Refreshed arrangements for place-based executive decision-making, improving collective ownership of challenges and solutions in East Sussex

·         Improvements in data quality, clarity and use by East Sussex partners, with agreed priorities for further action

·         Strengthened Trust-wide focus on hospital discharge - including assigning the Chief Nursing Officer as the Senior Responsible Officer, multi-agency discharge training, review of the hospital discharge policy, and Urgent and Emergency Care (UEC) programme structure and governance arrangements.

·         Implementation of the Transfer of Care Hub has got underway to bring together staff involved in discharge planning processes in one place to support individuals

·         Plans for 2024/25 that take account of Discharge Frontrunner Economic Modelling and review report focussed on improving discharge home, alongside increased therapy and assessment provision and associated plans to reduce bedded discharge pathways.



Deliver our children and young people’s programme plan with a key focus on priority workstreams to support getting the best start in life; promoting emotional wellbeing and mental health; physical health, needs of children with SEND, and our most vulnerable young people.

Family hubs with additional support for families with young children; strengthened support for long term conditions (Core20PLUS5 for CYP); clearer and improved pathway for mental health support and support for parent carers.

March 2024




The following progress has been made with our children and young people’s programme:


·         In 2023, 11 Family Hubs were opened in East Sussex which will provide additional support for families with young children.

·         A Child and Adolescent Mental Health Service (CAMHS) comprehensive stocktake exercise has taken place with Sussex Partnership NHS Foundation Trust (SPFT), to support a joint understanding of CAMHS community-based mental health service provision and how resources are currently used across each of the three Places. This will inform future CAMHS development.

·         A joint Mental Health and Emotional Wellbeing Strategic Plan (2023 – 25) has been developed to improve wellbeing and to promote whole school approaches to developing the emotional wellbeing of children and young people in educational settings.

·         The Core20PLUS5 ‘plus’ groups have been agreed for East Sussex to support a reduction of health inequalities in specific groups within the population. These are:

o   Looked after children, care leavers and young carers.

o   Children and young people with a learning disability or autism or life limiting illness.

o   Asylum seekers and migrants who have been staying in cohort hotels and in our communities living with families.

o   Children living in temporary accommodation.

o   Children who are LGBTQ+.

·         A comprehensive report on Looked After Children (LAC) and care leaver health was considered in September 2023, resulting in agreement to develop a Sussex wide health strategy focussed on the needs of LAC in 2024.

·         Agreement has been secured for East Sussex to be part of a Neurodiversity (ND) pilot programme to support primary schools.



We will deliver initial stages of integrated models of community mental health care within local communities, through Primary Care Network based offers and developing plans to support more people who need housing-based support due to their mental health.


In-year plan delivered

March 2024




An overarching description of the new model of community mental health services has developed and agreed by partners. An implementation plan for the model has been drafted to describe how new and pre-existing resources will be better utilised to create a more integrated and accessible community offer across East Sussex across generalist (primary) care and specialist mental health services.


Working closely with our Primary Care Networks (PCNs), the foundations of the new integrated community mental health offer has started to be established through the delivery of new Emotional Wellbeing Services (EWS) through new roles based in PCNs. Six of our twelve PCNs in East Sussex now have this and this is expected to rise to eight by year end.  Plans are being developed to ensure continued implementation of the EWS function, and milestones in 2024/25 are being reviewed to reflect this.


The available supply of mental health supported placements across the county has been increased in the last 12 months, taking the total number of placements in the county to 54, and social care and rehabilitation teams are working in a more integrated way for the benefit of people living in supported accommodation to help sustain placements. More work is planned through 2024/25 to build on these integrated practices and to improve joined up working between clinical teams and supported housing providers. Plans to increase the total supply of supported placements to approximately 80 units over the next 2 years have also been drawn up. The Supported Accommodation and Housing Group has reviewed overall progress with place-based plans, and have agreed a refreshed set of delivery plans which the East Sussex Mental Health Oversight Board has approved.  Based on this, milestones will be developed for 2024/25 to support further improvements in services and pathways.



Networks will be developed in communities to help co-ordinate access to local sources of practical support and activities, to boost emotional wellbeing and help with loneliness and isolation.

Consolidation of networks providing access and support to local people.


March 2024





Through our Community Networks Support Programme we have started identify existing local networks and categorised them based on their characteristics. For networks that work at the level of infrastructure and community these are:


Infrastructure Networks:

·         brings together organisations to support organisations

·         works to influence ways of working and collaborates to solve issues


Community Networks:

·         brings together organisations to support people

·         provides activities/ services which directly benefit local people.


From the initial mapping and engagement with partners, over 60 infrastructure and community networks have been identified across the county. Interviews are taking place with lead contacts from these networks to deepen understanding of their structure, support offers, beneficiaries, successes and challenges. This information is being used to co-develop a draft menu of support options which the CNSP could resource. Further engagement is aimed at:

  • Determining the primary and secondary functions of each
  • Identifying interdependencies that exist between each
  • Scoping connectedness with strategic priorities, for example relationships with other community-based service provision and care pathways through the development of Integrated Community Teams and facilitating ‘no wrong door’ models.
  • Gaining insight on success factors and support requirements

The 2023 Annual Report of the Director of Public Health (DPH), ‘Connecting People and Places - Bringing communities together in East Sussex’, has provided recommendations on multi-agency work to tackle loneliness and foster social connections. A series of partnership workshops have been held to identify how a collaborative group of system leaders and interested parties could be best supported to drive future actions, with a focus on tackling loneliness across the system.


As a result, the County Council and East Sussex Voluntary, Community and Social Enterprise (VCSE) Sector Alliance worked together to develop proposals and jointly appoint a host organisation within the VCSE sector, to establish and support the collaborative group and delivery of a ‘Connecting People and Places’ programme. This will define what success looks like and agree the vision. The group will be developing ways of working together, reaching and engaging those with lived experience of loneliness, providing learning opportunities, raising awareness of loneliness, and agreeing how to make further progress on other recommendations of the DPH Annual Report.



Develop our approach as an “anchor” system in East Sussex, including our plans for using our power as employers and buyers of services to stimulate sustainable economic and social wellbeing in our communities.

Approach approved by Place leadership board.

March 2024





East Sussex Health and Care Partnership contributed to the NHS Sussex baselining exercise of anchor aligned activity happening across the Sussex Integrated Care System (ICS), from the perspective of the East Sussex Place and Health and Wellbeing Strategy Healthy Lives, Healthy People, and our own early baselining work to consider what a whole system approach to Anchor would look like.  The NHS Sussex baselining exercise was undertaken to support the development of a broader Sussex Health and Care Social and Economic Wellbeing Plan, which will support the fourth purpose of the ICS, which is to “help the NHS support broader social and economic development”. The plan will outline how we will progress actions as an ICS in the short to medium term, to ensure the health and care system is doing all it can to support social value outcomes and economic prosperity for our most deprived communities.


In addition to specific role that the NHS Sussex ICB and other NHS organisations can contribute to supporting social and economic wellbeing in our communities, through their actions to impact on the social determinants of health at both an individual and population level, the baseline exercise also acknowledged that effective partnerships will be key to the success of the plan. In line with this, the role of partnerships driving economic and social wellbeing at all levels of governance will be emphasised as part of plan development. This will link with existing partnership infrastructure that supports social and economic wellbeing including relevant planning partnerships led by local authorities, to support closer working and integration opportunities between NHS organisations and their partners.


The next phase of collaborative work will take forward the scope, governance, and identification of links with the appropriate stakeholders to support co-development of a proposed ICS Social and Economic Wellbeing Plan during 2024. This will also explore relevant links with the local joint planning partnerships to maximise opportunities for participation in plans for economic development, learning and skills, estates, and financial inclusion, for example Team East Sussex (TES) | East Sussex County Council, local strategic partnerships, and the Health and Wellbeing Board. Milestones will be developed at a pan-Sussex level to support the development of the ICS Plan, and this will inform any further local action-planning focussed on the East Sussex population.


[1] This draft (29/02/24) represents expectations of planned achievements by year end (31/03/24) remaining on track