Report to:                  East Sussex Health and Wellbeing Board

Date:                           9 December 2025

By:                              Director of Joint Commissioning and Integrated Community Teams Development (East Sussex), NHS Sussex and Director of Adult Social Care and Health, East Sussex County Council

Title:                           Integration programme update

Purpose of Report:  To provide an update of progress with the East Sussex priorities in the Sussex Shared Delivery Plan in quarter 2 25/26, and an update on our collaboration and integrated working to develop neighbourhood health.

 

Recommendations:

East Sussex Health and Wellbeing Board (HWB) is recommended to:

1.    Note the progress in quarter 2 for the East Sussex HWB Shared Delivery Plan (SDP) priorities and plans in 25/26 as set out in Appendix 1;

 

2.    Endorse the early initiation work that has taken place as part of the Government’s National Neighbourhood Health Implementation Programme, focussed on Hastings and Rother;

 

3.    Note the expected content of the new neighbourhood health plan that will be developed under the leadership of HWBs for 26/27, and that guidance is awaited from the Department of Health and Social Care (DHSC); and

 

4.    Note and endorse revised Better Care Fund (BCF) metrics that reflect updated impacts and plans to support delivery of the SDP as set out in Appendix 2.

1.         Background

1.1       The Government’s new 10 Year Health Plan for England: fit for the future (10YHP) was published in July 25. It set out plans to reinvent the NHS based on three shifts as the core components of a new care model:

1.2       The shift from hospital to community care is driving the development of a ‘neighbourhood health service’, which aims to bring care into local communities, organise professionals into patient-centred teams, and reduce fragmentation. In Sussex, this is being implemented through Integrated Community Teams (ICTs), with East Sussex ICTs aligned to our five borough and district boundaries.

1.3       To support a whole health and care system approach to neightbourhood health, the 10YHP introduced an expectation that a new ‘neighbourhood health plan’ will be drawn up under the leadership of the HWB. East Sussex has also been successful in applying to participate in the first wave of the National Neighbourhood Health Implementation Programme (NNHIP) - focussed on Hastings and Rother - to support delivery of the shift from hospital to community.

1.4       These national developments align with our joint vision for a healthier Sussex, as outlined in the 5-year Sussex Integrated Care Strategy Improving Lives Together (2022), including the goal of more integrated community working through ICTs. Building on the East Sussex Health and Wellbeing Board Strategy Healthy Lives, Healthy People (2022 – 2027)  and insights from the East Sussex Joint Strategic Needs Assessment (JSNA) a 5-year Shared Delivery Plan (SDP) was agreed by partners in June 2023 and is updated annually to support this vision.

1.5       Our wider context involves major system change. The 10YHP reforms the NHS operating model, including changes to Integrated Care Boards (ICBs) and a new national ICB blueprint. As reported at the last meeting of the HWB, NHS Sussex ICB is clustering with NHS Surrey ICB ahead of a planned merger in April 2026. In line with the national mandate, the merged ICB will have roughly 50% fewer staff, and will cover a larger area and focusing on strategic commissioning to improve population health.

1.6       This report provides a brief update on our Place delivery plans, and shares progress on our collaborative work in East Sussex to support the development of neighbourhood health.

2          Supporting information

 

East Sussex HWB SDP progress in 25/26

2.1          A brief summary of our progress with our year 3 East Sussex HWB SDP objectives during quarter 2 (1 July – 30 September 25) is summarised in Appendix 1. It covers the following areas of collaboration:

·         Health outcomes improvement– implementing whole-system health action plans covering cardiovascular and respiratory disease, healthy ageing, frailty, and mental health.

·         Strengthening the role and vision of the HWB and our East Sussex Health and Care partnership across East Sussex by aligning partnerships, focusing on shared priorities, and deepening understanding of population health needs.

2.2          A summary of the last HWB development session was shared in September, and all session briefings to date are now published on the JSNA website JSNA: Health and Wellbeing Board briefing notes 2025. The penultimate session on Mental Health and Wellbeing was postponed to enable attendance from subject matter experts across our system. It is now being planned for 7 January 2026 to enable it to take place before the final scheduled session on 12 February 2026. If in the event we are unable to successfully re-schedule the session in January we will plan in a further final development session in the March – April time frame.

 

Integrated Community Teams (ICTs) and Neighbourhood Health

2.3          We have continued to develop the infrastructure to support shared leadership of neighbourhood health and care in our 5 ICT footprints (Eastbourne, Hastings, Lewes district, Rother and Wealden):

·           All five ICT leadership groups have met face-to-face every two months since January 2025, under agreed terms of reference focused on joint planning based on local needs. Despite some capacity-related variability, overall engagement and attendance has been good across all system partners

·           All groups have now nominated local Chairs, with some using a co-chair model. ICT Chairs are now invited to the East Sussex Place Delivery Board to support alignment with our shared health and care system priorities.

·           Each group is co-producing a joint work plan that sets out opportunities for local collaboration in relation to local population health and care challenges and alignment with system priorities.

·           Hastings and Rother have shifted to monthly meetings to support the move from planning to delivery as part of the national programme, and the other groups are also considering this. Each group also uses a dedicated Teams channel for communication between meetings.

·           Each group completed a self-assessment using an NHS England Southeast maturity matrix to identify development needs. A Sussex organisational development support offer has been created to aid multi-agency leadership team development, with sessions being planned for the new year.

2.4          A key focus is implementing multi-disciplinary teams (MDTs) working at neighbourhood level within our ICT footprints, to deliver more proactive care for people with high and ongoing complex health and social care needs, initially focussed on older and frail people and those with multiple long term health conditions aged over-65. The first step is using a risk stratification tool to identify groups of people with similar needs where we can have the greatest impact through a better coordinated proactive approach. The aim is then to establish more holistic closer multi-disciplinary team-working around these groups.

2.5          Improved outcomes for individuals include greater independence, better quality of life, reduced unnecessary hospital stays, and a better experience of integrated care and end of life support. Over time, through delivering more coordinated proactive care it is expected that this will lead to less reliance on urgent and unplanned care, and more specialist services.

2.6          Use of the risk stratification tool is now live. Work in the coming weeks will focus on increasing a shared understanding of the people on the lists generated by the tool and starting to shape a more integrated and proactive care offer across primary, community health and social care and other partners. The learning from this initial phase, will be used to progress to those with multiple long-term health conditions and rising risks across wider age-groups.

National Neighbourhood Health Implementation Programme (NNHIP)

2.7         As reported at the September HWB meeting, East Sussex is now part of the first wave of participants in the new National Neighbourhood Health Implementation Programme (NNHIP). This is focussed on Hastings and Rother where we have some of our largest gaps in health outcomes and an ageing population in coastal and rural communities. In summary, to accelerate the implementation and learning needed to shift to a neighbourhood focused health and care model nationwide, the national programme concentrates on three key areas:

 

·         Building capacity and leadership for Neighbourhood Health across local communities

·         Shaping the policy and strategy for what Neighbourhood Health looks like in England

·         Supporting rapid scale and spread of the NHS and social care working together in a more integrated Neighbourhood Health model. There is flexibility for local areas to design the ‘how’ to avoid a ‘one size fits all’ approach

2.8          The first wave of the national programme will focus on multiple health conditions and rising risks, and is expected to be delivered within existing system resources with much of the work taking place at the local level.

2.9          The initial work in Hastings and Rother has focused on onboarding local partners to the programme, leveraging our existing ICT leadership governance (see paragraph 2.3, above). The national programme coach has attended the local ICT leadership meetings, and participants are engaging with learning opportunities, including national webinars, a peer-to-peer knowledge hub, and a regional workshop held in November.

2.10       We will use the national programme opportunity to build on our early ICT work and accelerate our system plans in Hastings and Rother, establishing MDT working and a proactive care model across GPs, community nurses, hospital doctors, pharmacists, social care, and local voluntary organisations. The initial focus will be on supporting people with multiple conditions and complex needs to reduce hospital visits, prevent complications, and simplify access to care.

Neighbourhood Health Plan development

2.11       As reported at the last HWB meeting, the national 10YHP outlines Place’s role in delivering neighbourhood health through developing a local Neighbourhood Health and supporting place-based delivery plans. Led by the HWB, local government, the NHS, and partners - including public health, social care, and the VCSE sector - will collaborate to design and deliver neighbourhood health services.

2.12     At the time of writing, national guidance for developing these plans is still awaited. However, recognising that neighbourhood health involves the NHS, Local Government, and wider partners (including the VCSE) in improving local health and wellbeing, early indications suggest a strategic plan would address the following areas:

·         Agreement about neighbourhood footprints aligned to natural communities

·         Priority outcomes for places and neighbourhoods (for example including NHS-mandated and locally agreed, BCF,) and services in scope

·         Agreement on the development of integrated neighbourhood teams (MDTs) and defined leadership and accountability for delivery

2.13       An operational plan would then outline partnership arrangements for delivery, a timetable for aligning services around neighbourhoods (e.g. PCNs) and implementing integrated teams, and how collective resources are allocated and managed. It would also include plans for developing sustainable leadership of neighbourhood health.

2.14       Once the Guidance is issued, we will develop the East Sussex Neighbourhood Health plan based on existing plans for ICTs in Improving Lives Together and our SDP, and the new plans co-produced by the five ICT leadership groups. The recent NHS Sussex ICB commissioning intentions for 2026/27 and the pan-Sussex ICT and neighbourhood health framework will also inform the plan.

2.15       Looking ahead to 2026/27, this may shape other Place delivery plans, our SDP, and the refresh of the HWB Strategy. We are also reviewing East Sussex Health and Care Partnership governance to align better with expectations in the 10YHP and the national neighbourhood health programme. This will support delivery of a new neighbourhood health and care model at the same time as taking into account wider system changes, including ICB reforms and the creation of NHS Surrey and Sussex ICB in April 2026.

Updates to Better Care Fund (BCF) metrics

2.16       The East Sussex BCF provides for a range of services that underpin proactive and preventative care to keep people well, avoiding admissions to hospital and long-term residential care where possible, and to improve discharge and overall system flow within the East Sussex health and care system. Our current BCF plan was approved by the HWB at the meeting in July.

2.17       As reported to the HWB in July, when we agreed our BCF plan at the start of the year we decided to keep the 24/25 performance targets at their current levels, with the intention of carrying out further work during the year to set and approve more ambitious local improvement goals. NHS England granted conditional approval for our BCF plan, stating that they expected a more ambitious approach to improving performance, given how East Sussex - and Sussex as a whole - currently benchmarks on avoidable admissions and discharge delays. As part of this, they asked us to review and revise our metric targets for quarters 3 and 4 of this year’s BCF plan.

2.18       The review has now been undertaken. The revised metrics that reflect updated plans and impacts, in support of delivering our broader SDP objectives for avoidable admissions and discharge delays, are set out in Appendix 2 for the HWB to note and endorse.

3             Conclusion and reasons for recommendations

3.1         We are progressing well with our year 3 (25/26) HWB SDP Place delivery plans, including establishing the core leadership infrastructure across East Sussex’s five ICTs and developing frontline multidisciplinary teams for proactive care as the foundation for neighbourhood health in East Sussex. Over time, this will help reduce reliance on more costly services and support a sustainable, neighbourhood-based model of integrated care.  Our updated BCF plan metrics will also support delivery of our broader SDP objectives for reducing avoidable hospital admissions and delays to discharge.

3.2         Added to this, by taking part in the national neighbourhood health programme and continuing our work in 25/26 to strengthen the HWB’s vision and strategic leadership and the role of our East Sussex Health and Care Partnership, we are well-placed to develop a Neighbourhood Health Plan. This plan will support a more joined-up approach to health, care and wellbeing in our communities by better aligning our vision, ambitions and resources for our population.

ASHLEY SCARFF

Director of Joint Commissioning and Integrated Community Teams Development (East Sussex), NHS Sussex

 

MARK STAINTON

Director of Adult Social Care and Health, East Sussex County Council

 

Contact Officer

Email: Vicky.smith@eastsussex.gov.uk

Tel: 07827 841063

 

Appendix 1: Draft progress summary East Sussex HWB high level SDP quarter 2 (25/26)

Appendix 2: BCF Plan excerpt setting out revised BCF metrics