This report provides a summary of the overall Sussex Winter Plan. The plan spans the period from October 2022 to April 2023. The report highlights the Sussex wide and Brighton and Hove specific elements of the plan for assurance for the Health Overview and Scrutiny Committee.

The Sussex 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.

2.0 Background

The Sussex health and care system faces an extremely challenging winter. Locally and nationally, the health and care systems are experiencing significant operational pressure across many of their services. Some patients are experiencing delays in accessing both planned and unplanned healthcare, despite the best efforts of our workforce. There has been no reduction in operational pressures over the summer months and providers are entering winter with significant capacity pressures (availability of workforce and service capacity) for all organisations.

In addition to the current pressures, we face a range of hard to quantify risks such as the potential for further waves of Covid-19, high incidence of flu cases mirroring the Southern Hemisphere, increases in respiratory illnesses and the impact of the cost of living on both our workforce and our patients.

Recognising this risk, on 12 August 2022, in the letter titled ‘Next steps in increasing capacity and operational resilience in urgent and emergency care ahead of winter (B1929_Next-steps-in-increasing-capacity-and-operational-resilience-in-urgent-and-emergency-care-ahead-of-winte.pdf (england.nhs.uk)). NHS England described the actions they expected all systems and providers to take to increase capacity and operational resilience in urgent and emergency care ahead of winter.

Since the receipt of that letter on 12 August there have been two further national communications relating to winter. The Secretary of State for Health’s ‘Plan for patients’, issued on 22 September (Our plan for patients - GOV.UK (www.gov.uk)), and a further communication on 18 October titled ‘Going further on our winter resilience plans’ (NHS England » Going further on our winter resilience plans). Both set out additional measures which systems and providers are expected to implement to improve service delivery this winter.

The NHS Sussex Winter Plan addresses the requirements of the national letters and plans, and has been built bottom up, to respond to the capacity challenges surfaced through the modelling of expected pressure for this winter. In addition to locally agreed actions to address the capacity challenges, we have established rapid improvement workstreams that are being applied across the system, led jointly by NHS Sussex executives and executives from partner organisations. These workstreams are drawing on best practice examples, to ensure people receive the right care from the right organisation at the right time and are supported to return to their normal place of residence at the earliest opportunity.

3.0 Development of the NHS Sussex Winter Plan

NHS Sussex has developed its Winter Plan in conjunction with partners to ensure that we can deliver safe and effective services for Sussex residents throughout the winter. It has been developed taking into account feedback and learning following evaluation of the Winter Plan for 2021/22.

Contributors to the Plan include:

• East Sussex Healthcare NHS Trust (Acute and Community).

• University Hospitals Sussex NHS Foundation Trust (Acute).

• Sussex and Surrey and Sussex Healthcare Trust (Acute).

• Sussex Community NHS Foundation Trust (Community).

• Sussex Partnership NHS Foundation Trust (Mental Health).

• Local Authorities (Adult Social Care, Children’s Services, Public Health) and District Councils.

• South East Coast Ambulance Service NHS Foundation Trust.

• Primary Care.

• The Voluntary Sector.

The plan incorporates the requirements set out within these national communications. There are three key elements to our approach:

· The establishment of a system wide winter operating model.

· The development of our winter operational plan for delivery, incorporating the use of the National Urgent and Emergency Care (UEC) Assurance Framework – a framework developed by NHS England, designed to be a helpful tool to support Integrated Care Boards (ICBs) in managing winter pressures.

· The mobilisation of several targeted rapid improvement workstreams targeting admission avoidance and timely discharge from hospital.

These three elements are described in more detail in the remainder of this paper.

4.0 The Winter Operating Model

Considering the significant operational challenges and associated risks anticipated this winter, it is important that the system’s winter operating model delivers a responsive, well-coordinated, and effective approach to delivery of the winter plan and management of surge pressures. While our Winter plan outlines what it is that we intend to deliver, the Winter Operating Model describes how we will deliver it.

4.1 System Operations Centre

The national ‘Going further on our winter resilience plans’ letter issued on 18 October 2022 (BW2090-going-further-on-our-winter-resilience-plans-letter-october-22.pdf (england.nhs.uk)), sets the requirement for all systems to have in place a System Control Centre from 1 December 2022. NHS Sussex recognised the importance of having a Control/Operations Centre in supporting the management of a safe winter, and so has already instigated the establishment of its System Operations Centre (SOC) in September 2022.

The SOC went live on 3 October. The core team are supported by ‘subject matter experts’ (SMEs) from across NHS Sussex, including finance, nursing, medical, communications, transformation, digital, primary care, workforce, and operations. This team will co-ordinate the system response to any emerging pressures and work to help unlock issues and identify solutions.

4.2 Governance

The Winter Operating Model has a weekly cycle of system wide executive level meetings, supported by the outputs of the SOC, to ensure we have a mechanism for taking executive decisions on critical issues, in a joined-up way across system partners. Along with daily data insights there is a weekly data information pack which facilitates the monitoring and responding to emerging risks and trends.

A weekly Winter Board has been established, chaired by the ICB Chief Executive, and attended by NHS Provider CEO’s, System Executives and Local Authority colleagues. The purpose of the Winter Board is to ensure we take leadership decisions in a joined-up way in response to any issues being escalated by the SOC, or through National or Regional bodies. We recognise that there will be challenging decisions to be taken over the course of this winter and the Winter Board ensures that we have a mechanism to do that in a way that considers the needs of our entire population and the needs of staff working across both health and care.

System Winter Governance and Oversight chart

Figure 1: System Winter Governance and Oversight

5.0 The Winter Operating Delivery Plan

The NHS Sussex winter plan has been developed by building on individual provider and partner plans, and aligning with the areas covered by the NHSE assurance framework across the following core domains:

§ aligning demand and capacity,

§ discharge,

§ improvements in ambulance service performance,

§ improving NHS 111 performance,

§ avoiding admission and alternative ‘in hospital’ pathways to improve flow,

§ preparing for new Covid-19 variants/respiratory challenges,

§ workforce, and

§ communications.

The process for developing the system winter plan was agreed by the three place Sussex Local A&E Delivery Boards and covers all service areas across health and care, including the Voluntary Sector.

5.1 Aligning demand and capacity

The system has undertaken detailed demand and capacity modelling, informed by public health intelligence and seasonal trends, incorporating likely known pressures such as Flu and Covid, to understand the likely pressure on service capacity. Work is ongoing with UK Health Security Agency (UKHSA) to understand the potential health impact of the cost-of-living crisis so that this can also be incorporated into the modelling.

The Plan includes a range of actions being taken to mitigate the capacity risks identified by the modelling and our approach to delivering safe and effective care.

The impact of the agreed winter plan actions will be monitored through the system SOC throughout the winter period to understand whether these actions are delivering the expected impact or whether we need to increase our focus in particular areas where we continue to see pressures build or new issues emerge.

5.2 Discharge

Timely discharge is essential in supporting the right care in the right place. Discharging patients, with the right support, once they have no further need for acute medical is key to the quality of care received and ensuring a good experience for local people. It also supports improvements in flow through the hospital and a reduction in waiting times for patients in the Emergency Department (ED). This helps reduce the time ambulances may need to handover safely to hospital in a timely way and ensure people are admitted to the right wards where they receive care by the specialists they need to see.

The system has committed additional investment to fund discharge to assess pathways, supported by voluntary sector home support provision, and we are working to optimise workforce capacity through technological innovations including the implementation of a virtual care and virtual ward model.

All providers have local plans to address the ‘100 Day Discharge Challenge’, which is a national initiative of 10 key actions to improve flow through hospitals to support timely safe and effective discharges.

A system wide workstream to further improve discharge and system flow, building upon the continual improvement programmes at place, has been established as a key area for rapid improvement focus over the winter period. Detailed process mapping and evaluation of current pathways has been undertaken to inform the programme of improvement work.

While the majority of patients will be discharged back to their own home with no further care requirements, a number of patients will need additional support from community services or social care. Consequently, the work described above is a multi-agency approach involving all health, social care and voluntary sector organisations who play a role in supporting patients to be discharged from our acute, community or mental health beds.

5.3 Improvements in ambulance service performance

Improvements in ambulance service performance are a key area of focus for this winter, with a particular focus on reducing handover delays and improving ambulance response times.

In respect of reducing handover delays, a clear system escalation framework is in place, which identifies actions for acute providers to take – if there are handover delays at the hospitals. In addition, the Sussex Winter Board has committed to significantly reduce long ambulance delays and the system escalation framework has been amended to reflect this as a key metric.

In respect of improving response times, South East Coast Ambulance Service (SECAmb) have fully implemented their 2018-23 fleet strategy and fleet requirements, in line with their current delivery model. St Johns Ambulance (Ambulance auxiliary service) are in place to support SECAmb and a Care Home line supporting direct access to NHS111CAS to reduce avoidable conveyances.

Within our system plan rapid improvement workstreams there are areas of focused work to improve the response of urgent community services, including the falls response service to reduce the number of category 3 and 4 conveyances, which will in turn improve ambulance response times.

5.4 Improving NHS 111 performance

To support the improvement in NHS 111 performance, additional investment has been made to enable SECAmb to recruit an additional 111 whole-time-equivalent call handlers, which should enable the service to ensure that 95% of calls are answered in 60 seconds and to reduce call abandonment rate to <5%. Recruitment plans are in place and progress is being regularly monitored.

Action is also being taken to improve NHS 111 in respect of Mental Health (MH) crisis response, ensuring that 24/7 MH Crisis lines are in place and integrated with NHS111. SECAmb have seven embedded MH professionals across their footprint, working in their Emergency Operations Centres (EOC) and Clinical Advisory Service (CAS), providing specialist advice and support for people with mental health concerns who access services via both 111 and 999 routes.

5.5 Avoiding admission and alternative ‘in hospital’ pathways to improve flow

Action to avoid unnecessary admission and alternative’ in hospital’ pathways to improve patient experience, ensure the right service is available to best support people, and to improve flow, is a key component of the NHS Sussex Winter Plan, with rapid improvement workstreams mobilised to focus on out of hospital urgent care and the establishment of a consistent single point of access to urgent community response services across the whole county being implemented ahead of winter. In addition, there is a focus on strengthening existing community falls response to reduce pressure on the ambulance service where no acute medical support is required, and additional action is being taken to provide preventative personalised care to individuals at high risk of hospital admissions. Further examples of admission avoidance actions include:

· Expansion of Acute Same Day Emergency Care (SDEC) pathways in acute and community services including links to acute multi-disciplinary assessment teams in emergency departments.

· A system wide clinical model for ‘virtual ward’ (VW) care has been agreed for patients with frailty, respiratory and heart failure conditions. There are currently 54 virtual ward beds available across Sussex and this will increase to 125 by January.

· Urgent Community Response (UCR) to deliver streamlined admissions avoidance pathways to help support people in their usual place of residence.

· Consultant access for advice and guidance to health care professionals in Community and Primary Care services to support decision making and avoid unnecessary referrals to secondary care.

· Self-management advice materials for patients.

· Long Covid services and treatment services for those particularly vulnerable to Covid are in place including supply of oximeters for at risk patients in primary care.

5.6 Infection Prevention and Control

Given the challenges identified for this winter it is critically important that we maintain the highest standards of infection prevention control across our system, and the following core prevention and control measures are in place:

· Provision of Infection Prevention Control (IPC) teams across acute and community settings.

· Daily Covid-19 monitoring.

· Established infection prevention governance monitoring and reporting.

· Specialist infection prevention support across Sussex to provide outbreak management across health and social care providers.

Additional controls being implemented across Winter 2022/23 include:

· Development of an updated Seasonal Infection Prevention Surge Plan.

· System infection prevention cell meeting weekly.

· NHS support to social care providers via local authority Public Health teams.

· Provision of additional specialist training for new infection risks identified.

· Provision of specialist FFP3 mask FIT testing to ensure compliance with National requirements.

· Mutual aid support across IPC teams such as personal protective equipment (PPE).

· Updated Respiratory Syncytial Virus (RSV) and Paediatric Surge Plan for managing increased activity in paediatrics caused by seasonal RSV.

5.7 Seasonal vaccination programme:

Ensuring that we maximise the update of both the flu and Covid-19 vaccination in eligible members of the population and our workforce ahead of winter is a key priority, ensuring that we continue to work with system partners and local communities to improve uptake in parts of our community where there is lower uptake identified.

As of 8^th November 2022 53.4% (B&H 41.9%) of the eligible Sussex population have taken up an offer of the Covid-19 autumn booster vaccination with 94.3% (B&H 90.4%) of care home residents and residential workers, and 79.5% (B&H 77%) of over 80s, having taken up the offer.

To support vaccine uptake across Brighton & Hove, we are working with system partners on:

· Focused communication and engagement following the eligibility for 50+ age group including a media release, social media, and newsletter content.

· Developing the programme’s communication and engagement plan for autumn, which has been circulated to appropriate stakeholders.

· Key area of focus continues to be ensuring clear public information about the programme, current eligible cohorts, and delivery models – who, what, how, where.

· Developing areas of focus for hyper local activity to ensure equity of uptake. A specific approach has been taken for groups, which have seen lower uptake to date across the programme, including translated materials, work with trusted intermediaries, work through VCSE partners, and identifying community leaders to share information and gain support.

· An insight summary is being produced to have a clear understanding across the programme and at Place (e.g. Brighton and Hove) of the insight we have on barriers, challenges and hesitancy, and operational and communication solutions needed. A survey closed on 25 September to understand current attitudes towards the vaccination programme.

As of 30 October 38% (B&H 20.2%) of the eligible population have taken up the offer of a flu vaccination with 64.4% (45.7%) of all 65 and over having been vaccinated. Practices and providers continue to plan and host flu clinics at practice sites. Flu vaccinations are widely available for eligible patients at community pharmacists, local vaccination centres, and practices. Plans for Mobile Vaccination Units in each area are underway to provide additional capacity for the delivery of both Covid-19 and Flu vaccination in areas showing low uptake.

5.8 Workforce

Workforce capacity over winter is an identified risk within our system plan. Therefore, whilst we have been able to increase our workforce number, it is important that we continue with recruitment and retention activity, including overseas recruitment, and ensure that processes are in place to support the health and well-being of our workforce during the winter period and beyond.

The following measures are in place to ensure that optimum workforce levels are in place.

· Robust safe staffing escalation processes in place within each provider.

· System wide mutual aid systems and processes in place to enable the sharing of workforce across providers to maintain safe staffing levels and service provision.

· Sharing of pay rates across the system.

· Assessment of staffing levels daily, and implementation of local response actions to meet shortfalls in capacity.

· New roles and ways of working are being explored, for example the virtual ward programme.

· As a system we are a vanguard nationally in a violence reduction and prevention programme to keep colleagues safe in the workplace

· Our workforce vaccination programme commenced in September to support protection of colleagues from contracting flu and covid infection in support or sickness absence position.

5.9 Communications

To support the NHS Sussex Winter Plan, a Sussex communications and engagement approach has been agreed by all system partners. This aims to provide clear information about services and how people can access the health and care they need, influence behaviour change, maintain public trust and confidence and gain insight to support further operational solutions and responses.

The overarching approach follows the national ‘Help Us Help You’ campaign, and is structured over four key focus action areas:

1) Behaviour change campaigns – We will run a series of campaigns under the ‘Help Us Help You’ banner to signpost to services to encourage greater understanding and usage

2) Public Engagement – We will carry out targeted engagement with identified communities and groups to gain a greater understanding of their barriers/motivations to support operational interventions and delivery

3) Workforce – We will focus on specific communications and engagement with our workforce to support morale and wellbeing

4) Public confidence – We will develop a series of communications that outlines progress and issues in a honest and open way to help maintain public confidence

For each there is a focused action plan to share clear and effective communications with the public, stakeholders and patients. Materials and resources will be shared with all health and care partners, and wider VCSE and community partners to ensure wider sharing to the public and our communities.

Effective communication both with our citizens and our staff is key to ensuring that we can deliver high quality services and treat patients in the most appropriate service and setting for their needs.

5.10 Planned Care Recovery Programme

As a system, our priority is to ensure that the recovery of elective and cancer care services continues, by securing capacity across Sussex which will not be impacted by emergency admissions. This will include using mutual aid between NHS providers, use of the independent sector where necessary, and the further development of Community Diagnostic Hubs. This will help us to continue with our 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.

5.11 Mental Health

Mental health services have seen a rapid increase in need, which has placed considerable pressure on the services that are available. Children and Adolescent Mental Health Services have seen particularly significant rises in need as a consequence of the pandemic.

One of the main objectives of the mental health winter plan is to reduce the number of patients having to receive inpatient support outside of the county, recognising the challenges that this creates both for the patient and their families. The plan aims to do this by:

5.11.1 Reducing the need for admission to hospital by:

· Creating 2 new Mental Health Havens (Worthing and Crawley).

· Creating a new Mental health clinical decision unit at Worthing.

· Developing plans for a Mental Health emergency cohort facility at the Royal Sussex County Hospital.

5.11.2 Supporting better clinical decisions at the point of admission.

5.11.3 Reducing length of stay (LoS)

· Creating an Assessment / Triage Ward.

· Developing a clinically led complex case review processes.

· Tackling unwarranted variation in length of stay.

5.11.4 Reducing delays in discharging patients by:

· Maximising the use of Discharge to Assess model in Brighton & Hove.

· Review of the SPFT approach to bed management and patient flow from admission to discharge.

· Expanding the West Sussex Discharge Hub model to Brighton & Hove.

· Engaging staff in the new ‘Let's Get You Home’ Policy.

6.0 Enhanced Work Streams (Rapid Improvement Pathways)

The third component of the system winter plan relates to five rapid improvement pathways, which have been agreed by the senior leadership of the Sussex Health & Care system including local authority colleagues, which are summarised below:

6.1 Out of hospital urgent care

The focus of the out of hospital workstream is to improve ambulance response times

Objectives:

· To improve access to and utilisation of community pathways including a consistent single point of access.

· Develop clear standardised referral and handover pathways into consistent admissions avoidance and other community pathways, to increase direct referrals, and reduce conveyances where appropriate.

· Identify alternative pathways to safely convey suitable patients to destinations other than ED.

6.2 Frailty pathways

The focus of the Frailty workstream is to ensure we have clear and effective frailty pathways, including falls services in place, Sussex-wide with a focus on enhanced admission avoidance through early support and intervention in the community, in care homes and in Emergency Departments.

Objectives:

· To improve access to, and utilisation of community pathways to keep patients closer to home.

· Establish core clinical principles of frailty pathway for Sussex.

· Deliver agreed targeted actions across the Frailty Pathway.

6.3 Discharge

The focus of the Discharge workstream is to ensure full implementation of each Place’s discharge plan aligned to the Sussex agreed model, delivering the 100-day discharge challenge.

Objectives:

· To evaluate and optimise the current agreed discharge model.

· To agree and establish a set of system metrics across the end-to-end pathway.

· To agree and identify the high impact areas of focus, which will deliver improvements to ensure patients who are ‘medically ready for discharge’ can be safely discharge in a timely way.

6.4 High Risk Cohorts

The focus of the High Risk cohorts workstream is to identify and support people who maybe at high risk of hospital admission over winter, for example people with long term conditions.

Objectives:

· To offer proactive, personalised care for individuals at high risk of hospital admissions.

· Maximise support through social prescribing link workers, health and wellbeing coaches, and care coordinators.

· Improve symptom and condition self-management.

· Increase access to a broader range of support options in their communities.

6.5 Mental Health crisis resolution

The focus of the mental health workstream is to reduce the number of patients, adults, children, and younger people who are receiving their acute inpatient psychiatric care outside of Sussex

Objectives:

· Reduce number of inappropriate out of area placements (acute psychiatric care).

· Reduce length of stay within acute adults and older adults’ inpatient units.

· Reduce number of patients who are identified as medically ready for discharge and not yet able to be discharged.

7.0 Local Plans – Brighton and Hove

All the Sussex wide elements of the NHS Sussex Winter Plan apply to all parts of Sussex. The section below provides details that are additional actions Brighton and Hove are taking.

7.1 Local Plans – Brighton & Hove

Partners across health and social care have collaborated to develop detailed place-based plans to address the current and expected challenges in demand across the winter months.

The general principles that have been agreed across Brighton & Hove will help to support resilience across all partners to secure delivery of, and access to, health and care services.

The primary aims are to ensure patients have the right support at the right time, and in the right place to maximise reablement and minimise the risk of harm. The system is working together to redirect as many patients as possible away from Emergency Departments by increasing alternative options such as Urgent Treatment Centres and Urgent Community Response. The system will do all it can to support the timely discharge of patients and reduce the number of patients that are currently in acute and community beds, who are medically ready to be discharged.

Local system oversight arrangements are in place across the Brighton & Hove health and care system partners with senior operational touchpoint calls increased to daily (from twice weekly) during winter to help support the delivery of urgent and emergency care and discharge objectives. There is also weekly joint Executive oversight through the Operational Command Group (OCG), to solve any escalated issues or make timely decisions on new proposals so that we can remain responsive and flexible throughout the winter.

7.2 Acute Hospital Urgent Care Services

The main acute emergency department used by the city’s population is at the University Hospitals Sussex Royal Sussex County Hospital (RSCH) site. The RSCH also provides services for East and West Sussex populations, with up to 60% of patients coming from outside of the Brighton and Hove area.

The emergency department at the RSCH has seen a significant drop in performance through the Covid pandemic. An increasing number of patients are choosing emergency departments as their first port of call with medical conditions that could often be treated in a different urgent care setting. As such, work is ongoing to improve flow to the co-located and stand-alone Urgent Treatment Centres to maximise the number of patients that can be seen there. In addition, there is close work with a remote GP provider, offering on the day appointments daily, accessible through the Urgent Treatment Centres, therefore freeing up more time for the Emergency medics to treat the seriously unwell.

The challenge to maintaining performance is also associated with an increased number of people who are ready to be discharged but are delayed, which reduces the ability to admit patients through the emergency department. The RSCH Emergency Department is small and often congested with challenges admitting patients into hospital beds. This also results in long waits for patients before they are transferred to the wards. The department and patients will benefit from the opening of the 3Ts development that will improve capacity, and the configuration within the hospital will help support the timely transfer of care from the ambulance service to the hospital. Ambulance handover escalation triggers and actions have been agreed to provide a mechanism that all partners can react to provide support during times of challenged handovers.

University Hospitals Sussex has an Urgent and Emergency Care Improvement Programme which focusses on improving flow through the organisation to support the decongestion of the emergency departments. Escalation areas are open to increase the amount of bedded capacity to admit into, with further capacity to come online in the peak of winter. Working in partnership with key system colleagues, the introduction of an ‘Admission Prevention Team’ within the acute front door will also support this. Staffed by therapists and social care, this team can offer more appropriate alternatives and support to patients whose needs are not best resolved through the Emergency Department.

The system in Brighton & Hove is therefore working together to support as many patients as possible to be treated away from an Emergency Department and on our collective discharge arrangements. This will allow the Emergency Department to focus on treating those that are most unwell or injured and support local people in the right way for them.

7.3 Admission Avoidance

The Sussex wide enhanced work stream is developing an enhanced admission avoidance access point. The enhanced workstream is also developing the frailty response that will help support patients to remain in their own home rather than being treated in an Emergency Department. This will build on and enhance existing Urgent Community Response Services (UCR) provided by Sussex Community NHS Foundation Trust (SCFT). The UCR services are developing improved access and responsiveness to non-injurious falls, including supporting call outs to Care Homes to support them with assessing residents who have fallen but have not sustained any obvious injury. The UCR teams are working closely with the Ambulance Trust and its crews to increase awareness of the service offer and enable direct clinician to clinician decision making to support referrals into community as an alternative to conveyance.

An enhanced offering in the Urgent Treatment Centres (UTCs) will help direct patients away from the main Emergency Department if their condition is better suited to treatment there. The Admission Prevention Team and Care Navigators will focus on ensuring that patients whose needs can be best met through Primary Care will be streamed through to primary care, and any available capacity in the UTC is to be directed toward supporting ‘walk in’ attenders to the Emergency Department. In addition, the onsite GP’s hold bookable appointments in the UTC which means that patients, where it is safe and appropriate to do so, can be given a set appointment for later in the day – allowing them to leave the ED and return for a face-to-face appointment, avoiding a wait.

LIVI is a remote GP service which has been commissioned to provide remote consultations to 111 patients to prevent them having to attend face-to-face appointments. LIVI have successfully completed 70-80% of these consultation through remote consultation, saving the patient having to attend in person, and freeing up this valuable resource to be directed to those with more urgent needs. The RSCH will also support those patients who are ‘walk in’ and can be best supported via Livi, to return home with a pre-arranged phone appointment with one of their GP’s.

There is a nurse led ‘walk in centre’ model in the centre of Brighton (by the station), which is open 7 days and work is underway to ensure that patients with minor injuries, where appropriate, know that this facility is running and how its accessed.

Same Day Emergency Care access will be expanded with mechanisms for direct referral from SECAmb crews developed. A set of clinical condition criteria is being developed with each acute medical service to allow SECAmb to directly convey patients with predefined medical conditions. These are patients who would benefit from the experience of an acute medical consultant, but who otherwise would have had to go through ED and potentially have led to an unneeded overnight stay. This will by-pass ED and take the patient to the right clinician the first time with the goal to treat the patient and discharge within the same day, thus avoiding an overnight stay, whilst also freeing up more capacity within ED.

Finally, working closely with the British Red Cross, Brighton and Hove has expanded its ‘High Intensity User’ service. This is a specialist team that works with patients who frequently attend the Emergency Department, to support them and their family, carers, and Primary Care to reduce the number of times they need to come in.

7.4 Discharge

In Brighton & Hove there are well established discharge pathways for people who are able to go straight home with no or very little further health or social care support; for people who can go home with some immediate health and social care assessment through “Home First” service before being referred onto core community services; and for people who first need a period of rehabilitation in a bedded setting or who may need to go into longer term residential or nursing care. Brighton and Hove launched a new Discharge Transformation Programme in the summer, which will support better ways of working over the coming 18 months and 2 years. As a system, this is a key tool to the ongoing development and reviewing all these pathways.

Brighton & Hove commission services with the Voluntary Sector who play an essential role in the local health and care system. These are being strengthened further over the winter and provide support to patients who may need a little bit of extra help to get home (but don’t need formal support), or to avoid coming into hospital. These include the Ageing Well service, linking people into a range of community-based groups and classes, the British Red Cross ‘Take Home and Settle Service’ – which also extends to the Emergency Department and work with Possibility People, Age UK, and Impact Initiatives who all work in a flexible way to allow people to go home and stay independent at home – whilst linking them into community networks.

Brighton & Hove will continue to prioritise Home First as a preferred discharge pathway, aligning to the strategic principle to allow patients to return to their own homes following an acute hospital stay, wherever safe and practical, with funding going into the service for both clinical and domiciliary care capacity. A full pathway review of Home First is underway with health and social care colleagues to identify areas of process improvement to help increase efficiency.

In addition to Home First, there is also a requirement for rehabilitation beds to allow patients to be discharged from an acute bed to continue their rehabilitation journey in a community bed. There will be a review of the criteria for these rehabilitation beds to make best use of capacity and ensure that all patients who could benefit from a period of rehabilitation in a bedded environment are considered. This is working closely with a review of the way that therapeutic interventions are delivered to patients. Brighton and Hove are leading this review and will increase the capacity of Occupational and Physio therapists to target interventions to get people back on their feet faster and reach their goals- allowing them to go home sooner and stay at home longer.

Over winter a new process has been developed whereby the existing discharge hubs will escalate any patient that needs a senior level review to support timelier discharge. The discharge hubs will meet twice daily to highlight the current patient lists for discharge. In addition, there will be regular senior meetings to consider those patients who have been waiting the longest for their next steps, to consider other opportunities for them. Senior operational group meetings will review and monitor this to ensure maximum efficiency.

7.5 Primary Care Winter Planning

The approach to this winter has been influenced by patient feedback highlighted, and the experience of last winter. A £1.5m winter fund has been made available to those areas with the highest health inequalities to ensure better access to primary care. The key areas of focus will be to increase capacity; maximise its effectiveness; and improve communication between providers and with patients as set out below:

7.5.1 Increasing capacity

Appointment data is published by NHS Digital, and though still experimental and non-standardised, it gives NHS Sussex an indication of performance against this trajectory utilising a consistent methodology. What is clear is the number of appointments now exceed those offered in 2019, before the pandemic, as illustrated in table one

Brighton & Hove Total GP Appointments chart by year

Source. NHS Digital, available at https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/august-2022

Figure 2: total number of GP appointments in Brighton by year

We will use the 1.5m winter fund to deliver an additional 86,000 appointments across Sussex. This has been offered to those PCNS facing the highest inequalities in Sussex, including all six in Brighton, who will receive c.£3.27 per head of weighted population to increase capacity.

Increased roll out of the Community Pharmacy Consultation Service (CPCS) will enable GP practices to book patients with a minor illness for a same day consultation with their local pharmacy where appropriate.

We will support PCNs to recruit additional staff, including new GP Assistant, and digital and transformation roles, to ensure patients see the right clinician at the right time, rather than every patient having to go through the GP for a referral to them.

7.5.2 Optimising capacity

Same day data from GP practices will be automatically extracted to highlight where there are pressures in the system and offer support as soon as possible to ensure they can continue to meet patients need.

Improved Business Intelligence Systems will be commissioned for practices so they can identify those patients most at need and plan their appointments and workforce rotas accordingly.

Recognising the problems patients had contacting their practice (that was reported in the patient satisfaction survey), all practices will be supported to purchase advanced cloud telephony systems which will improve the patient experience, ensuring patients are informed on progress throughout the call and linked with the right healthcare professional.

7.5.3 Improve links / communications across the primary care system

The new Integrated Care System will encourage PCNs to integrate more fully with Community/Mental Health providers, Local Pharmacies, Adult Social Care, and the voluntary sector.

NHS Sussex will continue to work with Brighton Healthwatch, patients, and practices to codesign website ‘good practice’ templates and offer funding to those practices whose websites have been identified as being the most 'in need of improvement’, based on self-selection, Healthwatch ‘Mystery Shopper’ surveys, and a review by the Digital First team.

Digitally Excluded Groups will be supported to learn how to better use digital health technologies, but promoting use of the NHS App, online consultations and NHS 111 Online where digital exclusion is a recognised issue.

7.6 Public Health

The Brighton & Hove winter plan includes ongoing joint work with Public Health. This includes the work of the Brighton & Hove vaccination cell to maximise vaccine uptake among target groups such as those living in deprivation, minority groups, homeless people and migrant workers. They are also maximising uptake of shingles and pneumococcal vaccines in eligible older adults. Public Health protection team and the ICB infection control teams also work closely together to prove support to the Brighton & Hove care provider market with infection prevention control support.

8.0 Summary

There has been significant engagement from all system partners to develop a robust winter plan for the system, support local people to have access to the right services to support their need, and to put in place the mechanisms necessary to support delivery and respond in an agile way to pressures experienced across our services. Consequently, we are well placed both to deliver on the requirements set out in the national letters and plans issued in recent months, and to manage winter as effectively as possible with the resources available to us.

The plans set out the mechanisms through which we will remain sighted on the key issues, respond in an agile way topressures and ensure that system leadership remains aligned on the key actions that we take.