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1 Table of Contents
NHS Sussex Winter Plan: Update
2.1. Discharge, including rapid improvement workstream actions
2.2. Out of hospital urgent care rapid improvement programme
2.3. Improvements in ambulance performance
2.4 Improvements in 111 performance
2.5 Acute Hospital Urgent Care Services
2.6 Acute Hospital Emergency Care Services
2.6.1 Length of stay in the Emergency Departments
2.7.2 Examples of other pathways
2.9 St Johns Ambulance service to the homeless
2.10 Infection Prevention and Control
2.14 Planned Care Recovery Programme
2.15 Public Health – Brighton and Hove
3.0 Learning from the Winter Plan and Actions Taken
3.1 Winter Plan Review and Feedback
NHS Sussex Winter Plan: Update
This report provides an update on the Winter presentation done at HOSC (23 November 2022), and evaluation of, the impact of the NHS Sussex Winter Plan. It identifies learning to be taken forward to further enhance planning for Winter 2023/24.
It includes:
· Performance and recovery of Urgent and Emergency Services
· Workforce pressures and staff wellbeing
· An overview of Urgent and Emergency system performance
· An outline of key performance measures for the system:
§ Emergency Department waiting times. Proportion of patients >12 hours from arrival
§ Number of admissions for Covid-19 and seasonal flu
§ Ambulance handover times
As previously reported, the delivery of the Sussex Winter Plan was overseen by a weekly Winter Board, chaired by the NHS Sussex Chief Executive, and attended by NHS Provider Chief Executive Officers, System Executives and Local Authority Directors of Social Care. They ensured that strategic leadership decisions required in response to emerging issues or risks through the Winter were taken in a joined-up way and considered the needs of our population and the needs of staff working across both health and care.
The Sussex Winter Plan was informed by detailed capacity and demand modelling with evidence-based assumptions related to seasonal urgent and emergency demand trends, the forecast impact of further Covid-19 waves, and seasonal flu related demand.
2.1. Discharge, including rapid improvement workstream actions
As previously reported most patients in Brighton and Hove continue to be discharged home from hospital without the need of further support. However, for the small proportion of patients who might need social care, rehabilitation services or longer term residential or nursing care to support their discharge, the health and care system has collaborated to develop and implement full plans to support people over the winter period. This has included additional health, social care and voluntary sector capacity[1] to support people to return home; additional bedded capacity for people who are ready for discharge and need further assessment for their longer-term care needs; a range of measures aimed at improving the workforce capacity in the care market; and additional support for carers. Enhanced work with the councils is also supporting discharge pathways for more vulnerable and complex patients who are homeless or have housing difficulties.
Additional capacity for Winter
Within the context of this wide range of additional capacity and support in Brighton and Hove this winter, there was a sustained reduction in the numbers of patients who are assessed as medically ready for discharge and are waiting to be discharged.
Additional homecare hours (over 300 a week) and additional beds (over 30 new step-down beds) were secured for the winter and into spring, drawing on additional national funding. Specialist beds e.g. Homeless step down for patients with additional complexities were commissioned to support flow, and a pilot project to increase the in-reach therapy available across all our beds to get people fitter, quicker, was rolled out. A weekend discharge team was mobilised alongside key additional workforce to identify patients more rapidly for intermediate care services earlier in their pathway, which directly led to improvements in rates of weekend discharges. We increased the presence of health and social care at the front door of our acute hospital, supporting patients with what they needed to get them home and to prevent the need to be admitted. Other schemes including increasing utilisation of Voluntary Sector capacity to support discharge alongside Personal Health Grants were mobilised to improve system flow, patient support, and experience. Social Care Colleagues increased their ability to provide CareLink and other technology enabled services, keeping people safer at home. The ‘High Intensity User Service’ was expended, identifying, and then supporting patients who present very frequently at ED, often for reasons outside of an acute medical crisis.
2.2. Out of hospital urgent care rapid improvement programme
The focus of the out of
hospital urgent care workstream was to improve ambulance response
times by improving join up and input from alternative services to
best support our patients.
As previously reported a key development has been the Admissions Avoidance Single Point of Access (AASPA). This went live on 14 December 2022. It provides a single 24/7 telephone number for South East Coast Ambulance Service (SECAmb) for professionals. It is a clinically led service where SECAmb crews are able to discuss a patient’s condition, determine the right service for the patient and once clinically referred, have the confidence to leave the patient safely at home where clinically appropriate to do so, allowing the crew to get back on the road. It connects crews into alternative services such as Urgent Community Response services and reduces the number of patients being conveyed to hospital.
The ambition is to expand this service to become the single access point for all admissions avoidance contacts from health care professionals, including GPs, across Sussex. This means that for some people for whom other services can best meet their needs, they do not need to be taken to hospital for assessment or admission.
The continued development of the AASPA is a recognised priority in the NHS Sussex 2023/24 Shared Delivery Plan (SDP) and will be taken forward as a priority workstream within the NHS Sussex Urgent and Emergency Care Delivery Programme.
2.3. Improvements in ambulance performance
Overall, there has been continued high demand and the ambulance service has not consistently been able to meet its national response time targets.
Developments such as the rollout of the pan-Sussex Admissions Avoidance Single Point of Access, the funding of additional SECAmb resource to embed change and close working between SECAmb and community teams have been positive, and we expect to see performance improvements as the utilisation of alternative community pathways to reduce avoidable dispatch and conveyance increases. Sussex ICB has recently taken over as lead commissioner of the service from Surrey Heartlands ICB and will oversee the implementation of CQC actions which will contribute further to service improvement.
Ambulance handover delays continue to be an area of key focus across our system and the acute hospital sites have worked closely with SECAmb on improvement plans to ensure no delays.
Royal Sussex County Hospital Ambulance
2.4 Improvements in 111 performance
Following significant pressure and increases in call volumes experienced nationally, which saw call abandonment rates approach 50% in December, activity has now reduced to closer to seasonal norms and the abandonment rate has been reduced to between 15.44% and 18.65% between January to March. Clinical contact rates within the Clinical Assessment Service have exceeded 50% ensuring that patients can talk to a clinician when they need to. Where call handlers reach an initial disposition of either Emergency Department (ED) or for ambulance dispatch, clinicians continue to validate these calls to ensure either an Emergency Department or ambulance are appropriate with over 45% of people able to be directed to a more appropriate service for them.
Recruitment and training are ongoing to achieve the target establishment for call handlers and deliver the required improvements to move towards achieving 95% of calls being answered in 60 seconds and to reduce call abandonment rate to <5%. Trajectories for attainment are being agreed through contract management mechanisms. In the interim, additional capacity has been secured from VOCARE, a national provider of urgent and out of hours services commissioned by NHS England, as a temporary arrangement which has been in place from December 2022, whilst recruitment is ongoing and to meet the immediate need.
We continue to ensure improvement actions and targets are robustly overseen through agreed contractual and governance mechanisms.
2.5 Acute Hospital Urgent Care Services
As previously reported our plans to improve flow to our co-located and stand-alone Brighton Walk in Centre and the Urgent Treatment Centres (UTCs) have included increased face to face GP appointments and additional clinical workforce at Lewes Urgent Treatment Centre. These measures further improve the capacity of these services available to local people, therefore freeing up more time for the emergency medics to treat the seriously unwell.
Our local hospitals have continued to operate flexibly to support flow through their organisations by responding to varying levels of demand through opening additional escalation areas to increase the amount of bedded capacity available, ensuring access and support is available for the population of Brighton and Hove.
2.6 Acute Hospital Emergency Care Services
The winter pressures on Emergency Departments were considerable. Services to support admission avoidance, redirection away from Hospital and alternatives to hospital were fully utilised.
The performance of the system was measured by 4 clinical triggers:
1. Number of ambulance handover delays >60 minutes
2. Number of patients in the Emergency Department >12 hours
3. Number of patients receiving care in Emergency Department (ED) corridors
4. Number of super surge beds open (non-bedded areas used for inpatients)
The above metrics and associated triggers were used in addition to the existing system agreed Operational Pressures Escalation Levels Framework (OPEL).
Brighton and Hove A&E Delivery Board areas will operate Operational Pressures Escalation Level (OPEL) 1 when operating within normal parameters. At OPEL 1 and 2, we would anticipate operations and escalation to be delegated to the relevant named individuals in each organisation across the A&E Delivery Board. At OPEL 3 and 4 however, it is expected that there will be executive level involvement across the A&E Delivery Board.
The above metrics were and continue to be the principal measure of escalation and pressure levels across the system.
The framework was developed to identify site and acute hospital based escalation triggers for each of the 4 key acute metrics. The triggers were calibrated in a consistent way across all acute sites using historic activity data and are aligned to the variation in normal A&E demand observed at each site.
The response to these triggers is defined within action cards that have been developed for each organisation which describe the actions required to support de-escalation.
2.6.1 Length of stay in the Emergency Departments
The length of stay for patients within the Emergency Departments was impacted by a number of factors such as Covid-19, Influenza and Industrial Action. The performance is reflected in the graphs below. The impact has reduced since its peak in December 2022.
The Royal Sussex County Hospital saw high numbers of patients waiting >12 hours in the Emergency Department from the time a decision to admit them to hospital was made. The reason for the delays within the Emergency Department is multifactorial:
· Insufficient capacity across the hospital to support the current level of demand the hospital has been seeing.
· A reduction in the number of patients medically fit for discharge in acute hospital beds as result of the increased capacity. Key challenges to timely discharges were complexity, COVID and challenges in the care market.
The Princess Royal Hospital saw a small number exceeding 12 hours.
Hospital occupancy across Sussex continues to be high. Whilst there was a slight decrease in January and February 2023, March 2023 saw a slight incline.
Virtual wards provide an alternative for patients, who would otherwise be in hospital, to receive the acute care, monitoring, and treatment they need at the place they call home (including care homes) safely and conveniently. The model was successfully launched in Sussex in December 2022 and maximum capacity achieved has been 112 against 107 plan in April. Up to 25 May 2023 3585 patients have benefited from the new service in in Sussex, Supporting admission avoidance and timely discharge. The service offer in B&H includes Respiratory, Hospital at home, Community Respiratory and Frailty going live by March 24, with a minimum capacity of 35. In addition to adult Virtual Wards services, As of May 2023 Sussex Virtual Wards started to capture Childrens and Young Peoples capacity provided by Acorns at UHSx. By March 2024, the total Sussex capacity will be 146.
There continues to be very positive patient feedback on this service and further case studies will promote the use of the service this year.
2.7.2 Examples of other pathways
As previously reported, our Urgent Treatment Centres and Minor Injury Units (MIUs) continue to support patients where their condition is best suited to these settings. Our remote GP service, LIVI, has enabled patients to be reviewed and treated remotely where appropriate, therefore freeing up capacity for those with more urgent of complex needs to be seen by our Emergency Departments. Our Same Day Emergency Care (SDEC) services have also been enhanced through improved pathways between SECAmb and clinical services, removing the need to go via the Emergency Department; these services have also increased their medical workforce capacity to support demand for their services over the winter period.
Our work with our council and local voluntary and community sector continues to enable support to people who are homeless or have housing difficulties and those who may need help with more complex needs and people who need help with welfare benefits advice. Our Safe Spaces in Brighton City centre continued to operate on Saturday nights to support and advise vulnerable people as part of the night-time economy who may otherwise require support from an Emergency Department.
At times of pressure and peak demand we increased the capacity at Urgent Treatment Centre. This included GP cover at the Royal Alexander Childrens Hospital in response to Strep A
Additional winter funds were made available, weighted for areas of high deprivation, to increase capacity during the winter months. In total, about £800k was made available initially to bring in additional clinicians, offer specialist clinics, and generally increase access to GP services across Sussex. This has resulted in approximately 39,000 additional appointments.
Respiratory Hubs were set up to meet the additional demand caused by paediatric Streptococcus A (Strep A). In December, an unusually high number of patients were attending practices, UTC and A&E with Strep A and Scarlet Fever symptoms. 5 hubs, 9 spokes and 3 remote services were launched from early January 23 – April 23 for GP Practices, 111 and UTCs to divert patients for same day appointments, to ease pressure on the system. The hubs were spread across Sussex and saw a total of 12,000 patients. Additional capacity was also provided at UTC’s during busy periods.
The hub Brighton was at the Walk-in Centre by Brighton Station, with additional remote capacity covering the rest of the city. This offered 2022 Face to Face and 3162 virtual additional appointments between December 2022 and March 2023. These winter initiatives have now been independently evaluated by the Kent Surrey Academic Science Network, and draft findings confirm that they were welcomed by staff and patients demonstrated value for money. The full report will be available in July 2023 and will directly inform planning for winter 2023-2024.
Other schemes include a ‘High Intensity User Service’ -identifying and then supporting patients who present very frequently at ED – often for reasons outside of an acute medical crisis. In the first year of the service, in patients being support have experienced:
· 58% reduction in ED attendances
· 81% reduction in ambulance conveyances
· 31% reduction in non-elective admissions
· Service users reported improvements across multiple domains (happiness, loneliness and health interfering with social activities improved the most)
On 9 May 2023 NHS England and the Department of Health and Social Care issued their “Plan for Recovering Access to Primary Care” (PCRP). The plan builds on the Fuller Stocktake report and forms part of the Government’s commitment to improve access to general practice outlined in its Autumn statement. The PCRP focusses specifically on the aspects of the Fuller Stocktake report that concern “tackling the 8am rush”, with the stated aim of “reducing the pressure on General Practice” to allow it to stabilise and thus engage with the broader transformation agenda around themes such as Integrated Community Teams, as well as ensuring short- and medium-term improvements in patient experience and satisfaction. Its publication is timely given the ambitious programme of change set out in the Integrated community System Shared Delivery Plan (SDP). The ask for all systems is to produce a “System Level Access Recovery Plan” which will define our short medium and long term activities to improve the patient experience of accessing primary care, and will be presented to the NHS Sussex Board in Autumn 2023, with a further update to be provided in February/March 2024.
2.9 St Johns Ambulance service to the homeless
Targeted Podiatry and Wound care Support through a roving clinic with inclusion of social prescribing has supported a reduction in hospital admissions and attendance to A&E. Static and roving clinics in locations that meet the needs of the service users providing specialist wound care and specialist Podiatry care were in place all over winter. The service also provides holistic support: sign posting and advocacy, first aid, a safe space, flu vaccinations, sexual health advice and pregnancy testing, smoking cessation.
Opening hours:
Monday and Tuesdays 14.00—20.00 pm
Alternate Fridays 14.00—20.00 pm
Alternate Saturdays 09.00- 15.30 pm
The plans for mental health services over winter ensured a particular focus on supporting people with mental health needs in the right place for them; reducing the number of patients having to receive inpatient support outside of the county; and reducing delays in supporting patients to be discharged from inpatient services. There has been a significant amount of work undertaken with Sussex Partnership NHS Foundation Trust to support this, as well as across the wider system. Whilst mental health pressures have continued beyond the peak winter period the sustained reduction in patients receiving their inpatient care outside of Sussex has continued. The number of patients being assessed as requiring acute psychiatric admission over winter has been on a reducing trend although patients have waited longer for admission than is ideal. The root cause of the challenge in accessing timely inpatient mental health care is one of flow, rather than demand, primarily due to the number of patients whose onward care from hospital is delayed.
Key actions have included an increased use of Havens (dedicated, mental health crisis assessment facilities that provide support and assessment for adults 24 hours a day) especially to provide an alternative to waiting in an Emergency Department, the promotion of the Sussex Mental Health Line and Staying Well Cafes, the development of a Section 136 support service in Eastbourne & Worthing and the Blue Light Triage service in North West Sussex.
The highest number of total non-SPFT beds was 103 (81 SPFT commissioned acute Independent Sector beds in Sussex and 22 out of area placements) on 14 September 2022 which reduced to 0 in November 2022. There have been small numbers of Out of Area Placements used since that date and the current number of OAPs is two (May 2023).
As part of our system discharge plans, we have also invested in initiatives over winter to reduce the length of time patients are waiting to be discharged from mental health inpatient settings and to support children and young people who attend our Emergency Departments with a mental health need.
2.10 Infection Prevention and Control
This winter saw an increase across viral outbreaks and secondary bacterial infections such as COVID 19, Influenza, Norovirus and Group A Streptococcus (GAS). The Sussex Integrated Care System have a dedicated Infection Prevention Team that supports all NHS and social care providers with maintaining high standards of infection prevention to maintain high quality and safe services.
Influenza affected bed availability during December and January with a high number of admissions across all hospitals in Sussex. This significantly reduced from February onwards.
The following measures are in place to ensure that the workforce issues arising from industrial action are addressed:
The sharing of risks and issues at the weekly System Chief People Officer meetings across all our organisations
Shared intelligence about local derogations and liaison arrangements with strike committees
Sharing of real-time information about staff numbers participating in industrial action and services affected and regular communication with the Regional Operations Centre to support the smooth management of services across strike days.
Periods of industrial action have affected all aspects of the health and social care system. So far in 2023 there have been 28 days of industrial action affecting healthcare providers in Sussex from a number of healthcare workers unions, plus education and transport workers unions.
The ICB has managed a co-ordinated Sussex response to every period of industrial action to date that has had an expected impact on healthcare. Throughout each period of industrial action a battle rhythm of command and control meetings are set run to ensure a coordinated response, Incident Coordination Centres are established, virtually or physically, and collaborative working with system partners is coordinated by the ICB to ensure robust planning for service delivery across all industrial action days and management of the actions that need to take place to mitigate any risks that emerge during the action.
This is coordinated through the Sussex Incident Control Centre (SxOC) which operates 08:00-18:00 seven days a week. During periods of Industrial Action, the SxOC opening times are extended to match South East Regional Operating Centre opening hours. Health organisations across Sussex also have similar incident control arrangements in place, with a robust and well-tested on-call mechanism managing the response out of hours.
System partners work together to develop plans to identify and mitigate the potential risks associated with the industrial action, ensuring the system is in the best place possible entering into periods of action.
The key impact of industrial action on the system is the addition of significant operational pressures on an already pressured system and exhausted workforce, and the knock-on effect of the rescheduling of elective care, which is only undertaken when absolutely necessary to ensure patient safety. To mitigate this staff are moved around and rotas re-worked to prioritise critical areas, agency and bank staff are brought in where available to provide cover, and elective care appointments are re-booked as soon as possible to avoid delays to care.
System-wide debriefs, co-ordinated by the ICB, are undertaken after each period of industrial action and identified learning is shared and used to inform planning for future periods of action.
2.14 Planned Care Recovery Programme
The Sussex Planned Care Recovery plan has focussed on improving access to services for patients and reducing waiting time by maximising existing capacity across the system and transforming how care is provided. While winter pressures and industrial action have led to some cancellations of planned care, every effort is made to rebook those patients who are affected at the earliest opportunity.
2.15 Public Health – Brighton and Hove
The Public Health protection teams and the ICB infection control teams have continued to work closely together providing support to the Sussex care provider market with infection prevention control support.
3.0 Learning from the Winter Plan and Actions Taken
3.1 Winter Plan Review and Feedback
In April 2023, system partners were asked for their feedback as to how we had performed against our given aims. Respondents were asked to answer 4 simple questions:
1. What were our high-level achievements?
2. What have we learnt?
3. What are our outstanding priorities?
4. What is our Forward Delivery Approach?
Responses were received from across the Sussex system, including ICB Place Based OPEX’s, Acute Providers, Clinical Leads, Community Providers, Mental Health and Local Authorities.
3.2 Top Themes:
• Strategic Vision
• To develop and align place-based models for integrated health and care within overarching NHS Sussex strategy.
• To evaluate outcomes and focus on most impactful as priorities for the future.
• Develop a decision-making forum to develop and implement plans to support NHS Sussex Strategy.
• Continue with Sussex Discharge Frontrunner Programme
• Winter Planning
• To have a dedicated System winter clinical lead.
• To use a coordinated approach to winter planning, in particular discharge.
• To achieve clarity on recurring funding and budgets as early in the year as possible.
• To develop models now for next winter.
• Planning
• To balance central guidance vs local risk and longer-term planning for surge periods.
• For Operational Exec Groups (OPEX) continue to plan/ mitigate operational pressure across the system including industrial action.
• To consider resource to provide consistent comparable system wide evaluation of schemes.
• Pathway Redesign
• To establish a cross ICB Task and Finish Group to support continued SECAmb delivery and pathways optimisation.
• Digital Integration
• A dashboard of system impact to be utilised to ensure data-driven approach and ongoing monitoring against initiatives.
• Collaboration
• To continue to reduce organisation barriers to improve integrated working.
• To maintain cross service and multi system engagement.
In summary the operating model implemented for winter implemented by the system has enabled the system to effectively respond to and manage periods of significant exceptional pressure and elevated system risk as a whole system.
The winter operating model meeting cadence enabled the system to respond in an agile way with the model and system escalation framework being rapidly adapted and further developed in response to live learning and the specific issues and risks identified. However, there is a need to consider how clinical input into the system UEC surge planning and delivery/oversight infrastructure can be further strengthened ahead of next winter as part of the System Operations Centre function’ further development.
The approach to system capacity and demand modelling to inform surge planning and risk mitigations needs to be further developed to provide a more accurate assessment of the impact of deployed capacity schemes and there is a need to strengthen the alignment with internal provider capacity and demand models.
The focus on system agreed priority areas for rapid improvement over winter to provide risk mitigation has resulted in a range of positive achievements being achieved by the system.
Priority area improvements for next winter will be included as part of the system’s programme delivery architecture for 2023-24.