The Sussex Winter Plan 2023/24 is a whole system health and social care plan, that recognises the interdependencies of the system and its partners to meet the needs of the local population. There is a national requirement to undertake winter planning each year, to provide assurance that the system and partners have the necessary measures in place to deliver health and care for the local population.

The purpose of the Sussex Winter Plan 2023/24 was to develop a comprehensive and aligned system approach to ensure that the Sussex system achieved NHS England (NHSE) and local objectives, namely:

· Continue to maintain or improve the quality and safety of services.

· Ensure timely access to services for the entire population, supported by a clinical risk-based focus at times of surge in demand.

· Focus on the most vulnerable and at risk.

· Take forward learning from previous Sussex winter planning in 2022/23.

This report evaluates the impact and effectiveness of the Sussex Winter Plan 2023/24 and identifies learning and enhancements to strengthen planning for winter 2024/25.

2.0 Evaluation Process

The Sussex Winter Plan 2023/24 incorporated NHSE requirements to focus on the three key priorities of demand management, admissions avoidance, and hospital flow. The delivery of these priorities was underpinned by actions in a series of cross-cutting workstreams.

This evaluation considers:

· The success of workstream actions in managing system pressures (sections 3-7).

· The effectiveness of demand and capacity modelling to identify areas of risk (section 8).

· System partner feedback on the plan and its effectiveness.

3.0 Demand Management: Workstreams Review

3.1 Optimising 111 Usage

The operating model in place during winter 2023/24 included NHSE funded resilience support from Vocare to provide call answering for approximately 10% of calls per month to help the service be as responsive as possible for local people. Call handling performance was challenged during peak demand during December 2023 - January 2024, with the average time to answer calls at 348 seconds (January 2024). Performance improved towards the end of winter and was sustained into 2024/25 with average time to answer at 176 seconds (April 2024). Noting the improvement, the national benchmark for average call answering of 111 calls is 127 seconds.

A further improvement plan has therefore been developed by 111, containing actions to be taken forward during 2024/25. This includes improvements to call handling, optimisation of Directory of Services (DoS) profiles to ensure people are offered or signposted to the right service for them, and improvement of clinical pathways.

3.2 Optimising Primary Care Resource (including Community Pharmacy and Vaccinations)

3.2.1 General Practice (GP)

One of the focus areas in Sussex to support our overall offer to patients over winter, was to additionally invest in providing extra capacity across primary care. In addition to the regular number of appointments offered by GP practices in Sussex, investment was made to provide extra appointments during winter, particularly over the festive period. Further winter PCN funding provided over 27,000 additional appointments that were available over the duration of the scheme (January – March 2024). More than 18,000 (68%) of these were face to face appointments that took place on the same day as they were booked.

In addition, NHS Sussex has also invested in providing GP practices with further demand and capacity tools to support their understanding and management of services, including over winter. APEX is a GP analytics platform, providing an interactive overview of clinical data. The platform drives quality improvements across primary care, increases the use of Advanced Primary Care roles to support patients, and provides further enhancements to cloud-based telephony. APEX usage will continue to be optimised in 2024-25. Currently, 154 General Practices across Sussex have fully on-boarded, with a further 15 completing this process.

Place	Total Practices in Place	Onboarded to APEX
Brighton & Hove	31	31
West Sussex	76	76
East Sussex	49	47
Total	156	154

3.2.2 Community Pharmacy

The Pharmacy First scheme went live on 31 January 2024, enabling Community Pharmacists to supply prescription-only medicines (when clinically appropriate) to treat seven common health conditions, without requiring a GP visit. 288 of 293 (98%) Community Pharmacies in Sussex have signed up to provide the service.

86 of 157 (55%) General Practices are directing patients to Community Pharmacy, utilising the digital referral pathway which has been established to enable general practices who utilise the EMIS patient record system to refer patients directly to community pharmacy from their patient record, expediting the process for the patient:

Place	Total GP surgeries utilising digital referral by place	% GP practices by place
Brighton & Hove	19 of 31	61%
West Sussex	38 of 51	75%
East Sussex	29 of 75	39%

3.2.3 Seasonal Vaccinations

Seasonal vaccination uptake was optimised during winter 2023/24, with a successful flu and covid vaccination campaign undertaken across Sussex. Final uptake figures for the flu vaccination in the community for those aged over 65 was 79.3% and aged over 65 (at risk) was 82.8%.

407,726 covid vaccinations were delivered across Sussex during the autumn and winter 2023 campaign:

· 0.1% above the regional (southeast) uptake of 59.7%.

· 6.1% above the national uptake of 53.7%.

The evaluation notes that Sussex experienced a reduced impact of flu and covid in hospital settings during winter 2023-24, in comparison with recent years.

3.3 High Intensity Users (HIU)

The British Red Cross (BRC) provide HIU services in Sussex to support patients who frequently attend the Emergency Department (five or more attendances in a 12-month period). 11,450 patients had more than five Emergency Department attendances in 12 months between January and March 2024.

HIU services provide health coaching and social prescribing to reduce Emergency Department presentations and admissions, working in partnership with acute physicians. Whilst full winter data is yet to be evaluated by BRC, the service note a positive impact for Brighton HIU patients and NHS services, from October to December 2023 as follows: A screenshot of a graph Description automatically generated

4.0 Admissions Avoidance: Workstreams Evaluation

4.1 Admissions Avoidance Single Point of Access (AASPA)

AASPA provides a single, consistent access point for ambulance crews, Emergency Operations Control (EOC) and NHS111 to access alternatives to conveyance and admission for patients in the community, supporting people at home. The service includes Urgent Community Response services, Virtual Wards (VW) and is integrated with the Sussex Home Visiting Service (SHVS) to expand options out of hours.

AASPA was expanded to include care homes for winter 2023/24 with pilots undertaken across both West Sussex and Brighton and Hove places. Frequent caller data and usage is currently being reviewed to determine the outcome of these pilots. Further expansion plans for AASPA will be drawn out through 2024/25 operational planning, underpinned by the Sussex Urgent and Emergency Care Shared Delivery Plan Priorities for 2024/25.

4.2 Urgent Community Response (UCR)

All Sussex Community NHS Foundation Trust (SCFT) UCR teams have now gone live with SECAmb portal access, enabling the community team to view patients within the list of category 3 and category 4 calls received by the ambulance services who are awaiting a response and who may be suitable to receive their support in the community and avoid hospital conveyance. The UCR teams can extract patients directly from the SECAmb wait list and provide a response from their community service, reducing demand on the ambulance service and improving the response to those patients.

4.3 Virtual Wards

Virtual Wards are a safe and efficient alternative to NHS bedded care. Virtual wards support patients, who would otherwise be in hospital, to receive the care and treatment they need in their own home. This includes either preventing avoidable admissions into hospital or supporting early discharge out of hospital.

Virtual ward capacity and occupancy targets were achieved during winter 2023/24:

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Delivery of the NHSE trajectory plan was completed at the end of November 2023 with virtual ward capacity increasing to 156 beds across Sussex against a baseline capacity plan of 131 beds.

Capacity increased further during winter, reporting a position of 192 beds against a plan of 146 capacity, and 92.2% occupancy, exceeding the national metric of 80% (February 2024).

Whilst good progress was made in winter, Sussex remains an outlier, with 12 beds per 100,000 population, compared to the national average of 23 beds per 100,000. Sussex Virtual Health providers are currently reviewing the virtual health model and considering opportunities to reconfigure and increase capacity in 2024/25. This includes a review of additional virtual ward pathways, remote monitoring, and digital procurement.

Regional evaluations have been completed to review the effectiveness of virtual wards and findings demonstrate that 23% of patients in a virtual ward, achieved a more independent social outcome and patients recover quicker, feel safe, supported, and have improved quality of life. 2.5 times fewer patients treated on a virtual ward are readmitted to frailty beds and patients are five times less likely to acquire infection.

These findings are reflected in the Sussex virtual ward services. No Sussex virtual ward patients are waiting for packages of social care, and when referred early in their treatment needs, the length of stay on virtual ward is 1-13 days only. Feedback confirms that Sussex patients feel they recover quicker at home and that they receive a personalised care approach. Sussex virtual wards also demonstrate low readmission rates and no reported serious incidents.

5.0 Hospital Flow: Workstreams Evaluation

5.1 Emergency Department (ED) Improvement Plans

ED improvement plans were implemented at both University Hospitals Sussex NHS Foundation Trust and ESHT to support delivery and improved performance against the 4-hour standard during winter 2023/24. This work will continue throughout 2024/25. Whilst performance was challenged during winter, Sussex achieved the national standard of 76% at the end of March 2024, compared with a national performance rate of 73.9%. There was variance in performance at place and work continues to support improvements locally.

ED improvement plans continue to focus on leadership, optimisation of Clinical Decision Units and Same Day Emergency Care provision, improving discharge flow and, continuation of robust governance and assurance structures to track delivery during 2024/25.

5.2 Mental Health Improvement Plan

The mental health improvement plan commenced in July 2023. During winter, the system saw a decrease in mental health patient ED attendances:

Partners are working towards meeting the 20% reduction in Mental Health ED attendances by March 2025. There has also been a sustained reduction in the average waiting time for a mental health bed over winter. This further supports the targeted 20% reduction by March 2025.

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Many initiatives supporting improved access to mental health services this winter have continued for 2024/25. This includes Sussex Mental Health Line, signposting guidance on provider websites and ‘Text Sussex’; a messaging service providing free and confidential mental health support from trained volunteers. A partnership between SPFT and the voluntary sector, also improved access to Sussex ‘Staying Well’ crisis cafes, including open access models (walk-in) in Brighton and Crawley and same-day appointment services in Worthing and Eastbourne.

5.3 Community Flow Improvement Plan

Both ESHT community and SCFT saw improvements to flow in intermediate care units following the implementation of long length of stay meetings, appointment of Discharge Support Assistants and improved ways of working. Average length of stay (ALOS) reductions seen through 2023 in the run up to winter were as follows:

Location

May 2023

ALOS

December 2023

ALOS

Improvement

SCFT Intermediate Care

34.4 days

29.9 days

4.5 days

ESHT Rehabilitation Wards

30.98 days

23.45 days

7.53 days

5.4 Discharge Improvement Plan

Sussex Health and Care were part of the NHSE discharge front runner programme and have implemented a number of improvements. System partners have adopted the Transfer of Care Hub (TOCH) model within each place and TOCH managers have been appointed to lead each hub. This provides joined up multi-disciplinary support to plan and support appropriate discharge for local people. Escalations from the TOCHs were incorporated into the winter operating model and an integrated acute and community transfer of care dashboard is in development. This enables the multidisciplinary teams to carry out discharge planning and make informed decisions for onward care to best support patients.

The graph below demonstrates the average length of stay for discharge ready patients in the acute setting and this remains a key area of focus.

6.0 Clinical Pathways: Workstreams Evaluation

6.1 Urgent Community Response Plus GP Pilot (Brighton and Hove and West Sussex)

In November 2023, UHSx and SCFT developed an out of hospital urgent frailty response pathway across Brighton and Hove. The Urgent Community Response (UCR) teams support people to receive care at home and avoid admission to hospital. The ‘UCR plus GP’ pilot brings together existing UCR multi-disciplinary teams with dedicated senior clinical decision-making GPs. Inclusion of general practitioners ensures the UCR teams can support patients who are more unwell, enabling patients to be cared for in their usual residence and reducing hospital admissions. The following findings are noted:

· 297 referrals were received over an 8-week period in Brighton and Hove. Of these, 73 patients avoided admission into hospital through UCR plus GP.

· 11.5% of patients referred were admitted to hospital with an average length of stay of 2.6 days.

· Referrals were mostly higher acuity patients.

· The UCR Plus GP pathway will continue via the virtual health programme in 2024/25.

6.2 Paediatrics

Respiratory Syncytial Virus (RSV) is a known paediatric risk in the winter period. Epidemics tend to start in October and last for several months, peaking in December. Actions were completed across winter to manage the increased prevalence of RSV, including:

· Overview of paediatric capacity across the region with a clear plan to manage paediatric critical care capacity during surge periods.

· Acute Trust plans to proactively mitigate risks.

· Escalation process for mutual aid and key contact information sharing.

These actions were successful, and outbreaks of RSV were managed effectively during winter across Sussex.

6.3 Critical Care

Critical care surge planning was in place for both adults and children across Acute Trust sites during the winter period and this was available to be stood up as required.

7.0 Wider Workstreams Evaluation

7.1 Workforce and Wellbeing

Recruitment campaigns focussed on hard-to-fill posts such as healthcare assistants, staff nurses, bank, and volunteer staff. Other initiatives included e-rostering system use and forecasting of data, based on winter 2022/23 fill rates and demand. Recruitment campaigns were successful across providers during winter. Providers ensured regular wellbeing assessments were available for staff, with access to occupational health and employee assistance programmes (EAP) as needed.

Workforce sickness absence data for Sussex for December 2023 (latest data) showed a reduction in the average sickness rate to 5.84%, compared to a December 2022 average of 6.94%.

Sussex Health and Care Sickness Rates By Partner

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7.2 Infection Prevention and Control (IPC)

The following actions were successfully implemented, supporting Sussex Health and Care to manage IPC outbreaks during winter 2023/24:

· Development of a Winter Infection Prevention Plan to support learning from 2022/23.

· Development of IPC Surge Plan for winter viral illnesses.

· Delivery of training for health and social providers, including a Link Practitioner development day and Winter Preparedness Training.

· NHS Sussex Infection Prevention Specialist Team provided expert advice to health and social care settings and conducted reviews of provider IPC policies.

· Attendance at bi-weekly regional NHSE IPC meetings to support with horizon scanning and regional escalation as required.

· Daily review of IPC related bed closures and outbreak situation to support patient flow.

7.3 Local Authorities

In Brighton & Hove, there was additional investment to support those who were homeless during winter 2023/24, including a severe weather scheme and council funded homeless and mental health beds. The carers’ link workers project was extended over winter, with link workers raising carer awareness and supporting unpaid carers to continue in their caring role, across primary and secondary care. There was also an additional focus to resource post-discharge pathways.

Work continues with ongoing targeted action in Brighton and Hove including the dedicated homeless GP practice; improving on falls prevention for those at risk; VCSE support for high intensity users of acute services; VCSE proactive support to the most vulnerable, connecting people to health and care services across the city, empowering people to identify early health and social care needs; and the place based transformation partnership programme led by the City Council to support adults with multiple compound needs..

7.4 Planned Care

Work was undertaken throughout winter to maintain as much elective activity as possible with a focus on treating those patients who had experienced very long waits. University Hospitals Sussex NHS Foundation Trust delivered a significant reduction in the number of patients waiting over 78 weeks for treatment, although just missed delivering against its nationally agreed target.

Sussex Health and Care delivered against its national target to reduce the number of cancer patients waiting over 62 days for treatment and University Hospitals Sussex NHS Trust was commended by NHS England for the improvements it made in the second half of 2023/24.

The following graph demonstrates the increase in all Sussex Clinical Diagnostic Centre (CDC) activity for imaging:

The Brighton CDC at Falmer is now operating at near full capacity for all services. Imaging capacity is being fully utilised. This enables hospital imaging services to focus more on acute diagnostic activity and significantly adds to the overall system capacity for imaging in Sussex, provider quicker access for local people.

7.5 Industrial Action

Periods of industrial action affected all aspects of the health and social care system during the winter period. There were 16 days of industrial action between December 2023 and February 2024, affecting healthcare providers in Sussex from several healthcare workers unions, plus action undertaken by education and transport workers unions. A Christmas / New Year and Industrial Action Plan was implemented as an addendum to the Winter Plan to ensure a coordinated response and management of the actions that needed to take place to mitigate any risks that emerged during the action. This ensured Sussex was able to maintain access to safe services during these periods.

7.6 Communications

A system communications and engagement plan was developed with partners to ensure clarity and support of operational delivery over winter. The plan focused on winter demand, industrial action, and public messaging. Media activity included coverage on TV and radio, social media, advertising and promotion through community and voluntary partners. This was successfully achieved and there were high levels of positive engagement for the messages.

8.0 Demand and Capacity Modelling

Development of the Sussex Winter Plan 2023/24 was underpinned by demand and capacity modelling that utilised core bed and escalation bed data, provided by acute partners.

The model enables additional schemes to be put in place to meet the likely need for inpatient care. These schemes included the following:

· Discharge Improvement Schemes.

· Virtual Wards.

· Additional Capacity Schemes.

· Admission Avoidance Schemes.

Bed occupancy across Sussex acute sites, remained high at an average of 97% throughout winter and capacity was significantly challenged during and after the peak period. Providers accommodated the increased demand during winter by using additional escalation capacity, virtual wards, admission avoidance and discharge improvement schemes.

There was an increase in core beds open, with 2,405 average core beds open during November 2023 – March 2024 across Sussex, compared to 2,297 beds open during November 2022 – March 2023.

Core Bed Capacity - UHSX

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Core Bed Capacity - ESHT

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The increase in core bed usage is noted as the reason fewer escalation beds were open during winter 2023/24 (average of 15 beds during November 2023 – March 2024, compared to November 2022 – March 2023 average of 36 beds).

Escalation Bed Capacity - UHSX

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Escalation Bed Capacity – ESHT

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9.0 Learning from the Winter Plan

9.1 Winter Workstream Actions

66 actions were included within the Sussex Winter Plan 2023/24 and implementation was monitored throughout winter. Each action was assigned a status of ‘achieved’, ‘partially achieved’ (with ongoing work continuing in 24/25) or ‘not achieved’.

Two thirds of the Sussex Winter Plan 2023/24 actions were fully achieved during the winter period. 20 actions were partially achieved during winter and these actions will be progressed further in 2024/25. A number of these actions are now identified as business as usual (BAU) activity rather than providing additionality for winter in isolation. Four actions were not progressed during winter due to resource constraints or due to the action requiring further development to progress (impact of these was therefore not measured)

Priority Workstream	Actions achieved	Actions partially achieved	Actions not achieved	Total
Demand management	2	5	0	7
Admission Avoidance	9	2	1	12
Hospital flow	19	4	2	25
Clinical pathways	2	3	1	6
Other pathways	10	6	0	16
Total	42 (63.7%)	20 (30.3%)	4 (6%)	66 (100%)

Whilst some initiatives were not achieved within the winter period, concentrating on agreed priority areas for rapid improvement over winter, mitigated significant risks and resulted in a range of positive achievements for the system and its partners, whilst managing winter pressures.

9.2 Stakeholder Evaluation of the effectiveness of the Sussex Winter Plan 2023/24

Feedback was sought from key stakeholders regarding the development of the plan and its effectiveness in achieving it aims and objectives. Themes arising from stakeholder feedback recognised:

· The operating model supported the system to respond effectively during winter 2023/24.

· Detailing of the objective of the plan may help clarify its use as an operational tool (supporting management during winter) or an assurance provision of planned activities.

· A central repository of provider activities and clarification of roles and responsibilities of system partners may be beneficial.

· Workforce capacity challenges remain a key focus during peak periods of surge.

· The benefit of alignment between system demand and capacity modelling and individual provider modelling.

10.0 Next steps

Learning from evaluation of seasonal plans is routinely incorporated in future planning and the Sussex Winter Plan 2023/24 is no exception. Learning has also already been widely shared with Sussex Health and Social Care partners in local forums and meetings. All action from the evaluation will be completed prior to winter planning for 2024/25.

11.0 Conclusion

The purpose of the Sussex Winter Plan 2023/24 was to develop a comprehensive and aligned system approach to ensure that the Sussex Health and Care system continued to maintain and improve the quality and safety of services, whilst ensuring focus on the most vulnerable members of the local population and ensure timely access to services for the entire local population.

Based on the findings of this evaluation, the Sussex Winter Plan 2023/24 has been successful, noting the learning that this evaluation has provided and the opportunity to refine and make further improvements for future years.