Contents
2. Background and Strategic Context
3. Overview - Sussex Population
4. Overview - current service provision
5. Purpose of specialist dementia beds
7. Best practice examples & national evidence
11. Impact on adults requiring an acute bed admission
12. Impact on people with dementia
Appendix I - Strategy and policy drivers impacting dementia services
1. Executive Summary
1.1. Sussex ICB has drafted its adult mental health, learning disability and autism inpatient strategic plan for the next 5-years. The aim of the strategic plan is to ensure that every person in Sussex who needs inpatient support can access services that best meet their need, as close to home as possible and where people require an inpatient admission they receive excellent care.
1.2. Within the strategy clear ambitions have been made about improving the support we provide to patients with dementia, their families and carers whilst reducing variation in community service provision across Sussex.
1.3. Year 1 intentions include:
· Develop an intensive support team for people with dementia in East Sussex and redesign existing services to ensure a consistency of offer across Sussex.
· Develop (and subject to agreement) implement plans to remodel service provision away from an overreliance on inpatient dementia beds to a stronger community model.
· Strengthen partnership working with other community services, including the voluntary and community sector to ensure families and carers feel supported.
1.4. Sussex does not currently provide a consistent model of specialist community dementia care, with no provision for dementia crisis support in East Sussex and reduced resource and capacity in North West Sussex older adult community teams.
1.5. Within our wider strategic plans SPFT has received a recent capital award from NHSE to refurbishment of a ward at Mill View Hospital in Brighton to provide 15 adult acute beds. The proposed ward is Brunswick ward which currently provides 10 dementia beds. The intention is to increase adult acute beds in Brighton by 15 and reduce the dementia beds by 10 (a net gain of 5 beds overall for the system). This aligns with the particular bed types needed for the population of Brighton and Hove, and the Sussex wide demand for condition specific capacity.
1.6. This paper outlines proposals to deliver on the year 1 intentions to improve dementia inpatient services through reducing the dementia bed base, increasing intensive community support for people with dementia and changing the clinical model of the older adult functional wards so they can accommodate people with dementia if required.
1.7. NHS Sussex have endorsed this case for change noting the anticipated improved patient care and experience, service optimisation, and financial outcomes. The next step is to engage with Local Authorities and Health Overview and Scrutiny (HOSC) committees.
2. Background and Strategic Context
2.1. Dementia is a progressive and incurable condition that affects a growing number of people in Sussex. Dementia is an umbrella term for a range of conditions that cause cognitive impairment, behavioural and psychological symptoms and functional decline over time. Dementia can affect a person at any age, but the risk increases with age.[1]
2.2. Dementia services are provided in the community, inpatient and care home settings and involve a wider range of statutory and non-statutory partners. Specialist dementia services are provided for people where a greater level of clinical support is needed to help manage the dementia, comorbid mental health conditions and behavioural and psychological distress in the context of dementia.
2.3. For example, a person living with dementia may require inpatient care when they need more intensive support that cannot be provided at home or in the community. The purpose of inpatient dementia care is to assist the patients in recovering from their crisis and returning to their usual place of residence as soon as possible.[2],[3]
2.4. There are a range of national policy documents and guidance regarding dementia including NHSE's Dementia Wellbeing Pathway (February 2022) and the NHS Long-Term Plan (January 2019) that support systems to plan and provide optimal care for older adults and those living with dementia (Appendix I).
2.5. Within Sussex there is the ICS Improving Lives Together strategy and the adult mental health, learning disability and autism inpatient strategic plan (in draft) that both make consideration for how we can better support people with dementia.
2.6. Against this backdrop of policy and guidance there is variability in how specialist dementia services have been commissioned and the models developed. Some areas remain reliant on inpatient hospital models whereas others have very few/no specialist inpatient dementia beds and providing support exclusively through enhanced community provision/support to care homes. In addition, even within inpatient care there is national variation between having dementia specific wards and having wards for older adults that support people with both functional mental illness and/or a dementia.
2.7. There has been little change in the provision of specialist dementia services across Sussex in the last 5-years and therefore this paper is timely in considering how we might address variances within our existing models, take learning from other areas who radically changed provision as a result of Covid and seek to deliver services for our ageing population in a sustainable way for the future.
3. Overview - Sussex Population
3.1. Sussex has a population of 1.718m, of which 292,000 live in Brighton and Hove; 559,000 in East Sussex and 868,000 in West Sussex; and this is projected to grow by 5.4% by 2032.[4]
3.2. Sussex has a growing and ageing population with:
· 20% of people aged 0-17, 58% aged 18-64, 19% aged 65-84, and 3% over 85 years old.
· In East Sussex and West Sussex there is a higher proportion of people aged 65 years and over, 26.1% and 23.3% respectively, compared to other places in England (18.5%) and over half the future increase in population is expected to be in this age range.
· In Brighton and Hove there is a younger population, with 13.5% 65 and over, although the greatest population increase is expected in the 65 and over age group.[5]
3.3. Table 1 below shows the number of recorded people with a learning disability, depression, severe mental illness and dementia in Sussex and the associated recorded prevalence rates comparing Sussex to England, sourced from the GP Quality Outcomes Framework.[6]
Table 1: Recorded prevalence of Learning Disability, Depression, Mental Health and Dementia in Sussex in 2022/23
|
Place |
Learning Disability |
Depression |
Mental Health |
Dementia |
||||
|
People |
% |
People |
% |
People |
% |
People |
% |
|
|
Brighton & Hove |
1,722 |
0.52 |
37,346 |
13.36 |
4,496 |
1.36 |
1,923 |
0.58 |
|
East Sussex |
3,704 |
0.65 |
74,709 |
13.64 |
6,984 |
1.22 |
6,268 |
1.10 |
|
West Sussex |
5,412 |
0.58 |
102,436 |
16.01 |
9,050 |
0.97 |
9,215 |
0.99 |
|
Sussex |
10,838 |
0.59 |
214,491 |
14.33 |
20,530 |
1.12 |
17,406 |
0.95 |
|
England |
0.57 |
13.29 |
1.05 |
0.76 |
||||
Source: GP Quality Outcome Framework
3.4. The demographic profiles of Brighton & Hove, East Sussex, and West Sussex exhibit distinct variations, particularly in terms of age distribution. While East and West Sussex are characterised by larger proportions of older residents, Brighton & Hove stands out with a notably younger demographic and a higher concentration of working-age adults.
3.5. These age-related disparities have direct implications for the prevalence of specific health conditions across the regions. In Brighton & Hove, the younger population correlates with a higher reported prevalence of mental health conditions among working-age adults and young people. Conversely, in East and West Sussex, where the population skews older, there is a greater focus on addressing the healthcare needs associated with aging, including dementia and other mental health conditions prevalent in later life.[7]
Projections for people living with dementia
3.6. A recent UCL-led study suggests that up to 1.7 million people could be living with dementia in England and Wales by 2040.[8] Alzheimer's Research UK estimates that 1 in 11 people over the age of 65 have dementia in the UK, which means there are about 950,000 people with dementia in the UK, and this number could go up to around 1.6 million by 2050. It is estimated that 65% of people with dementia in the UK are women.[9]
3.7. Finding accurate future projections for dementia prevalence in Sussex can be challenging. This is due to varying research methodologies and the fact that older projections become less reliable as our population ages.
3.8. The last Dementia joint strategic needs assessment completed in East Sussex in 2016 estimated 10,172 people had dementia at the time (either diagnosed or undiagnosed). This is equivalent to 1.88% of the population, or 1 in every 53 people. The expected number of people living with dementia in East Sussex will have risen to 15,900 by 2030, slightly more than the current population of Uckfield.
3.9. In Brighton & Hove 2,949 people were estimated to have dementia in 2014, with this projected to grow to 3,892 by 2030.
3.10. In West Sussex in 2020, 16,650 people were estimated to have dementia, with this projected to grow to 22,450 by 2030.
3.11. Whilst the estimated number of people living with dementia in Sussex is 34,000 in 2024 it is anticipated to increase to 41,000 by 2030 with the largest rises in East and West Sussex and only a moderate rise in Brighton and Hove.
3.12. In summary, the contrasting demographic projections highlight the importance of tailoring services to the specific needs of each place. While Brighton & Hove might benefit from more mental health resources for working-age adults, East and West Sussex would likely require a greater emphasis on dementia care. Recognising these differences allows for a more targeted and effective approach to addressing the health needs of the diverse populations within Sussex.
Table 2: Sussex
population data (per place) and the percentage of people aged
65+
estimated to have dementia
Source: Population data from Office for National Statistics - Census 2021 (https://explore-local-statistics.beta.ons.gov.uk/). GP registered population from NHS England (https://www.england.nhs.uk/publication/supporting-spreadsheets-for-allocations-2023-24-to-2024-25/). Data rounded to the nearest 100.
4. Overview - current service provision
4.1. The current configuration of dementia services across Sussex is variable as they were historically commissioned by the different CCGs that now make up NHS Sussex. As a result, the offer to patients is different depending on where the individual lives.
Community Teams
4.2. The core, secondary care community services for older adults with complex mental health difficulties and for people living with dementia are provided in specialist multi-disciplinary teams across the whole of Sussex. These teams meet the needs of both older adults and people living with dementia because of the common skill-set required to assess and treat both these patient cohorts. The community team provision is broadly equivalent in type and function across all of Sussex.
Dementia Urgent Care and Care Home In-reach/ Liaison
4.3. There is variation in the urgent care and care home in-reach provision across different geographical areas in Sussex. In West Sussex, there are Intensive Support Teams for people experiencing a crisis in relation to their dementia, linked to the community teams. Patients within the community teams are escalated into the Intensive Support Team through a zoning approach when there is need of a more intensive approach to avoid admission or carer/ placement breakdown. The service works 8am-7pm Mon-Fri, and 9am-5pm Weekends and Bank holidays. The skill-mix is nurses, support workers and medical/multi-professional input from the community team. Additionally, the team have the ability to prescribe social care packages of up to six weeks using a selection of approved providers.
4.4. West Sussex resourcing for care-home in-reach was historically integrated into the dementia crisis function, and the Intensive Support Team therefore have the capacity to provide services into care homes where there is a risk of placement breakdown. In North West Sussex, there are also Mental Health/ Dementia specialist practitioners employed by SPFT who work into the Enhanced Health into Care Home Teams.
4.5. In Brighton and Hove, there is an Enhanced Duty Service for Dementia (ENDU), which takes referrals from GPs or the SPFT community team when urgent care is needed. The service works Mon-Sun 9am-7pm. The skill-mix is nurses and care managers from Brighton and Hove City Council, reflecting the integrated services in this area, plus medical input from the community team.
4.6. Brighton and Hove also have a Care Home In-reach and Mental Health Liaison Team. This team works with care homes in the city to develop their practice in working with people living with dementia, therefore preventing escalation of distressed behaviour in relation to unmet needs. They also develop bespoke action plans for residents who are at risk of admission/ placement breakdown. Additionally, the Liaison part of the team respond directly to GP referrals of individuals who live in care homes and have a need related to dementia and/or mental health.
4.7. In East Sussex there has never been commissioning of a dementia crisis function. In Eastbourne and also in High Weald, Lewes and Havens (but not in Hastings) there are small intensive support functions that work with people who are already in the community team caseload and in need of more intensive support (related to either mental health or dementia presentation). The teams work Mon-Fri 9am-10pm and Weekends 9am-9pm. The staffing mix is Band 5 nurses and support workers. There is no care home in-reach/ liaison service in East Sussex.
4.8. It is therefore possible to see that East Sussex has a lower level of resource to support people living with dementia who have a higher level of need and are at risk of carer/placement breakdown, or admission.
Inpatient Dementia Services
4.9. There are currently 50 dementia beds provided across Sussex. The majority of the beds are provided at the Swandean Hospital site in West Sussex, and 10 additional beds are provided in each of Brighton & Hove, and Uckfield, East Sussex.
Figure 1: Specialist inpatient dementia beds provided by SPFT
4.10. Beechwood Ward is a 10-bed mixed inpatient ward in Uckfield. The ward was set up as a temporary measure with a longer-term plan for a dementia ward at The Conquest, Hastings to be opened; however this was subsequently not feasible.
4.11. Brunswick Ward is a 10-bed mixed inpatient ward at Millview Hospital in Brighton. There are environmental limitations in the ward, for example, non-dementia-friendly flooring and lounge area and lack of access to outside space.
4.12. Forget Me Not Unit (FMNU), opened in 2021, is a 30-bed dementia unit in Worthing, which includes Rosemary, Sage and Thyme wards. The unit comprises three wards designed specifically for providing a purposely designed dementia-friendly environment and specialist dementia inpatient care. The FMNU was a finalist in the National Dementia Care Awards in 2023.
5. Purpose of specialist inpatient dementia beds
5.1. People with dementia can require inpatient admission to a specialist inpatient unit to assess their needs and establish a sustainable care plan to manage their distress:
· People with dementia often experience anxiety, depression, frustration and other expressions of emotional distress. This can result in behaviour that is challenging and this is often the primary reason for admission.
· People with dementia are more prone to developing delirium which in itself leads to increased confusion and complications. Unlike dementia, this is treatable and reversible with appropriate assessment and treatment and does not always require admission to a specialist dementia bed.
· An inpatient admission will involve an extended assessment of the person's needs, the nature and cause for any care challenge, and how this can be better managed.
· The principal purpose of admission is to identify factors and treatment goals, including treatment of physical health issues (for example, management of pain) and/or psychological distress related to anxiety, depression and psychosis.
· The outcome of the admission is likely to be a care plan focussed on the effective management of behavioural challenges and medical treatment where relevant and appropriate support for carers. There is likely to be a determination about whether ongoing care can be managed at home or in a different setting such as a care home.
6. What the data tells us
Admissions for acute adult mental health beds
6.1. This section examines the demand for adult inpatient mental health beds in Sussex providing context specific for the local populations.
6.2. We have analysed data for referrals for acute adult mental health beds between April 2023 and July 2024. This shows that there were a total of 3,100 referrals were made for adult mental health beds in Sussex.
6.3. Although Brighton & Hove residents comprise just 17% of the Sussex population, they generated 22% of adult mental health bed referrals (684 out of 3,100 referrals).
6.4. This disproportionately high demand translates to longer wait times for Brighton & Hove residents: an average of 9.7 days compared to 7 days in other parts of Sussex.
6.5. Admissions data indicates an average of:
· 28.6 admissions per month for Brighton & Hove residents (457 admissions)
· 146 admissions per month across East and West Sussex (2,336 admissions)
6.6. Our objective is to prioritise patient placements in acute beds within proximity of where they reside, facilitating continuity of care and access to established support networks. The data shows that only 30% (135) of Brighton & Hove residents requiring admission were accommodated within the city, with the remaining 70% (322) admitted in inpatient beds within East or West Sussex.
6.7. In contrast, East and West Sussex residents experience significantly higher rates of local bed access, with 74% admitted to facilities within their local area. This highlights a disparity in access to local acute care beds between Brighton & Hove and the broader Sussex region.
Dementia bed numbers
6.8. There is limited benchmarking information available for dementia beds as some organisations have dementia specific beds/wards and other organisations have older adult beds that are flexibly used for patients with dementia or a functional mental illness. Comparison is therefore made to Trusts that share this data which shows that Sussex has 1.6 dementia beds for every 50,000 people in the region. This is more than the number of dementia beds in Hampshire, which has 1.13 beds for every 50,000 people, and in Devon or Mid and South Essex, where there is one bed for every 50,000 people.
Inpatient admissions for people living with dementia
6.9. This section examines the demand for inpatient dementia beds to better help determine demand and capacity and trends in activity flows.
6.10. The key findings of our data analysis show that between June 2022 and June 2024:
· All admissions to dementia beds - there were 355 admissions - this equates to 14.8 admissions per month.
· Admissions for people living with dementia - there were 297 (84%) admissions, which is an average of 12.4 admissions per month.
· Admissions for people with functional mental health condition - there were 58 (16%) admissions, which is an average of 2.4 admissions per month. People with a functional mental illness are better supported in an older adult functional ward.
6.11. This means that on average, 14.8 people were admitted every month to a specialist dementia inpatient ward. This number includes an average of 2.4 admissions with functional mental health illness, who were able to be admitted because there were unoccupied beds.
6.12. Out of the 297 admissions for people living with dementia to all dementia wards:
· 79 (27%) were to Brunswick Ward, an average of 3.3 admissions per month
· 56 (19%) were to Beechwood Ward, an average of 2.3 admissions per month
· 162 (54%) were to wards at Forget Me Not Unit (FMNU), an average of 6.8 admissions per month
6.13. SPFT Dementia beds are managed as one resource across Sussex. People with dementia in crisis may need to be admitted to any specialist dementia ward in Sussex to receive prompt inpatient care when required and when it is not possible to provide the care in the community. Based on the data we analysed:
· Brunswick Ward received 3.3 admissions per month, of which 2.5 admissions were for patients from East or West Sussex.
· Beechwood Ward received 2.3 admissions per month, of which 0.8 admissions were for patients from Brighton & Hove or West Sussex.
· FMNU wards received 6.8 admissions per month, of which 2.3 admissions were for patients from Brighton & Hove or East Sussex.
6.14. This means that on average, out of the 12.4 admissions for people with dementia to inpatient wards, 5.6 people (45%) are admitted to wards outside of the local area where they live.
Table 3: Patient with dementia admissions per ward and area
|
Patient area |
Brunswick Ward |
Beechwood Unit |
Rosemary Ward |
Sage Ward |
Thyme Ward |
TOTAL |
|
Brighton & Hove |
18 |
3 |
1 |
5 |
5 |
32 |
|
East Sussex |
27 |
39 |
13 |
18 |
9 |
106 |
|
West Sussex |
33 |
12 |
44 |
35 |
29 |
153 |
|
Other |
1 |
2 |
2 |
1 |
6 |
|
|
TOTAL |
79 |
56 |
60 |
58 |
44 |
297 |
Bed occupancy and length of stay
6.15. The bed occupancy rate varied between wards and was in the range of 82% to 94%, which is an average occupancy rate of 92% across all wards.
6.16. Over the analysed period, the median Length of Stay (LoS) for patients in the inpatient wards was 99 days for people with dementia, and 64 days for people with functional mental health illness.
6.17. Based on the admissions, LoS and bed occupancy data presented above, we can conclude that:
· On average, people with dementia occupied approximately 39 beds
· On average, people with functional mental health illness occupied approximately 5 beds
· On average, there were approximately 6 vacant beds
6.18. It is important to note that these are average figures and the actual number of occupied beds can vary daily. However, this data provides valuable insights into the overall demand for specialist dementia inpatient beds across Sussex.
Clinically Ready for Discharge Patients
6.19. When they are clinically ready for discharge (CRFD), patients can leave the hospital and receive treatment at home (or in the community) or in a less-intensive care setting. Sometimes, however, patients remain in the hospital longer than they should because they are waiting for a care home or a care package. This can negatively impact patient outcomes and experiences and make their condition worse. The Trust's performance standard for the number of CRFD patients is 10%.
6.20. The data indicates that between June 2022 and June 2024 a high proportion of discharges were delayed:
· 56% of patients admitted to Brunswick Ward
· 38% of patients admitted to Beechwood Ward
· 40% of patients admitted to ward at FMNU
Figure 2: Total delayed patients by ward (% of bed occupancy)
|
Brighton & Hove (Brunswick Ward)
|
|
West Sussex (Forget Me Not Unit - all three wards)
|
|
East Sussex (Beechwood Ward)
|
6.21. Overall, the equivalent of 18 beds were consistently occupied by patients who were clinically ready for discharge and did not have to be in a specialist dementia ward.
6.22. In summary:
· Of the 50 dementia beds at any one time 18 beds have patients who are CRFD and there are 4 vacancies
· 16% of admissions do not have a primary diagnosis of dementia and an appropriate admission would be to a functional adult/older adult ward
· 75% of the referrals to Brunswick are for patients from East or West Sussex
· 43.75% of Brighton & Hove patients who are admitted already receive inpatient care in either East or West Sussex
Impact of temporary closure of Beechwood Ward
6.23. During the winter of 2023/24 Beechwood ward was temporarily closed for a three month period- this was part of a wider plan to reduce the use of temporary staffing over the winter period, maintain clinical safety within the urgent and emergency pathway and support delivery of Trust's 23/24 financial position. Patients were either transferred to another ward or supported within the community. The analysis of this period shows that when the ward was temporarily closed, there was no increase in the number of patients waiting for specialist dementia beds.
Figure 3: Number of patients with dementia waiting for specialist inpatient bed by day
7. Best practice examples & national evidence
7.1. There is precedent for novel models of intensive community services that have reduced need for inpatient care across several NHS Trusts through both reducing rates of admission and length of stay. Four examples have been listed below.
Functional Intensive Response & Support Team (FIRST) - Essex Partnership University NHS Foundation Trust
7.2. The FIRST team is a functional older adult service as the Trust has established organic dementia crisis services in the locality. The idea was to replicate that model to meet the needs of functional older adults, and this was done in the knowledge of their ageing population (expected to increase by 15.5% by 2029).
7.3. There are 20 dementia beds for Mid and South Essex, this equates to approximately 1 bed per 50,000 of the total population.
7.4. The population covered is 1.2 million. However, this is separated into three locality teams, one in southwest Essex, one in mid-Essex and one in southeast Essex.
7.5. The service has shown:
· 25-35% empty functional beds on older adult mental health wards.
· Operates seven days a week 0800-2000hrs
· Provides in-reach to the Older Adults wards facilitating home leave an early discharge
Hospital at Home Team (HAHT) - Hereford & Worcestershire Health & Care NHS Trust
7.6. During Covid, the trust temporarily closed an older adult mental health ward and moved to the Hospital at Home service provision. Using the pre-existing ward budget, the service was rolled out in a phased manner. Over two years, 343 patients were admitted to the caseload (the same number of beds on the closed ward would have supported 182 patients over the same period). The team is now working towards the service becoming permanent as an alternative to reopening the closed ward.
7.7. Their service has:
· Reduced average Length of stay (LOS) on the ward by 12 days to 44.1 (there have been no out-of-county placements).
· 343 patients supported over the year, whereas the ward would have supported 182
· LOS on a caseload of the Hospital at Home Service was 23.8 days compared to the original length of stay on the ward at 56.5 days.
· More intensive support, joint working, and weekend crisis support have eased the burden on CMHT, allowing them to more effectively support other patients.
· 22% of patients have cognitive impairment and 1/3 of these are living with dementia.
· Care homes have weekend support available from the team which wasn't available before.
· There have been no recruitment or retention issues, and the team reports that "staff want to work here".
Older Persons Mental Health (OPMH) Home Treatment Teams - Berkshire Healthcare NHS Foundation Trust
7.8. The OPMH Home Treatment aims to provide safe and effective home-based assessment and treatment for older adults experiencing urgent mental health problems (urgent is defined as otherwise requiring hospital admission within 48 hours or requiring more intensive CMHT weekly visits). The team serves any age patient with dementia and over 75s with mental health and provides 6 weeks input with service support 24 hours a day, seven days a week. The caseload is 5-8 patients.
7.9. Their service has:
· Reduced LOS.
· Reduced re-admission and admission avoidance.
· Reduced demand on the ageless CRHT overnight phone support.
Services for Ageing & Mental Health Home Treatment Team (SAMH HTT) - Camden & Islington NHS Foundation Trust
7.10. In Camden and Islington, they operate with one Dementia Ward with 14 beds and the Home Treatment Team, which was set up following the closure of a ward in 2015. They cover the population of Camden and Islington who are aged 65+, under an older adult community team or any age with a confirmed diagnosis of dementia in a mental health crisis.
7.11. The aim of the Acute Care Pathway is to improve the care on offer for this population and enable them to receive treatment in their own home as an alternative to admission. Triaging is done over the phone at the point of the referral to ensure that the patient meets the referral criteria.
8.12. The service:
· Holds a caseload of up to 18 patients
· Provides treatment for up to six weeks
· Sees anywhere between 30-40 patients a month
8. Rationale for Change
8.1. The current model of dementia inpatient care in Sussex is unsustainable, both financially and clinically, and promotes an inequity of access to specialist services. The COVID-19 pandemic resulted in several Trusts moving to community-based provision and, in doing so, highlighted the possibility of reducing reliance on hospital-based care, promoting community-based alternatives that are safer, more effective, and facilitate more person-centred care. The way we deliver specialist dementia inpatient care needs to come in line with the strategic direction of our Trust and the wider health and social care system.
8.2. In this section, we will explain the rationale for our proposed change and how it will benefit people with dementia, their families, and our staff and support the Trust's financial sustainability.
8.3. Emphasis on community care - while we know that dementia rates are going to rise across Sussex over the next few decades, there is a growing consensus that dementia care is most effective when delivered in a familiar environment. Care and support provided in a patient’s home can lead to better outcomes and improved patient experience. Surveys undertaken by the Alzheimer’s Society indicate that people with dementia want to stay in their homes for as long as possible. Although clinical practice shows that there will always be a small proportion of people needing purposeful admission to a specialist dementia bed, admission numbers can be reduced by improving community care and home treatment.
8.4. Better use of resources - our data shows 24 of our 50 beds are not being occupied by people requiring specialist dementia inpatient assessment, intervention, or treatment. This is due to three factors: an average of four beds are unoccupied at any one time, and another 18 beds are occupied by patients who no longer need to be in the hospital (CRFD) and several patients being on dementia wards who do not need specialist inpatient dementia care.
8.5. We know that across Sussex, there is variation in the current community provision for patients with dementia who experience crisis. Through improved community services, including closer working with system partners and the emerging neighbourhood community mental health teams, alongside improved discharge processes, we would not require as many beds as there are currently in the Trust.
8.6. Benchmarking with other Trusts - Sussex has 1.6 dementia beds for every 50,000 people. This is more than the number of dementia beds in Hampshire, which has 1.13 beds for every 50,000 people, and in Devon or Mid and South Essex, where there is 1 bed for every 50,000 people.
8.7. Proven feasibility - the recent closure of 10 beds at Beechwood demonstrates that we can maintain safe and effective patient flow with a reduced inpatient capacity. This indicated a potential for efficiencies without compromising quality of care and with no impact on system partners. A caveat to this is that the Beechwood closure was only over a three-month period, and the level of need for dementia beds fluctuates over time. To maintain sustained flow with fewer beds, it would be necessary to also improve crisis avoidance/ response and home treatment services for dementia.
8.8. Meeting local need - Brighton & Hove has a notably younger population compared to other parts of Sussex. This demographic trend is reflected in demand for mental health services, with the JSNA highlighting a significant prevalence of mental health conditions among adults in the city. Conversely, the demand for specialist inpatient dementia beds in Brighton & Hove is lower than in East and West Sussex govern the relatively younger age profile of the population.
9. Options appraisal
9.1. As part of SPFT's financial recovery planning a small task and finish group was brought together to look at options for aligning this with the Trust's strategic intentions for dementia services. This group included clinical and operational leaders.
9.2. Proposals developed were scrutinised by the Executive and Senior Leadership teams with Quality Impact Assessments and Equality Impact Assessments being signed off by the Chief Nursing Officer and Chief Medical Officer.
10. Proposal
10.1. Our proposal is to consolidate our specialist dementia inpatient capacity by initially closing one ward with 10 beds and investing in the strengthening of community services that will address current inequity and provide preventative care, reduce admissions and support patients with dementia in their own homes in the community when they experience a crisis.
10.2. This proactive change follows the model of community-based care models, generates necessary cost savings, and strengthens the resilience of our Trust and the wider Sussex health and care system.
10.3. This strategic approach will also allow for a more integrated and responsive care pathway, which will help us to effectively reduce the length of stay in our inpatient units, further improving patient care and delivering efficiencies. In addition, the expertise within the community will prevent admissions, support timely discharges and help people to remain in their familiar place of residence.
10.4. Our vision is to transform community care for patients with dementia by providing a holistic approach that considers biological, psychological and social factors through integrated and aligned services. The outcomes will be to enhance the quality of life for people living with dementia and avoid escalations of distressed behaviour and unplanned admissions or transfers of care.
10.5. In summary, in our option we will:
· Enhance community provision - commence recruitment efforts to bolster community-based intensive support teams in East Sussex and strengthen provision in North West Sussex. In addition, extend the ability of teams in Brighton & Hove and East Sussex to prescribe short- term social care packages during a time of crisis. In East Sussex we expect community teams to provide support to an estimate of 90 people per year, reducing the need for inpatient admissions by effectively managing patients in the community and in their own place of residence. This figure is based on projected activity taking into account short termintensive community support for approximately six weeks, the number of staff in each proposed service and the current number of dementia admissions each year. Each Intensive Support Team will involve direct patient contact, collaboration with other healthcare professionals, participation in multidisciplinary team meetings and support to carers. The teams will also provide lower-level intensive support to a wider group of patients, in collaboration with colleagues from neighbourhood mental health teams social care and the community and voluntary sector to offer preventative care.
· This work will align to the developing model of Integrated Community Teams across the ICS, enabling the improvement of joined-up care pathways with physical health and frailty teams The intensive support teams will also improve joint working with the voluntary and community services working with older people and families affected by dementia, and work in partnership with Urgent Care Response Teams and Virtual Wards, leading to a ‘wrap-around’ responsive service to people within their usual place of residence
· Convert Brunswick Ward as adult acute inpatient unit - facilitate a smooth transition by re-providing 15 independent sector beds to Brunswick Ward to realise efficiencies and enable further recruitment for community provision.
· Redesign older adult inpatient model - ensure that if there is occasionally a higher level of need for dementia admissions, older adult functional inpatient wards will be able to support people with dementia, thus mitigating the reduction in dementia specific bed capacity.
· Consider future opportunities to reduce the dementia bed base in 2026/27, realising the benefits from the enhanced community services (from the proof-of-concept), achieve our indicative bed model and maximise the benefits of a Sussex-wide Centre of Excellence for specialist inpatient dementia care at FMNU.
11. Impact on adults requiring an acute inpatient admission
11.1. The proposal to convert Brunswick Ward into an adult acute ward will help to address the greater local demand for adult acute mental health beds, ensuring resources are aligned with the most pressing needs.
11.2. Having 15 additional adult acute beds in the city will mean that circa 60-70 more patients per year will receive their inpatient care in Brighton & Hove as opposed to having to travel to East or West Sussex.
11.3. Receiving care closer to home improves patient outcomes because people receive inpatient care nearer their personal support networks and it ensure that there is more communication and engagement from their local community team.
11.4. It is also anticipated that the additional 15 inpatient beds in the city will reduce the length of time patients wait for admission across all settings noting the particular pressures at the Royal Sussex County Hospital.
12. Impacts on people living with dementia and carers
12.1. The proposed conversion of Brunswick Ward to an adult unit will have a minimal impact on Brighton & Hove residents with dementia. The city already has robust community-based dementia services, ensuring better care for local patients compared to those in East Sussex.
12.2. While admission would necessitate travel to Worthing or Uckfield, the actual number of Brighton & Hove residents requiring inpatient dementia care is low (approximately one per month), with a proportion already being admitted to these locations. The current occupancy rates of the Beechwood and FMNU wards mean there is sufficient bedded capacity to accommodate Brighton & Hove residents who may require inpatient admission. For people living in Brighton who require an admission to a dementia bed currently on average one a month will travel to a unit outside of Brighton. If these proposals are accepted this would increase to two to three a month. The additional length of the journey to either of the other units is on average 15 minutes by car.
12.3. Conversely, the change primarily affects East Sussex patients, of which 21% of people admitted are currently admitted to Brighton or Worthing. The closure of Brunswick Ward means these individuals will need to access care in Worthing or in Uckfield. We will mitigate the impact of this by the development of Intensive Support Services (IST). These teams, which are at the centre of our proposals, provide direct, evidence-based interventions to patients and their carers/care home staff in their own homes, offering crucial support and monitoring during periods of increased need.
12.4. Overall, while the ward conversion necessitates some adjustments, the established strength of Brighton & Hove's dementia services and the introduction of robust community support mechanisms will ensure continuity of care and minimise disruption for patients across the region.
13. Implementation
13.1. Implementation is proposed, subject to NHS Sussex approval, over a 2-year period.
13.2. It is proposed to undertake engagement work with partners to test and socialise the proposals over the next two months whilst working towards temporarily closing Brunswick from 1st November. A particular focus during this time will be on reducing those patients clinically ready for discharge to give capacity in the other hospitals.
13.3. Simultaneously an intensive support service in East Sussex will be implemented from December 2024 to provide additional capacity to support patients with dementia in crisis and reduce the need for an inpatient admission.
13.4. Over the next 12 months further work will be undertaken to ensure consistency of clinical and operational models across the three places and ensure that variation (e.g. in access times) is warranted as opposed to for historic reasons.
14. Risks and Quality Impact
14.1. A Quality Impact Assessment and an Equality Health Impact Assessment were completed and agreed by the Chief Nursing Officer and Chief Medical Officer which showed a favourable benefit of the changes.
15. Summary and recommendations
15.1. Sussex ICB has drafted its adult mental health, learning disability and autism inpatient strategic plan for the next 5-years which makes clear intentions about the provision of inpatient dementia services in Sussex.
15.2. This paper develops those intentions and presents a case for change to repurpose Brunswick ward at Millview Hospital, Brighton from a 10-bed dementia ward to a 15-bed adult acute ward.
15.3. This proposal is in alignment with both our intentions to reduce reliance on hospital care for dementia patients and strengthen community provision and also avail ourselves of the opportunity of capital monies from NHSE to increase the adult acute bed capacity in Brighton and reduce our reliance on independent sector beds.
15.4. NHS Sussex has endorsed this case for change noting the anticipated improved patient, service optimisation, and financial outcomes. The Brighton & Hove Health Overview and Scrutiny (HOSC) Committee are asked to support the recommendations of this case for change.
Appendix I - Strategy and policy drivers impacting dementia services
|
Strategy / Policy Document |
Key Themes and Case for Change Strategic Fit |
|
A Consensus Statement on healthy ageing – published October 2019; updated February 2023[10] |
· The consensus statement outlines principles to support healthy ageing, including improving living conditions, health education, workplace support, housing quality, and narrowing health inequalities to improve a disability-free life for longer. |
|
Sussex Health & Care Partnership – Improving Lives Together – Shared Delivery Plan – published July 2023[11] |
· The plan outlines the agreed priorities and actions to be taken in health and care in Sussex. A particular focus is placed on the development of Integrated Community Teams (ICTs) designed to help health and care services work together better, which is important for managing and supporting people with complex conditions, such as dementia. |
|
NHS England’s Dementia Wellbeing Pathway (The Well Pathway for Dementia) – First published February 2020[12] |
· The pathway provides guidance for frontline health and care staff to use their trusted relationships with individuals, families, and communities to promote the benefits of focusing on dementia. · The pathway promotes a comprehensive, coordinated response to the needs of individuals with dementia at all stages of their journey, from initial concern and diagnosis through to end-of-life care. · The pathway promotes care that allows people with dementia to live independent and healthy lives. |
|
NHS Long Term Plan – published January 2019[13] |
· The plan outlines a comprehensive approach to dementia care, with a focus on improving the quality of care, promoting early diagnosis, and enhancing support for people living with dementia and their families. · The plan recognises the importance of supporting people with dementia, including support for getting people home from the hospital without unnecessary delay. · The plan emphasises the importance of implementing NICE guidance to ensure access to post-diagnostic treatment and support. |
|
The Dementia: Good Care Planning guide – published February 2017[14] |
· The guide provided guidance on how to deliver person-centred care planning for people living with dementia and their carers. · The guide covered the key components of good care planning, such as assessment, diagnosis, communication, information, support, review and evaluation. |
|
NHS Dementia 2020 Challenge –published February 2015[15] |
· The NHS Dementia 2020 Challenge provided a comprehensive framework for improving dementia care, from prevention and diagnosis through appropriate crisis management to treatment and support to patients and carers. · It highlighted the need for a person-centred, integrated and proactive approach to dementia care. |