Although a formal committee of Brighton & Hove City Council, the Health & Wellbeing Board has a remit which includes matters relating to the Integrated Care Board (NHS Sussex,) the Local Safeguarding Boards for Children and Adults and Healthwatch.
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Title: Brighton & Hove Shared Delivery Plan Report 2025/26
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Date of Meeting: 16 December 2025
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Report of: Steve Hook Director Health & Adult Social Care & Tanya Brown-Griffith NHS Sussex Director for Joint Commissioning and Integrated Community Teams – Brighton and Hove
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Contact: Chas Walker
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Email: Chas.walker@brighton-hove.gov.uk
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Wards Affected: All
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FOR GENERAL RELEASE
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Executive Summary The report provides the Health & Wellbeing Board with a mid-year review of our performance against our Place-based 2025-26 Shared Delivery Plan Objectives for the purposes of assurance The Shared Delivery Plan is a statutory requirement that each Integrated Care Partnership across the country has an Integrated Care Strategy, which includes an annual Joint Forward Plan (what we call a Shared Delivery Plan). The Sussex Integrated Care Strategy includes the aims and objectives of each of the three Place partnerships and their Joint Health & Wellbeing Strategies. This is translated into local Place-based Shared Delivery Plans that support both the delivery of the Joint Health & Wellbeing Strategies and the delivery of the Sussex Integrated Care Strategy. The report covers:
The Board are asked to consider progress against our agreed three priorities areas and 13 associated objectives. Noting that out of the 13 objectives we set, we are on track with 10, one is delayed and two are behind on anticipated delivery targets. At the meeting we will focus more time on the objectives that are delayed and behind on anticipated delivery.
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Decisions, recommendations and any options
Brighton & Hove Health and Wellbeing Board is recommended to: 1. Note the performance of our 2025/26 Shared Delivery Plan Objectives |
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- Background & context
1.1. The Sussex Integrated Care Strategy Improving Lives Together is a five-year strategy that was established in 2022. The strategy sets out the following ambition
Our ambition is to improve the lives of everyone living across Sussex now and in the future. We want local people to thrive to be the best they can be; to be healthier and feel supported; and have the best possible services available to them when and where they need them.
The strategy and associated Shared Delivery Plan (SDP) have four delivery areas- 1) long-term improvement priorities 2) immediate improvement priorities 3) continuous improvement areas 4) health & wellbeing strategies and local health & care partnerships
1.2. The Brighton & Hove Joint Health & Wellbeing Strategy was agreed in 2019 as a long-term strategy to 2030. The strategy sets out the following ambition:
Everyone in Brighton & Hove will have the best opportunity to live a healthy, happy, and fulfilling life
The strategy is based on a life course approach (starting well, living well, ageing well, dying well)
1.3. The SDPs are refreshed annually based on the five-year timescale of the Sussex Integrated Care Strategy (noting we are currently in year 3) and focus on delivering the ambition set out in the Integrated Care Strategy. In meeting the formal requirements of this Board, the report focuses on the SDP objectives specific to our local health & care partnership
1.4. Our Place-based SDP objectives were developed through our health & care partnership and responded to the Sussex health & care system priorities for 2025/26 and our agreed local Health & Wellbeing Board priorities. The delivery of the objectives has a strong connection with the work of Integrated Community Teams including the Neighbourhood Mental Health Teams and the objectives were formally signed off by the Health & Wellbeing Board at its meeting in April 2025
2. Performance against our Place-based Shared Delivery Plan objectives 2024-25
The table below sets out the agreed SDP priorities for 2025/26 and the current performance rating for each objective
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Brighton & Hove Shared Delivery Plan Objectives 2025/26 |
RAG Rating |
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Priority 1 - Highest & Ongoing Health & Care Needs As agreed through the MCN Partner summit Nov 24 we will: • Establish the Brighton & Hove Multiple Compound Needs Integrated Community Team (MCN ICT) • Action the recommendations, via the MCN ICT, of the external evaluation of the MCN pilot service • Deliver the agreed outputs from the MCN partner summit through the new MCN ICT partnership Through the development of our local ICT Partnerships we will: • Embed the learning from our neighbourhood ICT 65+ frailty pilots as part of the development of our local ICTs |
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Complete |
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On track |
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On track |
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On track |
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Priority 2 - To prevent ill health, maintain health and reduce future demand Through the development of our local ICT partnerships we will: • Develop a local ICT plan that supports System aims for CVD, Tobacco cessation, falls prevention and Act on Cancer • Ensure our Local ICT Plan targets our core20plus5 communities across the city • Deliver locally on aims of the Sussex Health Inclusion Framework Deliver the agreed priorities of our Local Health & Care Partnership and its local Health & Wellbeing Plan • Children & young people’s mental health & emotional wellbeing with a focus on transition to adult services • Respond to the B&H Health Counts Data and insight |
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On track |
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On track |
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On track |
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Off track |
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On track |
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Priority 3 - Our neighbourhood first transformation programmes Through our Place Delivery Group and Local ICT partnerships we will: • Align our local family hubs with our ICTs to improve our health & care offer to children, young people & families • Establish the work of our Neighbourhood Mental Health Teams with our Integrated Community Teams • Establish the new women's health hub through our Integrated Community Teams • Deliver Work-well programme pilot through our East Integrated Community Team Partnership |
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On track |
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Delayed |
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Off track |
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On track |
- Shared Delivery Plan Outcome Area- Highest and Ongoing Health & Care Needs
3.1. Highest & Ongoing Needs is an NHS national priority within the neighbourhood health reforms. In Sussex this priority is being delivered through the Sussex Highest & Ongoing Needs Programme, which is being led through the Sussex Neighbourhood Alliance (a formal alliance of Sussex NHS community Health Providers) and supported at Place through the local ICTs. The programme is central to the new NHS Sussex Commissioning Intentions 2026 27 with its strong focus on reducing avoidable admissions into our hospitals through taking a more integrated and pro-active care approach in the community to meeting the needs of those people with the highest and ongoing health & care needs. The new Sussex Neighbourhood Health Framework sets a performance metric for all ICTs to reduce by 3% avoidable admissions in over 65’s this year and 5% the following year. Achieving these targets will enable left shift of resources, up to 3% of acute hospital budgets, into neighbourhood health services
3.2. Homeless & Multiple Compound Needs- is one of our agreed population health priorities as well as population group with some of the Highest & Ongoing Needs in our local community. Last year our health & care partnership agreed to take the learning from our Homeless & Multiple Compound Needs frontrunner programme and establish a city wide Homeless & Multiple Compound Needs Integrated Community Team (H&MCNs ICT) as set out in the model below.
3.3. Key achievements, so far this year have been:
· We have established a local H&MCN ICT with a group of H&MCNs system leaders agreeing a new Compact Agreement that provide the basis for the way partners will work together to improve outcomes for people who are H&MCNs
· The H&MCN ICT have completed a Multiple Needs Audit to better understand the levels and nature of presenting H&MCNs in the city.
· The H&MCNs ICT is finalising the long-term model for a Multidisciplinary Team (MDT), sustaining and building on the learning from the Changing Futures Team. The MDT will use the Multiple Needs Audit to prioritise access to the MDT to ensure those most at risk of using our hospital system are reviewed and provided with an integrated and pro-active health, care and support services.
· The H&MCNs ICT is testing a digital integration approach through a digital Interface tool that enables partners to access required patient/ service user records held by the different partners in their localised data systems. The interface tool is being tested through the MDT with a view to rolling out more widely across H&MCNs ICT partners and using the learning to support moe widely the development of ICTs
· H&MCNs ICT leadership group have agreed a set of outcome metrics that align to the agreed domain areas in the Sussex ICT outcomes framework and have focus on highest & ongoing needs, staff activation and development, pro-active care and co-design.
3.4. Integrated Community Teams & Highest & Ongoing Needs Programme- the programme is built around a risk stratification model for identifying existing patients whose health & care needs are such that they are most likely to end up in hospital. The risk stratification approach utilises specialist predicative analytics software that uses the patient information held in the Sussex Integrated Data set to provide risk stratified list of patients. Local Health & Care Partners are being asked to come together at a Primary Care Network (PCN) level and set up multidisciplinary teams (MDTs) to review these patient lists and agree a pro-active care plan for each patient.
3.5. Across our three Brighton & Hove neighbourhood partnerships we have agreed 5 MDTs, two within each or our West and East partnerships (based on PCN boundaries). In our Central neighbourhood partnership we are going to have a single MDT because population size and patient numbers, with highest & ongoing needs, are lower in this part of the city
3.6. Sussex Community Foundation Trust (SCFT) have employed 3 MDT co-ordinators to lead on the coordination of our 5 highest & ongoing needs MDTs. All our GP practices have signed up to the locally commissioned services contract which provides primary care with some funding to engage in the MDTs and enables the highest and ongoing needs patient list information to be gathered at practice level.
3.7. All the patient lists have been provided to the co-ordinators and highest & ongoing needs MDTs will start in December involving primary & secondary health care, social care, VCSE partners
3.8. In addition to the work above the West ICT have extended their original frailty pilot from last year and will merge this work into the development of the highest & ongoing needs programme. Work between SCFT and University Hospital Sussex NHS Foundation Trust to better co-ordinate their support of local residential care and nursing homes is also underway as a key approach to reducing hospital admissions and promoting timely and safe discharge in our nursing and residential care homes
- Shared Delivery Plan Outcome Area- to prevent ill health, maintain health and reduce future demand through the development of our local Integrated Community Team (ICTs) partnerships:
4.1. We have three neighbourhood-based ICT partnerships across the city (East, West Central). These partnerships align to PCN boundaries and are consistent with our Neighbourhood Mental Health Teams with population sizes ranging from 73,000 to 105,000 in each ICT area.
4.2. Our ICT partnerships have been running now for 12-18 months, are co-chaired between our VCSE community development partners and our clinically led through Primary Care and well supported by all health & care partners. As part of the national Neighbourhood Health programme Integrated Care Boards (ICBs) are being asked to assess the maturity of their Neighbourhood partnerships. The assessment of our ICTs ranged between ‘developing’ and ‘maturing’ and were generally a little higher in their maturity ratings than the partnerships in East and West Sussex
4.3. This year we have refreshed our original ICT data-packs to include more health & care information at an ICT level than was available in the original packs and to also bring the results of the recent Health Counts survey into the new data packs. Brighton and Hove ICT data profile by Brighton and Hove City Council
4.4. The data packs are complimented by the new Sussex ICT Dashboard, which provides data on agreed ICT performance metrics, aimed at improving population health, at an ICT level. The metrics focus on data and performance around key areas of reducing hospital admissions and prevention of illness.
4.5. Each of our ICT partnerships are using the local data packs and performance dashboard to develop local ICT plans to improve the health of their local populations. These plans are expected to be completed by end of March 2026 and will inform and be part of the refresh of our local Health & Wellbeing Strategy.
4.6. All our ICT partnerships are actively developing localised and integrated community-based health service models, with a focus on tackling local health inequalities. In the East they are focusing on an integrated health hub targeting some of our most deprived communities across the Whitehawk Estate with satellite hub models bringing health services into established community settings in Bevendean and Moulsecoomb. In the Central ICT they are delivering similar approach focusing on deprived communities and utilising existing community infrastructure to deliver more accessible preventative health & care services. In the West they are building on their well-established being well in the west community health events
4.7. These localised ICT models are currently being supported through Public Health grant, Primary Care funding and existing provider resources. There is a strong desire to build on these models over time as key local infrastructure for the delivery of the neighbourhood health ambition. The new NHS Sussex Commissioning intentions and the anticipated national neighbourhood health framework and plan will be key to achieving this.
4.8. Shared Delivery Plan Outcome Area- Health & Wellbeing Board Objectives
4.9. Improving children & young peoples (CYP) mental health transition from children to adult services. This is an objective we have highlighted as behind in its anticipated delivery trajectory. Changes to the roles the ICB as strategic commissioner and NHS providers as leading strategic implementation is still bedding in and has left a gap in project managing this objective area and ensuring there is a clear action plan for delivery.
4.10. Some initial assessment work carried out by ICB commissioners confirmed several structural barriers to improving transition including- inconsistent eligibility criteria across children and adult mental health services, the size of waiting lists in children’s and adult services, insufficient access to preventative and early support for young people, over 18’s services not sufficiently tailored to the needs of young people.
4.11. This objective remains a priority for our health & care partnership, so the Local Authority and SPFT have been reviewing there existing work around transitions and how this can be leveraged to ensure we are taking a strong partnership approach. The Local Authority is considering how its current transitions strategy can further act as an enabler for this outcome area and the possibility of recruiting additional programme management resources to facilitate delivering the aims of the strategy. SPFT also recognise the importance of this work and are identifying leads to work in partnership with system partners to progress this. A key outcome of the Community CAMHS transformation is to see a reduction in wait times for assessment and treatment which will limit the risk of young people 'aging out of CAMHS' without having been seen.
4.12. Actioning Heath Counts survey result- the results of Health Counts 2024 showed a declining trend in how healthy people felt in the city, with this trend being most evident in our most deprived communities pointing towards a growing health inequalities across our city.
4.13. In the summer we held a Health & Wellbeing Board partnership workshop bring partners together to review the results and get some early feedback on how we should interpret and action the results. One of the themes coming out of the workshops was the responsibilities of Health & Wellbeing Boards to set out plans to improve population health and on the back of these results the need to refresh our local Health & Wellbeing Strategy in responding to the needs identified in the survey. The Board agreed this as a next step and has started the work to refresh the strategy through a number of additional Health & Wellbeing Board development sessions, with the first one being held in November.
5.1. Children & Young People (CYP) ICT offer- the Sussex Neighbourhood Health framework sets out a clear expectation that ICTs will support improved health & care outcomes for CYP and this work is being taken forward by Directors of Children’s Services and the Sussex Neighbourhood Health Alliance. Local ICTs are being asked to support the development of a CYP offer based around Local Authority children & family hubs. Locally we agreed that the detailed governance of this work would be supported by the city’s Family Help Partnership Board. At their last meeting the Board agreed to take a frontrunner approach using our West ICT partnership to test and develop a CYP ICT offer. It was agreed to form a CYP Subgroup of the West ICT Leadership Group to develop a more detailed front runner programme of work. The subgroup will be co-chaired by LA and NHS provider and convened through Hangleton & Knoll Project.
5.2. Neighbourhood Mental Health Teams (NMHTs)- this is a joint programme of change being delivered in partnership by SPFT and the VCSE. Originally, NMHTs were scheduled to go live alongside the launch of a new Electronic Patient Record (EPR) across SPFT which was scheduled for November 25. However, with the EPR rollout now planned for early 2026, it was agreed that the NMHTs will go live in December to maintain momentum and build on the integrated working already underway. Until the new EPR launches, NMHTs will continue using existing online patient record systems. Once the new EPR is rolled out, NMHTs will strengthen their model through a shared online patient record, shared performance data, and fully aligned NMHT teams to ICT boundaries.
5.1. Women’s Health Hub are part of national programme to improve access for women to eight core women’s health services, with each ICB asked to pilot and develop women’s health hubs. This is the other objective area that we are at risk of not delivering. The Brighton & Hove Hub Pilot was launched through Brighton GP Federation as citywide service meeting the health needs of women across the city. There was a small amount of funding available to support the launch of the Hub infrastructure with the expectation that local systems would work closely with primary and secondary care to better align existing resources into the Hubs to build their capacity. This process hasn’t worked as effectively in Brighton & Hove as it has in East and West Sussex with our Hub delivering far less women health hub appointments than our neighbours. The reason for this is the Federations model has not been able to leaver in existing primary care payment mechanisms for specialist women’s health interventions that would make the model sustainable. In East and West Sussex the Hubs have been delivered directly by particular practices with existing expertise in Women’s Health, which has enabled a successful funding model to be aligned with a hub approach. Brighton & Hove Health & Care partnership are reviewing their existing arrangements and developing a plan utilising the learning from colleagues in East and West Sussex to create a more sustainable model. We will bring this work back to the next Health & Wellbeing Board meeting to update on progress
5.2. Work-well Programme- is another national NHS programme focused on supporting people who are on health-related benefits back into the work-place. The programmes are being developed through local pilots and then the learning from these pilots will inform future models of delivery. Local consultants are working with systems to help analyse data and support the development of the pilots. In Brighton & Hove the data pointed to the East of the city having the greatest prevalence of people not in work due to health-related issues. It was agreed to run the pilot through the city’s East ICT partnership and utilise the East Health Hub infrastructure. The pilot model has been agreed by local partners signed off by the Sussex Work-well Programme Board and has moved successfully into the delivery phase.
7. Important considerations and implications
Legal:
7.1. The Shared Delivery Plan objectives support the statutory duties [prescribed by The National Health Service Act 2006 (as amended by the Health and Care Act 2022)] of the Health & Wellbeing Board in relation to the delivery of the Sussex Integrated Care Strategy and the Brighton & Hove Joint Health & Wellbeing Strategy
Lawyer consulted: Sandra O’Brien Date: 5 December 2025
Finance:
7.2. The Shared Delivery Plan objectives are supported through existing budget commitments across both BHCC and NHS Sussex with specific support through the agreed Better Care Fund for 2025-26.
Finance Officer consulted: Jane Stockton Date: 02/12/2025
Equalities:
7.3. Equalities is built into the Shared Delivery Plan and is referenced in detail within the main report
Sustainability:
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7.4. None
Health, social care, children’s services and public health:
7.5. The roles and implications for all partners are set out in detail in the main report
8. Supporting documents and information