- The development of our mental health service offer provided by adult social care to deliver a progressive service
- Our Prevention Assessment Teams who ensure people who might otherwise not be eligible for adult social care have access to multi-disciplinary, community centred support, advice and guidance, at an early stage in their journey
- The development of our extra care model to increase choice and control by providing customers with housing that enables independence
Working with people
In the overview and summary section, we have described how our front-line services have been on a major journey of change since Covid-19. In this section we include examples which demonstrate that change, either in terms of the what or the how. We have also focused on areas which are key to the next stage in our improvement journey.
- Embedding our approach to strengths-based practice
- Review and develop our approach and processes regarding Direct Payments
- Further work on improving our hospital discharge process
Key Activity (2023-24)
“I would just like to take this opportunity to thank you for all you have done - although an extremely difficult and challenging time, it has been so incredibly helpful to have either your voice at the end of the phone or your words at the end of an email!” From a relative of an Adults' Services customer
"I am writing to express my sincere thanks for the exceptional service you have given to my family. Your attention, care, and timely responses during difficult and crisis times have been truly recommendable. Your expertise and dedication in delivering outstanding services have greatly impressed us. I cannot express my gratitude enough. We know that you have made us a firm foundation. There were times when I had no words to explain how deeply your actions have moved my family from a state of despair and pain to good mood and relief. Thank you so much for your support, care, and guidance." From a relative of an Adults' Services customer
"Our worker was always approachable and friendly. They always spoke in a calm and clear manner. They never made us feel that we were unimportant or stupid for not knowing the process. They listened well and always sent me an email covering what we had spoken about to avoid any confusion. Our worker often took the time to answer questions that were not in their area of responsibility. They took the time to understand our and my relative's needs and views as well as explaining all the decisions made and the rationale behind them. Most of all, our worker was always making decisions and recommendations in my relative's best interests. My communications with them, via email or phone, were always useful. Quite often they was able to put our minds at rest by talking us through
the process of my relative needing a residential placement in a nursing home. The whole process of my relative losing capacity and requiring a placement in a residential nursing home would have been far more stressful if our worker had not been available to talk to. They took the time to make the next steps in the process clear to us. We were very satisfied with our dealings with our worker. If we could, we would want them to remain as my relative's assigned social worker. They made such a positive difference to us in what has been a very difficult and emotional time. It is not an easy job and we appreciated them very much." From a relative of an Adults' Services customer
"A very big thank you for the way you have all rallied to make things happen for my relative. My relative seems very happy and comfortable. Please pass on mine and my family's heartfelt thanks for what you have achieved for our relative." From a relative of an Adults' Services customer
"I would just like to thank you all, especially our workers, for the kindness & understanding you have given to me, over the last few months. From the phone assessments, their visit & talking to my husband. The whole process could have been an added stress for me but it wasn’t - thanks to you. Your due diligence has been such a comfort - knowing, that possibly in the future, you will be there. West Sussex are lucky to have such amazing teams. So, once again, my sincere thanks." From a relative of an Adults' Services customer
Assessing needs
“We maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them”.
Assessing Needs
Assessment has been a major focus for us with an increase in demand and complexity, particularly as a result of the Covid-19 pandemic, which has been experienced nationally. Activity has been multi-faceted, but at a high level has been centred around implementing a new workflow and assessment tool and developing our strengths-based practice model, to focus on a person-centred journey rather than a system led one, and supporting those customers already in receipt of care and support. 71% of staff (73% of frontline staff) agreed that the service maximised the effectiveness of people’s care and support by assessing and reviewing their health, care, wellbeing, and communication needs with them. Staff commented on the effect on customers and carers of delays caused by demand pressures and workforce shortages. They also emphasised the impact of this situation on their practice, such as delivering a strengths-based approach, and their wellbeing.
Hospital discharge
Our work on hospital discharge has ensured fewer people stay in hospital no longer than they need to, however across the system we recognise this as an area for improvement. In 23/24 we supported over 3500 customer discharges from hospital, and a further 266 pieces of work to divert people from a hospital admission. We also completed 472 unplanned reviews in 2023/24 on people with long term services due to hospital admission.
Our approach stems from cross-system partnership working evidenced from staff feedback and is well aligned to other services, such as the jointly commissioned and delivered Home First service which supports people to discharge from hospital. Further details on the service are included under the Supporting People to Live Healthier Lives section. In 2023/24 there were 4827 referrals to the Home First pathway, of which 4119 remained in their own home after the service. We know there is more work to do in this area and it has been identified as an area of improvement.
In West Sussex, discharge from general acute hospitals is managed via the "Transfer of Care Hubs" to manage discharge pathways with clear plans once people no longer meet the criteria to reside in hospital. Progress towards discharge is managed via daily “touchpoint calls” and system wide meetings. Social workers are involved with discharges from both acute and community beds and take a lead in moving people on from Pathway 1 (intermediate care and reablement services provided in own home). Innovative use of temporary funding from the ICB enables us to seasonally flex our social work capacity and manage demand effectively throughout the year.
We have implemented a permanent brokerage and sourcing team to ensure sufficient capacity and focus is given to patients being discharged from hospital requiring care and support. This team is proving highly effective in managing referrals, making best use of our resources by accessing appropriate care and support for people at the right time.
Sussex Integrated Care System have a programme to improve experiences of people requiring acute general or psychiatric hospital care. This includes improvements to intermediate care and the implementation of Transfer of Care Hubs mentioned above, which will link all relevant services across sectors to aid discharge and recovery, as well as admission avoidance.
In January 2024, a review of post-acute-hospital intermediate care services was undertaken by Professor John Bolton on behalf of the Sussex Integrated Care System (ICS). The review identified the system needed to find a way to both reduce demand and improve efficiency. The conclusions and findings from this report have been incorporated into the development of an improvement plan which sets out our priorities for hospital discharge. The actions and outcomes are detailed below:
- Useful, reliable data to help us understand and manage daily operations around hospital discharge and inform decision making for future improvements for the council and system
- Best practice and efficient processes in place for the ASC hospital discharge teams, aligning with transfer of care hubs. Promoting people to regain independence and return home wherever possible and towards a discharge to assess and recovery model
- Partner and system relationships for clarity around leadership models, funding structures and desired outcomes to enable smoother working and transitions
- Ensuring adequate social work workforce which is resilient and able to meet seasonal escalation in demand and developments in approach to hospital discharge
Mental health
Our adult services mental health offer has been through a period of rapid change over the last two years. Following a joint review with health partners, the Section 75 provider-to-provider staff secondment agreement ceased in April 2021. This was due to concerns that compliance with social care legislation and practice was not being prioritised as expected.
A significant improvement programme was undertaken during 2020 and resulted in the creation of a new service model, underpinned by solid social work practice. This has resulted in both a robust mental health social work service with a significant increase in Care Act assessments being carried out, and an approach which encourages effective partnership working, innovation and excellence.
ASCOF data for 2022/23 shows that people in contact with secondary mental health services living independently with or without support is 47% in West Sussex against the England average of 20.3 People in contact with secondary mental health services in employment in West Sussex is 17% against an England average of 5.5%.
The national challenge for the mental health service is a workforce shortage of Approved Mental Health Professionals (AMHPs). West Sussex County Council have, however, implemented a twenty-four-hour, seven day a week hub-and-spoke model in response to the difficulties experienced managing the increase in demand for Mental Health Act (MHA) assessments. This has enabled us to better manage the workload, respond to risks and optimise existing resources. We have developed a recruitment and retention action plan to ensure we have sufficient AMHPs to meet the needs of the population, in both the short and long term.
The mental health service secured some additional funding which we have used to support the acute general hospitals by providing an onsite Accident and Emergency (A&E) AMHPs. These AMHPs are based at the hospital during peak times to ensure timely assessment under the MHA where this is indicated. Part of the role of the A&E AMHP is to provide advice and guidance to health partners, diverting assessments where appropriate and signposting to other services using a least restrictive and strengths-based approach.
Strategic work has been undertaken to ensure that the mental health needs of the population are given equal priority in terms of system-wide investment. This resulted in funding being agreed from the Hospital Discharge Grant to develop a mental health discharge hub, jointly with the local mental health trust. The Mental Health Social Worker Discharge Team (MHSWDT) was set up in 2022 and provides a service covering the entire county of West Sussex. Where a West Sussex resident is in an out of county hospital, we will support the discharge for that patient and liaise with the other local authority.
The MHSWDT discharge hub enables timely and effective assessment and discharge supported by a team of staff who are solely dedicated to support mental health hospital discharge, daily touchpoint calls with NHS partners to ensure clear communication, sharing of information and joint decision making and better relationships built through the multi-disciplinary approach which improves outcomes for patients.
The challenges for the MHSWDT include ongoing funding, the care market and its capacity to provide suitable services to meet the needs of our customers, including developing new services to meet demand.
We were recently invited by the Department of Health and Social Care (DHSC) to discuss the A&E AMHP pilot and MHSWDT pilot with civil servant colleagues who are interested in our model and we received excellent feedback.
We have led a joint international recruitment project in partnership with colleagues from Sussex Partnership NHS Trust to fill vacancies across mental health teams in the council and the mental health trust. This has been very successful and has helped both organisations to fill much needed roles.