ICS System Learning from Winter 2022 - 2023

1. Introduction Friday 12 May 2023 - Adastral Park, Ipswich ICS System Learning from Winter Pressures 2022/23 Dr. Ed Garratt, CEO NHS Suffolk and North East Essex, Susannah Howard, ICP Director and Dr. Tim Nye, West Suffolk Hospital After a short introduction to the day from ICP Director Susannah Howard, Ed began by thanking everyone present for their considerable efforts over the past year, recognising it was a year like no other in terms of the impact of the pressures upon services. We now have an opportunity to take stock and think about how we can redouble our efforts in the coming year. In Suffolk and North East Essex we have a culture of learning, and this report will help us to be stronger as we move forward together. This is important for our communities because as ESNEFT says, ‘Time Matters’. Too often local people have been on the wrong side of time. Currently we have over 110,000 patients on waiting lists, and over 5,000 people waiting over a year for elective care. We have concerning patient safety issues: in our emergency departments we have seen a steep rise in waits over 12 hours which increases risks of ill-health and morbidity, and delays in ambulance handovers which prevent ambulances from a timely response to support people back in the community. There have been concerns about access in primary care, particularly in dentistry, and a steep rise in mental health issues, particularly self harm among children and young people. Our communities want us to improve in these areas. We thank our staff, who are very creative, compassionate and committed. But they are facing a very difficult situation, they have been under huge pressure, having to sustain increased demand but also facing shortages in resources, together with the cost of living and concerns about fair pay. Even with all these concerns, we have seen incredible innovations in the past year. For example, we now have some of the most sophisticated technology in social care today, the Cassius service in Suffolk has received over 3,000 referrals in the past year with a 98% satisfaction rate and a demonstrable impact on keeping people healthy and independent. Our neighbourhood teams are making a real impact, now with the benefit of population health management technology capabilities. Our Alliances continue to mature and see the benefits of joined-up working with the NHS, social care and community organisations. We are modelling integrated care in the community hub recently developed with the ambulance trust, which is proactively supporting people waiting for ambulance response and successfully keeping them independent in their community. 1 | Suffolk and North East Essex Integrated Care System

Clinical leadership has moved from a period of competition to one of collaboration; clinicians at West Suffolk and ESNEFT have moved from a 30-week gap in waiting lists between the hospitals to working together to equalise waiting lists across the system, an amazing achievement. We have also now launched a mental health collaborative, and associated services, some of the most impressive of which are in the voluntary sector. The children’s crisis team has seen a reduction in Tier 4 placements, bucking the national trend. In general practice, the national ‘Delivery plan for recovering access to primary care’ published this week includes a case study from Suffolk on a demand-led approach which has been used as a model nationally. Our innovations have led to some fantastic results in the past year. In cancer we have seen an 18% increase in first treatment on average compared to prior to the pandemic. We have bucked the national trends in hospital discharges across the system. We have seen a very significant reduction in ambulance conveyances, in part due our collaboration. We also have the prospect of significant new resources coming into our system in the next year. The community diagnostic centre in Clacton benefits the community by delivering over 100,000 tests a year, and in 2024 a similar centre opens in Newmarket. In 2024 we have a new emergency department, urgent treatment centre and surgical hub at Ipswich, and the Dame Clare Mark orthopaedic centre at Colchester. All of these resources will help our resilience and our recovery and importantly, attract the best staff into Suffolk and North East Essex. In conclusion, we should be very honest about what hasn’t worked and where we’ve fallen down in the past, and where we think we can improve. We should be open minded about innovation, and the potential combinations and partnerships that might deliver those innovations. We hope that everyone’s voice is heard, and that everyone can contribute and shape ways to move forward in the coming year. Suffolk and North East Essex Integrated Care Board ICS System Learning from Winter 2022/23 | 2

2. What happened? 2.1 What local people have told us “What matters to me is the right support at the right time. For instance right now our service users don’t always get services like ambulance services and other services quick enough. So that really matters to me.” “I don’t know why now I’m pregnant, whenever I call it’s really hard to get a [dentist] appointment. In the pregnancy time we are getting an exception, but most of them are refusing, that they’re saying that they’re not accepting NHS patients. So this is happening, it’s after the Covid times, but I think it’s not the right thing, it’s the right to have a proper appointment and check ups for pregnant ladies.” “Well, regarding my husband. He came out in a rash, a really bad rash, and six months ago we went to the doctors and he gave him some cream. But then he just deteriorated, deteriorated and he was sleeping on the floor in the lounge, just on a sheet because he was bleeding quite a lot. Then they took him into hospital for two weeks. Sent him home with no diagnosis whatsoever, and they said that he’d have to wait over six months to see a dermatologist and to be honest, I think this is disgusting. He’s 83 in age and he has been in so much pain. He’s got it in his head, everywhere. So I do think strongly that that should be looked into really.” “I think you think about families that have got mental health issues, financial issues, problems with their children and behaviour issues, might not specifically be health problems but definitely services that we can signpost them to where they can get that support while they are waiting for either referral or diagnosis.” “I just wanted to give feedback on treatment I’ve received recently. A mammogram a couple weeks ago which showed issues. I came to see the doctor on Wednesday, was diagnosed with breast cancer and I’ve had an MRI scan today, on Monday, two days later. I was phoned up two hours after I got home on Wednesday from seeing the doctor and everyone I’ve dealt with so far has been fantastic. I just wanted to say thank you.” “I’ve got psoriasis, it flares up in the winter. And then I phone up at 8 o’clock in the morning I don’t get a call back until 5.30 at night. Just to speak to a doctor and they prescribe me cream without really seeing how bad my psoriasis has flared up. I think my psoriasis needs a bit more, it needs to be looked at to see what it is.” “I know there are people who I feel go to A&E because they feel it’s their only option, because they can’t get the service they need at the right time by from their GP. So if you’re talking about thinking differently I would be thinking about 24 hour GP care, seven days a week. So more people have more access without worrying about time off work and can go at the times that suit them.” “What matters to me is to feel that my health concerns are being taken seriously. Which means that staff should pick up the phones when they ring and I don’t have to keep calling for 4 or 5 days just to speak to someone, just to have the call picked up. And when I speak to staff I need them to understand that I am suffering from a health condition and I’m not wasting their time.” “Well what matters to me is that, locally, GPs and our local hospital here in Newmarket, that the facility is available on our doorstep rather than having to travel to Bury St Edmunds or to Cambridge. Because there is room here within the hospital for consultants to visit and there is room here within the hospital grounds to put in a unit to carry out surgery on knees and hips.” A film of messages from people living and working in Suffolk and North East Essex was shared. 3 | Suffolk and North East Essex Integrated Care System

2.2 How did it feel? Wendy Herber, Chair, Healthwatch Suffolk, and ICS Chairs Group One of the most difficult things about being part of Healthwatch is that we need to respond to the whole healthcare system and we’re not a big organisation so that’s a bit of a challenge. But it’s also one of the great things about being Healthwatch. Like patients and like the public, we get to see the good and the bad in lots of organisations. But recently what we’ve been seeing is that everybody is struggling in a way that I don’t think any of us have seen before. As chair of Healthwatch I am part of the ICS Chairs Group which always has a full and frank exchange of views from people who are seeing things from a strategic point of view. And recently, in the light of the issues that are going on, we have asked: why are we not having this conversation? So I am really glad that we can be here today because I think we urgently need this reflection time. I think about the James Baldwin quote ‘Not everything that is faced can be changed, but nothing can be changed if it is not faced’. So today is a really good start – in facing and hopefully changing. When I think about the evidence that this has been a year like no other, and how it feels, there are three things that come to mind. The first is that everybody feels like they are the point of last resort, whether you’re a GP, in the ambulance trust, in the emergency department, in the voluntary and community sector, whether you’re a family. It can feel like we’re left holding the baby, working beyond our capacity and often our skills, and that’s making everybody feel really isolated. We feel like we’re competing, we’re blaming, trust is going out the window. That’s a national issue, it’s not just happening here. The second thing is that we’re all frantically busy, and most of it isn’t with patients. We have created a system that is huge and is very, very hungry and the number of meetings, boards, groups. strategies is just unbelievable. We are all trying to do that on Teams, not getting a break or the chance to reflect. People are very tired, the humanity has drained out of the system and we can’t find each other to check we are OK. The third issue is about prevention. When everything is about urgency and crisis, we can’t think about going down the river of preventing things happening in the way that we have done before. That never felt more urgent that in Covid, where we recognised for the first time that we couldn’t be well unless we were all well. The #whatarewemissing initiative and the vaccination programme showed us that we need to reach out. In the work that we’ve done at Healthwatch recently around elective care, dementia, and end of life, it was clear that people understand that there are waiting lists, they can’t change their situation, but they are asking for people to listen, be honest and to help them deal with the things impacting on their whole life. It’s not just a medical issue, it is a whole life that we need to address, we need to put the humanity back in. Gabor Mate said that safety doesn’t come from the absence of threat, it comes from the presence of connection – and perhaps that’s what we’ve lost. We need to believe that we can make change together and decide that we’re going to do together. In a way we have lost our vision, and our commitment to our higher ambitions – and perhaps that’s not surprising given the challenges of the last few months and years. If we want to see change, we need to do things in a different way, and I’m really glad to be here today and be part of that. ICS System Learning from Winter 2022/23 | 4

2.3 The experiences of frontline staff Jemma Varela, Advanced Paramedic in Critical Care & Head of Operations for Suffolk and North Essex, East of England Ambulance Service NHS Trust From the ambulance service perspective, I genuinely feel that last winter felt like being exposed to personal trauma on a daily basis. I’ll give you a couple of brief examples. Anyone dressed in green will always have a radio with them, it is always turned on and it is always turned up, whatever you are doing. We have a ‘general broadcast’, like a mayday, which goes out to everyone when one of our most time critical patients has received no response at all. When you hear the general broadcast, if you are able to stop what you are doing, whether using the facilities or queuing outside the hospital, you drop back and attend to that patient. Throughout winter, this went off continuously, you would hear it all day, knowing that every time it went off we were failing another patient, potentially seeing another death in our community. Secondly, as you know every clinician for the in the NHS has a slogan: ‘Hello, my name is...’. In the ambulance service we had to change this to: ‘I’m really sorry was taking so long to get to you. Hello, my name is...’. When we got to an address, patients were frustrated, scared, terrified because often we should have been there within 18 minutes according to our national targets, and instead we were taking 2-3 hours to get to them. That made us making a connection and the ability to get them to open up to us and share, so much more difficult. They were also often by this point having a much higher level of acuity due to the delays in us arriving. I am going to finish on a positive. We used to talk about ‘your patient in 111’ or ‘your patient in the acute’ or ‘my patient in the community. Now we are talking about ‘our’ patients, because they are. I think that change is really going to be valuable moving forward. Andrew Seale, Emergency Department Matron, East Suffolk and North Essex NHS Foundation Trust I asked my team what resonated with them this winter. The first thing they said was crisis management. We haven’t really been running as a proper emergency department for a while, every day we are just managing the crisis, we know over 200 patients will come in, we have 40 patients waiting to go through to a ward, and we still have patients left over from the day before. We have labelled our corridors as we are consistently in them, an outbound corridor going into the ward and the inbound corridor coming into the department. One of the things that I found hard was having to take over the outpatient waiting area as emergency care wasn’t big enough, making a mini Nightingale hospital in the waiting room. This was something that we’ve never had to do before, having to say that we haven’t got the space and we have to effectively park you up here and will get back to you as quickly as we can. We know that when people are waiting on the back of the ambulance the risk of mortality increases. We hate that but we know we have no choice, so we have to get on with that. We have had a redesign and we now have a new department which is really good, but we still have patients with us waiting for a bed, which is heart breaking. Managing mental health patients presenting in crisis is out of control. We have had a patient waiting over 100 hours for a mental health bed. The standard is that these patients should be in and out in 4 hours and we are so committed to trying to make that happen, but we feel let down from some of our partners. We are trying our best to look after someone that is in absolute crisis, but we’re not the right place. 5 | Suffolk and North East Essex Integrated Care System

I am one of the junior doctor representatives at West Suffolk Hospital and I been spending time rotating through medical wards and the emergency department. Up to the end of January 2023 I was working in a medical ward and data from February shows we had an average of 62 people across the hospital every day not meeting the criteria to reside in an acute care setting, that means they they’re all medically optimised for discharge, all ready to go to a care home or to their own home with care. For the doctors on the wards, this means that you have very fluctuating requirements, so if I have 12 patients allocated to me, it may be that on one day only two of them have medical needs and the next day, suddenly ten of them do. This unpredictability makes it very hard to staff appropriately in that context. When beds in the community do become available, there is a rapid need to prepare for discharge in a timely way, especially medications. That inevitably that happens exactly when you have somebody else who’s sick and needs your full attention, and possibly a colleague as well. We do try to mitigate that by preparing discharge medications in advance, but we may still alter medications while the patient is medically ready to discharge, so when they do leave you have to start from the bottom again and this takes time. For trainee doctors there is a knock-on effect that we find it difficult to get our educational opportunities that we need to progress. We can become so focused on service provision that there is a lot less time for on-the-job training and mandatory attendance at outpatient clinics, as we are needed on the wards just to keep things moving and get people out of hospital. I moved into the emergency department at the start of February 2023. In West Suffolk Hospital, 904 people in February spent more than 12 hours in the emergency department, which is over 30 patients a day and over 13% of all attendances. The physical space issues make it really difficult for us to do our jobs, we have patients who we need to assess in the waiting room, but there’s no space to see them because all the cubicles are full of people who are ready to go to a ward. This is incredibly frustrating for us and the patient especially when the problem could well be very simple and resolved in just a few minutes. Some patients need to be in a cubicle with close monitoring for medications and procedures, but are in the waiting room, which again is really frustrating for us, the nursing staff and the patients. I want to end on some positives. When beds do become available for patients we do have good collaboration with the community, but also within the hospital. The doctors, pharmacists, nursing staff and discharge planners all work together to make sure that as soon as that bed is ready, we can get the patient moved quickly. Those of us working towards specialty training have found that West Suffolk Hospital has been really good at protecting Dr Tim Nye, West Suffolk NHS Foundation Trust For us the winter hasn’t stopped yet and it’s really good that we’re here talking about what we can do and what we can learn from that. Since Covid we know things are changing, but we still do not have enough isolation bays, and the bays we do have are for patients waiting to go onto wards. We recently agreed together on a target to get ambulance crews back on the road to see patients in the community as quickly as possible, known as the ‘45 minute drop’. It I absolutely the right thing to do, but we recognise it will stretch everyone in the ambulance department who will be caring for all our patients. There are positives, we have adapted and we have continued to care for our emergency patients coming in and also the patients that are referred waiting to go on the ward. We are good at looking after people in an emergency, but we know we are not as good at looking after people for perhaps 20 or more hours, so we are trying to care for our referred patients well while balancing the next heart attack that will be coming in. We have adapted really well, we have some good initiatives in place and we have been assessed as having safety processes that are outstanding. We are managing the risks as well as we can, but we really do need to get some support from partners, in particular in mental health. So there are some good things happening, but it is tough. ICS System Learning from Winter 2022/23 | 6

all our teaching time. It can be difficult to attend some of the optional sessions, but I can’t recall a single mandatory teaching session that’s been cancelled because of service pressures. And during the industrial dispute, which we hope is resolved soon, the experiences of colleagues covering has led to a greater understanding of the complexities of the tasks we carry out. So perhaps having decision makers coming and experiencing how things are on the ground has been really, really good to push for change and to consider change in a bit more depth as well. 2.4 Dan’s story East of England Ambulance Service NHS Trust East of England Ambulance Service NHS Trust East of England Ambulance Service NHS Trust My name is Dan Howard and I suffer from COPD. Now I have had attacks before, but just before Christmas I had an extremely bad attack. I woke up about 1 o’clock in the morning and really couldn’t breathe at all, I was struggling really badly. My wife phoned for an ambulance and I was told it would be 5 hours before I could get one. This really frightened me as I didn’t think I could last 5 hours. However half an hour later an ambulance did turn up and they took me to hospital, but they didn’t take me into hospital. We sat in the ambulance for about 3 hours, then another strange thing happened, an ambulance pulled up beside us and I was transferred to that ambulance. It was 5 hours before I was taken out of the ambulance and into the hospital, where I was stuck in a corner and ignored. After about 3-4 hours someone came along and took a blood test and an hour later the person came back and said I had flu, and explained that was why my attack was so bad. I had COPD attacking my lungs and flu at the same time. I sat in the hospital with my wife for probably 5 or 6 hours more, then another doctor came to see me and said because I had flu I couldn’t be put on a regular ward because I could give it to other patients, I had to go in a side room but there was no side room available. It was 10 o’clock at night before I was found a side room. I was hungry, I hadn’t eaten or day or had anything to drink so I called somebody and a man came in the room. He said, ‘they won’t feed you’, I said, ‘what do you mean they won’t feed me?’. He said, ‘because you’re not on a ward’. I explained to him that I was in a room because I might give my flu to others. However next morning they did feed me, and I was there for about a week. Then they said because of a shortage of beds they were going to send me home to complete my treatment there. They sent me home with loads of drugs and told me to go to bed, which I did. Two days later I had a terrible exacerbation, far worse than anything I’ve ever had before. My wife phoned the GP and he said ‘I’ll have to readmit him as an emergency. He phoned back 20 minutes later to say there would be no ambulance available for 5-6 hours. Once again I was frightened, I knew I couldn’t last that long. So he said ‘have you got a car?”, my wife said yes, so he arranged for me to go to A&E and the same thing happened. My wide and I were put in a large room, we sat there for hours. Probably 4-5 hours later they took a blood test, and they said I still had the flu and I’d have to go into isolation like I did before. And actually about 10 o’clock at night I was put into a side room and the next day they started treatment. About 10 days I believe I was isolated, and then they sent me home. And I was OK, I was cured. But I wasn’t happy about being told I can’t have an ambulance when I’m seriously, desperately ill. And it happened twice. And I wasn’t happy about sitting in an ambulance for 5 hours when I desperately needed treatment. 7 | Suffolk and North East Essex Integrated Care System

2.5 What our population data can tell us I have been exploring what happened over the winter from the perspective of data on our population, and I would like to thank Doctor Danny Showell, Essex Public Health, who worked with me on this, and Tanya Kimber in my public health team who did a lot of the analysis. Socio-demographic and environmental influences on local health Our population in Suffolk and North East Essex (SNEE) ICS is older than England as a whole, and this is a fundamental challenge in terms of our population’s health needs. Anna Crispe, Consultant in Public Health, Assistant Director Knowledge, Intelligence & Evidence, Suffolk County Council Food and non-alcoholic beverages Housing, water and fuels Jul 2021 Category Oct 2021 Jan 2022 Apr 2022 Jul 2022 Oct 2022 Jan 2023 -5% 0% 5% 10% 15% 20% 25% 30% In terms of the weather, over recent winters, 2021 was colder than average and unsettled; 2022 was the eighth mildest winter since 1884; and 2023 overall has been marginally milder and drier than average, although with a prolonged cold spell in early December and again in midJanuary. The mechanisms through which cost of living pressures may translate into worse health outcomes are complex, and will be long-term in some cases. Employment levels in Suffolk are now rising which is positive, but we know local pay levels are relatively low, and the extremely high levels of annual inflation in key categories is very likely to be having an impact, particularly in the lowest paid households. While cost of living pressures may be increasing mental ill health and stress, we do not yet have clear evidence that so-called ‘deaths of despair’, including deaths by suicide and deaths related to substance abuse, are increasing locally. The exception of an apparent increase in drug related deaths in Tendring and Colchester during Winter 22/23 (preliminary data only). Tendring and Colchester: • The number of suspected suicides in Tendring & Colchester between October 22 – March 23 appears, based on currently available data, to be similar to previous years. • The most recent winter saw more drug related deaths compared to previous years. • A high number of these drug related deaths involved prescription medication for mental health & pain management. • Almost all deaths occurred in private residences, and more than half of all deaths had a previous contact with mental health services. Population pyramid - SNEE ICB Black line is England 85+ - 80 - 84 - 75 - 79 - 70 - 74 - 65 - 69 - 60 - 64 - 55 - 59 - 50 - 54 - 45 - 49 - 40 - 44 - 35 - 39 - 30 - 34 - 25 - 29 - 20 - 24 - 15 - 19 - 10 - 14 - 05 - 09 - 00 - 04 - Female Male 2% 0% 2% Annual inflation rate by commodity or service category ICS System Learning from Winter 2022/23 | 8

Suffolk: • The number of suspected suicides in Suffolk between October 22 – March 23 appears, based on currently available data, to be either similar or slightly lower than in previous years. • Data on suspected suicides over the winter period that involved drugs show a majority involved prescription medication. • There is no current evidence to suggest any differences to previous years in relation to the number of drug related deaths. (Please note – it can take many months for deaths by suspected suicide to be registered, and so we do not yet have final data for the winter 22/23 period. In addition, we do not report small numbers to prevent possible disclosure. Therefore the above statements represent our best understanding of the current situation, but this may change over time.) Disease rates, Immunity, and early detection of disease in the population We saw a very sharp rise in cases of influenza at the end of 2022, which then fell again sharply. Local testing data for Covid is no longer reliable, however the National Infection survey shows a rise in local cases peaking in early January, before falling back towards the end of January to a prevalence rate of around 2% of the population. Vaccines can offer very effective and important protection against disease. Pneumococcal Polysaccharide Vaccine (PPV) uptake has increased in SNEE over the last three years. • Between the 1st April 2022 and 31st March 2023 inclusive, 4.6% of patients age 65 years and older that were registered to a SNEE GP received their PPV, bringing the cumulative total of vaccinated 65+ in SNEE to 74.2%. • The cumulative PPV uptake in 2022/23 increased by 1.7% percentage points from 2021/22 (72.5%) and increased by 2.4% percentage points from 2020/21 (71.8%). • However, we know that vaccine take up varies within our population. Reported cases of influenza in 2022-2023 season for Suffolk - Second Generation Surveillance System (SGSS) 200 150 100 50 0 Source: UKHSA EoE iGAS SitRep, UKHSA EoE ARV Bulletin • The East of England and national coverage levels are not yet in the public domain. The East of England regional average in 21/22 was 70.0%, with the national average at 70.6%. SNEE is achieving higher levels that that – but nationally, the highest PPV coverage in 21/22 was 81.0% - so there is some room for further improvement. Uptake of flu vaccinations is slightly lower this winter (2022/23) when compared with previous years across the eligible groups, but overall levels remained high and similar to previous years, especially in the over 65s. Again, this will vary within the SNEE area. • Slightly fewer SNEE patients aged 65 years and older had received their flu vaccination by February 2023 (82.2%) compared to previous years (February 2022, 84.8%; February 2021, 82.9%). • At risk Patients aged under 65 years also had lower flu vaccine uptake by February 2023 (52.4%) compared to previous years, (February 2022, 58.1%; February 2021, 55.7%). 9 | Suffolk and North East Essex Integrated Care System

A&E Attendances – all ages Number of attendances October to March, 2019/20, 2020/21, 2021/22 and 2022/23 Residents of SNEE ICB area 0 1000 2000 3000 4000 5000 6000 7000 8000 1 2 3 4 5 6 7 8 9 10111213141516171819202122232425 Number of attendances A&E Attendances - all ages Number of attendances October to March, 2019/20, 2020/21, 2021/22 and 2022/23 Residents of SNEE ICB area 2019/20 2020/21 2021/22 2022/23 4 year average Week number (First week October to End March) Data incomplete for 2022/23 COVID-19 pandemic Christmas week Week number (First week October to End March) • Since the 2020/21 winter, flu vaccine uptake has declined in pregnant women each year, from 44.2% by February 2021, to only 34.2% by February 2023. • While SNEE achieves over 65’s vaccination rates which are very similar to national and regional averages, the highest uptake nationally in 21/22 was 88.8%. Covid-19 vaccine coverage levels also remain high and were higher earlier in the winter period compared to last year. Within just over 2 weeks of launching the COVID-19 Autumn Booster, 80.1% of SNEE registered patients aged 65 years and had received their Autumn Booster. While the impact of health screening is generally longer term, breast screening rates have fallen, while bowel and cervical screening coverage has increased or remained stable locally. Breast screening coverage (age 50-70) for 2021/22 decreased in all local sub-ICS areas, as well as nationally. Coverage is highest in West Suffolk and is higher than the 70% national target. Coverage is lowest in North East Essex which is also below the England average. Bowel screening coverage (age 60-74) for 2021/22 increased in all local sub-ICS areas, as well as nationally. Coverage in all areas is higher than England and is above the national target of 52% and the achievable threshold of 60%. Cervical screening coverage (age 25-49) increased in West Suffolk in 2021/22 and remained stable in North East Essex and Ipswich and East Suffolk, despite a decreasing trend nationally. Coverage is above the England average in all local areas, but is below the national target of 80%. A&E attendances by SNEE residents of all ages were consistently higher during the 2022/23 winter period than in the two previous winters. In comparison with the last ‘non-Covid’ winter (2019/20), total A&E attendances were also higher until the middle of January 2023. While we don’t have complete data on the reasons for A&E attendance, it is clear that the majority of this increase in attendances was in the under 18s. Rates of adult attendances were similar Outputs and outcomes to 2019/20. However, almost all this increase in A&E attendances occurred in children, probably driven by understandable concerns around iGAS. A&E attendances by adults were certainly higher than in the previous two winters (which drive the average down) but at a population level they were very similar in volume and pattern to the last nonCovid year in 2019/20. ICS System Learning from Winter 2022/23 | 10

Hospital admissions – all causes Rate per 100,000 population of all ages. October to March, 2019/20, 2020/21, 2021/22 and 2022/23 Residents of SNEE ICB area Week number (First week October to End March) There was an average of 5,560 hospital admissions per week during October - February across 2019/20 and 5,210 emergency admissions per week during 2022/23. Rates of admissions were statistically significantly higher than the 4-year average for some weeks in Winter 2022/23 but not for any extended period. The last two weeks of January 2023 had statistically significantly higher rates than the 4 year average. Emergency admission numbers this winter have been higher than in the last two years, but they have remained consistently below the last ‘non-Covid’ year (2019/20), with the exception being Christmas week, when they were similar to 2019/20. There was an average of 2080 emergency admissions per week during October - February across 2019/20 and 1915 emergency admissions per week during 2022/23. In 2022/23 the rise in admissions at Christmas may be linked to the peak of flu prevalence at that time. Numbers of emergency admissions for flu in winter 2022/23 were much higher than in previous years. Over the two week Christmas break, emergency admissions for flu exceeded 100 in each week. There was an average of 5 emergency admissions per week during October - February 2019/20 for flu, compared to an average of 27 per week during the same period in 2022/23. Average emergency flu admissions for the winters of 2020/21 and 2021/22 did not exceed 1 per week – measures taken to contain Covid also effectively contained flu. Data suggests that the acuity of patients may also be increasing over time – while distorted by the impact of the pandemic in previous years, the number of patients in receipt of oxygen is higher this winter than in the last two. However, this may also reflect increased elective activity. The national picture in relation to excess deaths is stark. • During the period March 2020 to December 2022, there have been 167,356 excess deaths in England and Wales, two thirds of which occurred in men. • Excluding deaths from Covid-19, there were 17,288 deaths above the five year average in the same period, with the distribution very strongly skewed to men. • During 2022, including deaths due to Covid-19, there were 10 consecutive months where the number of deaths were above the five year average. Excluding Covid-19 deaths, there were 8 consecutive months in 2022 (May to December) when excess deaths were higher than the five year average. • The relationship between excess deaths due to Covid-19 and other causes has changed as the pandemic has gone on – at first they were positive correlated, probably due to the lack of testing; now they are inversely correlated. Nationally, excess deaths excluding Covid-19 have been particularly high during 2022, driven by a range of causes. 11 | Suffolk and North East Essex Integrated Care System

0 0 10 20 30 40 50 50 100 150 200 0 0 10 20 30 40 50 10 20 30 40 50 Number of deaths in Suffolk residents (suppressed) by ISO week Number of deaths in Suffolk residents (suppressed) by ISO week ISOWeekOfYear ISOWeekOfYear Number of deaths per ISO week (suppressed) Number of deaths per ISO week (suppressed) • During May to December 2022, deaths were higher than average in 16 of the 20 age groups, with the highest proportional excess occurring in 75-79 year olds. In December 2022, excess deaths in people 90 or above was 14.6% above average – even after the mortality displacement caused by Covid-19. • The leading cause of death in people aged 80 years and above, with the highest number of excess deaths, was ‘symptoms, signed and ill-defined conditions associated with old age and frailty’. Two thirds of these deaths occurred in females (41.4% above average). • For males the leading cause of excess death in the period May to December 2022 was ischaemic heart disease (11.4% above average). • December 2022 saw a particularly high number of non-Covid excess deaths driven by flu and pneumonia and chronic lower respiratory diseases. Deaths due to circulatory disease also increased. • Deaths due to accidental falls were higher than average during 2022, with a particular 40.6% increase in June to October 2022. • Chronic lower respiratory disease was consistently a top-five lead cause of excess deaths for people aged 65-79 during May – December 2022. We are very clearly continuing to see excess deaths in the Suffolk population. Some of these are due to Covid-19, but not all. While our local numbers are too small to power comprehensive analysis, we do know that deaths from respiratory disease (excluding Covid) are consistently higher than 2022 figures. Excess deaths from all causes remain higher in the early weeks of 2023 than in the previous year. Excess deaths from heart disease and dementia spiked early in January 2023 Excess deaths from respiratory disease (not including Covid) have been consistently above 2022 figures, despite generally high PPV and flu vaccine rates. ICS System Learning from Winter 2022/23 | 12

In summary, while many factors were similar this winter to the last non-Covid winter of 2019/20, the impact of a sudden increase in flu cases and admissions over the Christmas fortnight is clear. The SNEE population is ageing; and the cost of living is hitting everyone, with those who have the least hit the hardest, but the impacts of this on health may take time to manifest. There is no clear evidence as yet of higher numbers of deaths by suicide during the winter of 22/23, although drug related deaths have increased in Colchester and Tendring. Infectious diseases were circulating during the winter period. However, this did not happen at particularly high rates or over very sustained periods with the exception of flu cases over the Christmas period, which also coincided with an increase in the background levels of Covid, and the iGAS cases. Vaccination levels remained high and similar to previous years. There were increases in A&E attendances, but much of this increase was in children. Admissions remained similar to pre-Covid levels and patterns – despite high vaccine levels, respiratory disease (excluding Covid) was the main driver of emergency admissions. There is some suggestion of rising acuity in the admitted population; it would be helpful to triangulate that with length of stay and discharge data (not easily available to public health). Excess deaths continue to occur both locally and nationally, particularly in the elderly, and in men. Excess deaths from respiratory disease have been consistently high locally during 2022, with smaller spikes in excess deaths from CVD and Dementia during January 2023. 13 | Suffolk and North East Essex Integrated Care System

3. What did we do? 3.1 What did the NHS do? Primary care In 2021-22 there were 5,782,425 GP appointments throughout SNEE. In 2022-23 this increased by 3.7% to 5,997,392. September to November are the busiest periods within primary care. 2021-22 saw an average of 545,455 attendances within this period, 2022-23 saw 545,601. NHS111 performance • 75.33% of calls have been handled and closed this year by the 111 team at contact. 12.07% of calls have ended up being directed to the emergency department (ED) with a further 12.60% being referred to 999 within the current year. • In 2019-20 14.25% of calls went to 999 and ED within the same period. Ambulance performance Category Definition Target response times C1 Calls from people with lifethreatening illnesses or injuries Respond to Category 1 in 7 minutes on average and respond to 90% of calls in 15 minutes. C2 Emergency calls Respond to Category 2 in 18 minutes on average (amended to 30 minutes for 2023/24) and respond to 90% of Category 2 calls in 40 minutes. C3 Urgent calls Respond to 90% of Category 3 calls in 120 minutes. C4 Less urgent calls Respond to 90% of Category 4 calls in 180 minutes. C5 Includes incidents closed with advice or onward referral Paul Gibara, NHS Suffolk and North East Essex Integrated Care Board 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 Apr-21 May-21 Jun-21 Jul-21 Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Feb-22 Mar-22 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 GP Practice Appointments ICS System Learning from Winter 2022/23 | 14

Response: The average response time for C1 ambulance calls from October 2022 was 10 minutes 52 seconds. Within March 2023 it was 10 minutes 34 seconds. Average C2 response times Jan 2023 Apr 2023 The average response time C2 ambulance calls from October 2022 was 1 hour, 6 minutes, 44 seconds. Within March 2023 it was 57 minutes 11 seconds. Access to the 999 stack referrals (C3-C5): In March 2023, 404 stack (the queue of ambulance calls awaiting a response that are triaged and prioritised to be attended to) patients have been referred to the community which 68.00% have been accepted by these services. The daily acceptance rate increased in March with an average of 9 per day compared to 5 in January. Ambulance handovers: Average handover times in 2022-23 are 38 minutes compared to the 24 minute average of 2021-22. February 2023 saw an average handover time of 36 minutes and 9 ambulances per day waiting over 60 minutes. March 2023 had an average 16 ambulances per day waiting over 60 minutes. Ambulance conveyancing: There has been a decline in the number of ambulance conveyances from 83,313 in 2019-20 to 68,392 in 2022-23. This equates to an reduction of 17.91%. 29.30% of ED attendances have arrived by ambulance in 2022-23 against 30.80% of attendances in 2019-20. Our high impact activities: include the Community Hub. Phase 1 involved Interrogation of the live ambulance stack to find alternative solution other than ambulance and ED, through an integrated multidisciplinary team. Reactive transport to move urgent patients has been appropriated. Next steps: include an aspiration to have total capacity oversight, utilisation of 999 STACK potential, and falls management. Emergency department (ED) • The average monthly number of ED attendances has decreased by 5.96% from 21,078 in April 2019 - March 2023 to 19,822 in the same period 2022-23. In March 2023 this number reduced by -2.73% to 20,842 compared to March 2022 which had 21,426 attendances. • Major attendances in ED have increased from 64.8% April 2020 - December 2021 to 65.39% April 2022 -December 2023. • We have seen an increase of Urgent Treatment Centre (UTC) attendances by 20.09%. • 63.24% of patients have been treated and discharged in ED & UTCs during March 2023 within 4 hours of arrival. • Patients waiting over 12 hours has increased by 44.19% during March 2023 with 2,594 compared to 1,799 within February 2023. Bed occupancy: within the acute trusts has Increased from 95.35% in February 2023 to 95.44% in March 2023. The available bed stock has increased by 7.74% meaning that even more patients have been in beds than the previous month. Our High Impact activities include creating additional bed capacity, virtual wards, a ‘Hospital full’ protocol and co-horting patients. Hospital discharges • Patients staying over 7 days within the acute trusts have remained consistent throughout the year with between 43% - 47% of beds being occupied. Within March 2023 we have seen a 1.78% increase. 0 Feb 2023 Mar 2023 200 >30 >60 Delays over 30 minutes 15 | Suffolk and North East Essex Integrated Care System

• Patients who are within pathways 1 to 3 (needing care on discharge) equate to between7.55% and 14.80% of bed occupancy within the acute trusts. • On average 35.22% with a discharge to assess are within pathway 1, 36.82% are within pathway 2 and the remaining 27.96% are within pathway 3. • The use of the Urgent Community Response Services (UCRS) pathways has increased significantly over the last 6 months. December 2022 saw around 170 referrals to UCRS, 80 to the Reactive Emergency Assessment Community Team (REACT) and 40 to the early intervention team (EIT). Within March 2023 we have seen 148 referrals to UCRS, 86 to REACT and 39 to EIT. Our high impact activities include Alliance based seasonal plans, discharge investment, enhanced end of life care for hospices, integrated community teams, integrated transfer of care hubs, integrated alliance director across health & care, and rapid release. Our next steps include implementation of virtual wards, maximising Same Day Emergency Care, revisiting the SAFER care model, frailty hubs, an aspiration to have total capacity oversight and fuller stocktake, a greater focus on no criteria to reside and reasons for delays, criteria led discharge and improving weekend discharge, greater visibility of who is on discharge pathways P1-P3, and reviewing demand for additional Covid positive discharge pathways. Suffolk and North East Essex Integrated Care Board 3.2 What did Social Care do? Simon Froud, Essex County Council In Essex, we held a workshop to look at our response in Winter 2022-23. We found: In contributing to system wide winter planning, Essex County Council was guided by the following considerations: 1. With limited time, we prioritised what could be secured compliantly and moved to delivery at pace. 2. Utilising and supporting the care workforce we already have was key (encouraging new recruitment was desirable but challenging, given the lead times). 3. While there were schemes which covered the whole county, locality responses were critical as they can be tailored to the unique challenges and assets in each area. 4. We discounted ideas that require extensive procurement exercises or relied on bringing new staff into the sector to deliver within the limited time we had. 5. Proposals which complicated or disrupted existing system processes and flows were also discounted, given the imperative that whatever we do needs to make a positive difference quickly. ICS System Learning from Winter 2022/23 | 16

Countywide responses included: • Investment in the care workforce (£4.4m) to support providers to recruit and retain workers and pay/reward workers during the winter period. • One off incentive payments to support hospital discharge and capacity challenges in ‘hard to source’ areas. • AMHP and bed capacity to boost support for people with mental health challenges to be supported and discharged from hospital. • 10% increases in Alternative Reablement Capacity deliverable through existing contracts. • Extension to block bed capacity at Cedars in Halstead which had the potential to convert to Covid+ isolation should the need have arisen. Local schemes included: • Ward led enablement launch and expansion. • ‘Home to Assess’ Provision to better support those going home from hospital who won’t benefit from reablement. We have a range of programmes and projects in neighbourhoods, making sure we have leadership in place to support the system. In terms of delivering these activities, it is a ‘whole family’ approach, and a preventative approach working with the voluntary sector. We want to keep what works as we move into the next phase. In our Alliance in North East Essex, and I know across SNEE, we are having conversations, consolidating our approach, and building resilience and sustainability in our system to ensure we spend money in the best way. Finally, we must always start, as we did today, with Countywide projects: • Connect Programme • Intermediate Care • Reablement • Carers Support Neighbourhoods: • Comms Lead • Mapping Tool • ABCD Training • Hub space • Leadership and Programme Support Domains: • Change and Domain Delivery • Domain Dashboards Stepping Stones: • Short-term alternative housing and care provision System resilience: • 24 hour Wrap Around Service • Ward Enablement Project • Home to Assess • Trusted Assessor from Reablement providers within the TOCH • Resource and demand mapping for D2A and temporary increase in staffing for front line and back office services hearing lived experience so that we can start solving some of the issues. We can learn from experience and think differently to get head of the winter pressures next year, and we need to start planning now so that we have sustainable systems not just for one year but in the longer term. 17 | Suffolk and North East Essex Integrated Care System

3.3 Supporting our Communities Stuart Keeble, Director of Public Health, Suffolk County Council The Suffolk Collaborative Communities Board (CCB) is a system-wide group focused on four strategic outcomes. The CCB administers the Local Welfare Assistance Scheme (LWAS) Suffolk Local Welfare Assistance Scheme - Suffolk County Council in Suffolk using the Household Support Fund from the government. For 23/24 the amount of Household Support Fund available is £10.2 million. Eligible individuals in financial hardship can apply to LWAS for a cash payment. During winter 22/23 CCB partners came together to administer local support schemes, including the Community Support Fund, which provided additional funds to district and borough councils to fund local groups keeping people connected, warm and well. Warm Packs/Items were available to support those suffering from the cold, these were also used to support hospital discharge. We are currently evaluating the CCB actions with a view to planning for this year. October 2022 to March 2023 Spend: £1,810.050 Number of approved applications: 10,007 Proactive Contact Letters Sent: 18,565 New case management system to streamline processing of applications and includes - fraud prevention - quicker application review times - auditable customer communications - direct payment or post office cash out vouchers SCF Surviving Winter Provision of home fuel support, CA income maximisation and referrals to Warm Homes Healthy People £500,000 Free School Meals October 2022 - March 2013 October half-term £209,140 Christmas £652,860 FSM children not on school roll £27,000 Feb half term - £330,000 Easter £666,000 Emergency foodbank stock (Foodbanks) Non-perishable food and non-food items. £300,000 Housing support via D&B teams £500,000 Finally, it’s important to mention that CCB partners support communities all year round including supporting the wider determinants of health, housing, leisure, VCFSE support, community safety and many more. Gave district and borough councils the ability to offer small grants to communities, keeping people warm and safe throughout the winter. Outcomes: • 190 VCFSE organisations awarded grants. • Kept existing community spaces open. • Provided new warm spaces. • M anaged building hire rates enabling continued groups and activities. • Reducing social isolation. 2 energy advisers. Responsible for identifying prepay households and completing in-home energy efficiency surveys. Distribution of emergency prepay vouchers to households at imminent risk from cold due to disconnection. Started April 2023. ICS System Learning from Winter 2022/23 | 18