Dear very City Trust;

In response, the Trust is in the process of developing new Crisis Resolution Home Treatment Team (CRHT) Operational Policy: An interim policy was presented to the Operational Management Board in December 2020 and it was agreed the CRHT teams would work to this whilst the policy is further developed by the newly appointed Trust wide Urgent Care Pathway Lead. The interim policy includes details of when an inpatient admission has been agreed for a patient but bed is not immediately available, then the CRHT will support the person whilst are waiting to be admitted. Within the interim policy it also details that if the level of risk increases and the CRHT are not able to safely support the patient, then this will need to be escalated to senior managers and support put in place from other urgent care services such as The Havens_ Along with support the Adult Operational Services, the Urgent Care Pathway Lead will be leading on finalising the interim CRHT operational policy. This work which is underway, will include a clear referral pathway for AMHP's who have assessed a person as needing admission. This pathway will reflect the integrated working arrangements in Brighton and Hove and is being jointly developed by BHCC and the Trusts Operational Leads and will define the key responsibilities and tasks of the Approved Mental Health Practitioners, Urgent Care Services and Assessment and Treatment Services in the management of patients awaiting informal or compulsory psychiatric admission. Operational Leads are also completing further work to identify points of contact within the Trust outside of the operational hours of CRHT. As this work is currently being completed, the Trust can forward this policy once finalised if required As widely reported nationally, the demand for acute mental health provision is profoundly challenged, in part, due to the impact of the Covid 19 pandemic Both the Trust and the wider health and social care economy are undertaking a number of actions to improve the position which includes purchasing an additional 45 acute psychiatric beds in the independent sector within Sussex; to ensure that patients receive their care as locally as possible and to ensure we can facilitate acute admissions for patients with the least delay_ The Trust has developed close working relationships with other Providers , enabling patients to receive the same level of care, treatment and discharge planning that would if under the care of Sussex Partnership NHS Foundation Trust (SPFT). This includes attendance at weekly ward rounds and oversight of all admissions and discharges by our Clinical Lead Nurses for acute bed management and the recent development of our clinically led Intensive Support Teams (IST): The IST is a senior multi-disciplinary team of SPFT clinicians who work closely with independent sector providers to ensure optimum care for all our patients as well as discharge planning: Locally, the Care Delivery Services [CDS] in Brighton has established an Urgent Demand Oversight meeting that enables the CDS Leads to have daily oversight of our patients requiring admission to hospital: This meeting is informed by the various Operational meetings that take place daily in our Community, Urgent and Acute Care Services and is described in enclosed Terms of Reference (appendix 1).

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The function of these meetings is to consider and review the service demand for the ahead, confirming available resources and re-planning as needed to ensure teams are able to deliver services safely and as required_ Representatives from these service areas then attend the Oversight Meeting, along with the Deputy Service Director and Bed Manager to review the overall demand for Urgent and Acute Care Services. The Oversight Meeting provides a focus on patients like Elena_ who are waiting in the community for inpatient care , confirms the support package that is being provided, and by whom_ The Trust and their Commissioners have developed a number of additional urgent care services posts, pre and during the Covid-19 pandemic, in response to the demand on services but also as part of the wider strategic investment into mental health services and the response to the NHS Long Term Plan. This includes the expansion of the Sussex Mental Health Line to become a 24 /7 Sussex wide phone service, an A&E diversion service for Children & Young People_ the opening of Crisis Cafes in Brighton, Worthing, Eastbourne and Crawley and clinical pathways to redirect patients with mental health presentations away from A&E departments _ The Trust has system of clinical bed management led by senior nurses which operates days a week_ This system is supported by administrative bed managers and single point of access for referrals to the Trust's_Health Based Places of Safety (HBPoS) both of which operate on a 24/7 basis_ The Trust manages its acute bed provision on a Sussex wide basis to ensure patients can access acute care as soon as is practicable once decision to admit has been made AIl demand for inpatient care is subject to clinical prioritisation as outlined in the Trust's Bed Management Policy and prioritisation is subject to immediate adjustment in light of continuous and dynamic risk assessment by the Trusts Urgent and Assessment and Treatment Services as outlined in the above point: 2 It is requested that the Trust consider ways of providing extra support and supervision to those patients who are waiting for an urgent admission, particularly those who may be left alone at home for any period until bed is available. When a patient is assessed as requiring admission but the person will need to wait for a bed to be available_ the Approved Mental Health Professional (AMHP) will develop an immediate safety plan with the patient and familylcarer aimed at keeping person safe until a bed is sourced. As part of the process of requesting a bed this immediate safety plan will be shared as part of the CRHT gatekeeping process and the Lead Practitioner if applicable_ In addition, as part of the Sussex wide investment and developments in Urgent Care, the Trust is developing trusted assessor model so that AMHP's and s12 Doctors can complete assessments on behalf of CRHT in order that patients can avoid being repeatedly assessed and can start receiving care and treatment sooner

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Current practice is that the CRHT will accept referrals as made by the Councils AMHP's; independent s12 Doctors and Lead Practitioners working within the Assessment and Treatment Services in order to provide patients with package of care whilst an inpatient bed is identified_ This package of support would be formulated and delivered in partnership with other services, including the patients family and carers as clinically indicated and depending on the assessed level of risk_ In June 2019, Brighton and Hove Mental Health Services opened the Haven at Mill View Hospital which has 4 Assessment in Brighton psychiatric decision unit which provides 24/7 service for patients to receive an extended period of assessment whilst presenting in crisis. Where patients present in extremis, provision can be made to accommodate them at the Haven for longer than 24hrs During the early stages of the Covid 19 pandemic, the developed an additional Haven in Worthing and expanded the capacity and opening hours %f the Urgent Care Lounges in Eastbourne, Hastings and Crawley Where the patient's individual profile and risk allow it, both Havens and Urgent Care Lounges throughout the Trust can be used to support patients, for a short period of time, i.e: patients who have been identified as requiring an admission to hospital whilst waiting for an acute bed to become available. This would be considered on a case by case basis and forms part of a total package of care and support for patient based on an assessment of their needs and risk_ The Trust has five HBPoS co-located within acute psychiatric hospitals which are used for the assessment and treatment of patients who have been detained under Mental Health Act 1983 Section 136. During the first wave of the Covid pandemic, the Trust designated three of the Havens and Urgent Care Lounges as Alternative HBPoS in order to increase capacity and avoid patients having to attend Acute Trust A&E departments for support and treatment with mental health. In the event of significant acute bed demand and to meet patients assessed needs, in extremis the Trust can temporarily admit patients to a HBPos whilst an acute bed is identified. When this occurs, the use of the HBPoS is actively monitored by the Clinical Bed Management Team with person seen as having priority for an inpatient bed_ All Acute Hospitals across Sussex have 24/7 Mental Health Liaison Teams in place and therefore, in extremis patients can be supported to attend A&E departments to mitigate any risk whilst awaiting an acute inpatient admission. A&E Departments were formally classified as HBPoS in the national guidance in response to the changes to the Mental Health Act in December 2017 . In the most urgent situation, if a patient's presentation alters dramatically, the Trust would seek support from Sussex Police or the South East Coast Ambulance Service as appropriate_ The Trust's core community secondary mental health care services are described as Assessment and Treatment Services (ATS): These are multi-disciplinary teams which provide care and treatment under the Care Programme Approach. Elena was known to the East Brighton ATS and had an allocated Lead Practitioner

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In the circumstances to which this response is directed, the patient's Lead Practitioner would provide part of the patient's care plan whilst waiting for an admission to acute psychiatric hospital, in partnership with other community and urgent care services_ provision from the community and voluntary sector and any identified carers or family resources as appropriate. plan of care in these circumstances would be subject to the Trust's Care Programme Approach and Safe and Effective Assessment and Management of Clinical Risk Policies . Our colleagues at BHCC approve and support the above arrangements and lines of communication between the local AMHP Services and the Trust is now clear on its clinical responsibility for patients like Elena_ trust this letter reassures you that we have taken steps to improve the support that we provide to our patients at the are recommended for inpatient admission and throughout their pathway_