Joint Forward Plan 2023 to 2028

Purpose

The Joint Forward Plan sets out how our local NHS, partner local authorities, voluntary, community and social enterprise (VCSE) sector, our Places and Neighbourhoods will deliver the ICS strategy and NHS Long Term Plan commitments for our local population over the next five years.

The Joint Forward Plan describes how we will:

• Deliver on local strategies, including the Surrey Heartlands Integrated Care Strategy and Surrey Health and Wellbeing Strategy.
• Deliver NHS specific ambitions, including the NHS long-term plan, national planning guidance priorities and constitutional standards.
• Organise and develop the system to deliver on these ambitions.
• Work together to achieve financial sustainability, transformation and to integrate our delivery model.

We face significant financial challenges.  Surrey Heartlands Health and Care Partnership is working together to achieve financial sustainability for our system, as we integrate and transform our ways of working.

The creation of this document reflects the legislative requirements of the Health and Care Act 2022 in relation to system Joint Forward Plans.

Acknowledgments

This document has been created by Surrey Heartlands Integrated Care System in partnership and with collaboration from:

• The citizens of Surrey and their families
  • Surrey Carers Partnership Board
• NHS and social enterprise partners
  • Ashford & St Peter’s Hospitals NHS Foundation Trust
  • CSH Surrey
  • Epsom & St Helier University Hospital NHS Trust
  • First Community Health and Care
  • Royal Surrey NHS Foundation Trust
  • South East Coast Ambulance Service NHS Foundation Trust
  • Surrey and Borders Partnership NHS Foundation Trust
  • Surrey and Sussex Hospitals NHS Trust
  • NHS Surrey Heartlands Integrated Care Board
  • our 101GP practices who work as part of 26 primary care networks
  • six GP Federations.
• Local authority partners
  • Surrey County Council
  • Elmbridge Borough Council
  • Epsom & Ewell Borough Council
  • Guildford Borough Council
  • Mole Valley District Council
  • Reigate & Banstead Borough Council
  • Runnymede Borough Council
  • Spelthorne Borough Council
  • Tandridge District Council
  • Waverley Borough Council
  • Woking Borough Council
• Voluntary and Community Partners
  • Healthwatch Surrey
  • Surrey Voluntary, Community and Social Enterprise (VCSE) Alliance
• Our Independent Providers

Next Review Date: January 2025

Foreword

We all want people in Surrey to live in good health for as long as possible and that they are supported to get the right help, when and where they need it.

Surrey is already one of the healthiest places to live in England, with better cancer survival rates and people less likely to have a stroke or heart attack than many other areas. Our services also perform well, with most health and care providers rated good or outstanding.

We know that there are health inequalities in Surrey, where not everyone shares the same advantages. Those living in the most deprived areas can expected to live approximately 6 years less compared to those living in the least deprived areas.Because most people in Surrey are living longer that also means more people living with ill health and conditions such as dementia, with social isolation and loneliness increasing.  We also know that clinical care alone will only ever impact about 20% of someone’s health and wellbeing; the rest is influenced by factors such as education, housing, employment, the environment and hereditary factors.  Which is why it’s so important for organisations to come together to tackle these wider issues collectively.

Surrey Heartlands is a formal partnership of health and care organisations working together to do just that.  This means health organisations, the local authorities and others taking collective responsibility for improving the health of the local population, managing resources (including money) and delivering high quality health and social care.  Doing this in partnership gives us much greater scope to have real influence on people’s health and wellbeing in ways we couldn’t if we simply focused on fixing symptoms rather than the wider causes of poor health. 

In Surrey Heartlands we want to create a health and care system that values the role of the local community and organisations, focused particularly at the most local, neighbourhood level, enabling people and families to take more control of their health and wellbeing, with easy access to high-quality care when it’s needed. 

By 2028, we will have put greater focus on prevention and targeting support where it’s most needed, so no-one is left behind.

At the same time, we want to take advantage of what we have in Surrey to pursue innovation with business, public sector partners and communities, joining up services for residents and developing digital technologies to create smarter ways of managing health and accessing support. 

The creation of statutory partnerships – known as Integrated Care Systems - via the Health and Care Act 2022 - has given us the right framework to make this step-change and the opportunity to make genuine long-lasting change through delivery of our new Integrated Care Strategy.  At a critical time of rising demand for services, the need to reduce waiting lists, improve access and continuity of services, we have the mandate to work differently and create the transformation that’s needed to improve people’s health and wellbeing and provide sustainable, high-quality services into the future. 

This document sets out how we plan to do this over the coming years, working in partnership with both our workforce and local people, to continue to support the people of Surrey Heartlands to live healthier lives.  We face significant financial challenges as our partnership works together to achieve financial sustainability, transformation and to integrate our delivery model across our four Places.

This is our second Joint Forward Plan.  It will be refreshed by the end of March each year reflecting the evolution and maturity of our plans.

Health and Wellbeing Board Statement

The Surrey Heartlands Joint Forward Plan (JFP) is welcomed by the Surrey Health and Wellbeing Board due to its shared focus on prevention and close alignment with the ambitions of the Surrey Health and Wellbeing Strategy (HWBS) to reduce health inequalities. This is reflected in the common understanding of Priority Populations and Key Neighbourhoods between the Joint Forward Plan, the Integrated Care Strategy and HWBS.

It is encouraging to see the examples of collaborative working referenced through e.g., the work on Multiple Disadvantage and Green Social Prescribing, alongside programmes that are examples of community led approaches at a geographic level such as Growing Health Together. This is particularly important as we seek to locally sustain programmes which are demonstrating significant positive outcomes which have previously received external funding. Given the priority we are seeking to place on effective preventative approaches in the system going forward we recognise our collective need to effectively understand the impact and outcomes of our current resource allocation. This will be important as we continue to invest in existing programmes where effective or move to longer term investment in new approaches that are developed to support implementation of the HWB Strategy. We look forward as a board to improving our shared understanding of the importance and impact of such programmes in relation to health outcomes and reducing inequality.

It is clear that there are already some joint opportunities for this, for example, through use of our local Better Care Fund and Mental Health Investment Fund and we look forward to exploring and learning from these and other innovative ways of working together.  Finally, underpinning all the above, we recognise the importance of ensuring that delivery of the Surrey Data Strategy enables better sharing of data as well as improving our understanding of both need and impact in relation to the delivery of the preventative programmes in Surrey.

March 2024

One System, One Plan

Vision

By 2030 we want Surrey to be a uniquely special place where everyone has a great start to life, people live healthily and fulfilling lives, are enabled to achieve their full potential and contribute to their community and no one is left behind.

Strategy

1. Prevention and keeping people well

• Priorities
  • Supporting people to lead healthy lives by preventing ill health and promoting physical well-being
  • Supporting people's mental health and emotional well-being
  • Supporting people to reach their potential by addressing the wider determinants of health

1. Delivering care differently

• Priorities
  • Neighbourhood teams – teams of different professionals working together to care for people with more complex needs across very local geographies
  • Provider collaboratives – local providers of health service working collaboratively to consider the best way to deliver some services across a wider geography

1. What we need to deliver these ambitions

• Priorities
  • Working with our communities
  • Workforce
  • Finance
  • Research and innovation
  • Digital and data
  • Estates

Our Critical Five

1. Keeping people well and redesigning urgent care pathways
2. Safe and effective discharge
3. High risk care management
4. Effective hospital management
5. Surrey Heartlands wide efficiencies

Integration

• Place based communities
• Integrated urgent care
• Chronic and complex care
• Preventative care
• Provider collaboratives

Executive Summary

Our Integrated Care Strategy describes how we intend to meet the health and wellbeing needs of local people, building on existing collaboration. This is about promoting the right partnerships – at System, Place and Neighbourhood level – that will lead to improvements in health and wellbeing and the socioeconomic conditions of local people.  Our strategy reinforces the importance of prevention and keeping people well, as the major catalyst for change.

The strategy is based on three ambitions that reflect where we are and what our populations have told us, so that ‘no-one is left behind’.  These set out our key areas of focus with significant emphasis on reducing inequalities.

1. Prevention
2. Delivering Care Differently
3. What we need to deliver these ambitions

This our second Joint Forward Plan in which we have taken the opportunity to strengthen and update three areas which were less developed last summer.  These are prevention, the trust provider collaborative and sustainability & productivity.  We describe how we will move towards realising our vision for people’s health and wellbeing and start delivering our strategy.  It builds on work already underway through the Community Vision Surrey in 2030 and the Surrey Health and Wellbeing Strategy, focusing on the prevention of ill health and the greater integration of health and care services including the wider public and voluntary sectors, reflecting the NHS Mandate and what local people are telling us.  It sets out how we will deliver local health and care services alongside broader care delivery, focusing on the first two years of our strategy. 

We know that clinical care alone only makes around a 20% contribution to health and wellbeing with a 30% contribution from individual health behaviours; the rest (the wider determinants of health, excluding genetic and hereditary factors) is influenced by things such as education, housing, employment, and the environment. 

This plan describes our strategic delivery plans through our wider partnerships and the work we are doing across our four Places and local neighbourhood teams, shifting the focus from treating sickness to collectively using our resource to focus on prevention and keep people healthier.  Positive intervention in a child’s life represents prevention in their life as an adult, interventions which should be made at the earliest opportunity from pregnancy onwards.

We will put greater focus on prevention and targeting support where it’s most needed by:

• working proactively with our communities to support people to lead healthy lives
• providing more personalised care
• working together to offer a wider range of support closer to people’s homes.

In doing so, we will achieve the ICS four purposes:

1. Improve outcomes in population health and healthcare,
2. Tackle inequalities in outcomes, experience and access,
3. Enhance productivity and value for money,
4. Help the NHS support broader social and economic development.

Overall, our health and care needs are changing, our lifestyles are increasing risk of preventable disease and affecting our wellbeing, we are living longer with more multiple long-term conditions like asthma, diabetes and heart disease and the health inequality gap is increasing. Population Health Management helps us understand – at system, ‘Place’ and neighbourhood - current health and care needs, creating informed predictions of what people need to help prevent ill health.  We will increase personalised care, designing more joined-up services and incorporating our working with communities principles, to make best use of our collective resources and improve people’s overall health and wellbeing.

Through social research and local insight, we know our combined efforts are making a difference. For example, improved access and communication to and from primary care, greater experience of personalised care and improved experience of integrated adult social care.  Local people have highlighted common themes to inform our ambitions, including the need for more health and care integration, better access to services and the importance of supporting our valued workforce.

These strategic ambitions are a key part of our One System, One Plan framework – a single view of transformation and recovery which is reflected in the plans and strategies of all partners.  Embedded within these is the vision from the ‘Next steps for integrating primary care: the Fuller Stocktake’ to:

• streamline access to care and advice for people and ensuring care is always available in their community when they need it
• provide more proactive, personalised care with support from a multidisciplinary team of professionals to people with more complex needs
• help people to stay well for longer as part of a more joined-up approach to prevention.

To achieve our ambitions, we need to create the right conditions for success.  This includes how we work with communities enabling them to lead locally driven change, involving and listening to what people are telling us, progressing digital ambitions and use of data, and developing a workforce with the right culture, skills, training and leadership.

Our Trust Provider Collaborative, was formally established in summer 2023, working together, as experts in service delivery, to address immediate challenges and deliver longer-term service transformation to ensure future quality, workforce and financial sustainability.

In 2028, when we have delivered this plan, our population will benefit from the priority outcomes detailed in our strategy and experience:

• Increased services focusing on prevention, providing communities with the right access to preventative support.
• Integrated Neighbourhood Teams shaped and designed by partners from across the health and care spectrum – statutory, voluntary, community and social enterprise organisations.
• Improved access to same-day urgent care, general medical practice and general dental practice, enabling Neighbourhood Teams to take an active role in creating healthy communities by working with local people, and developing closer relationships with local authorities, voluntary and community sectors.
• Streamlined access to integrated urgent, same-day care and advice from expanded multi-disciplinary team, using data/digital technology to find patients the right support.
• Our ‘Team of Teams’ will have the physical space to work together in their neighbourhoods.
• Multidisciplinary teams with new skills and capabilities, through successful recruitment, retention and learning to support the communities they serve.
• Digital technology and data underpinning how our teams work, how our communities interact with us and how we analyse and use data to continuously improve services.
• Health on the high street driving town centre reimagination through our health diagnostic offer and positive economic impacts driven by the ICS supply chain helping to deliver sustained socio-economic outcomes.

Over the next two years, we will continue to deliver against the national NHS priorities: 

Recovering services and productivity

• Urgent and emergency care
• Community adult and children’s health services
• Primary care
• Elective care, diagnostics, cancer
• Maternity, neonatal and children’s services
• Mental health

Delivering transformation and NHS Long Term Plan ambitions

• Learning disabilities and autism
• Improve health and reduce inequalities
• Invest in our workforce
• Use of collective resources
  • Continuing Healthcare
  • Medicines Optimisation
  • ICS running costs
  • Workforce and agency spend

Across these priorities we will be considering what we do at an individual level to provide more preventative and personalised care, how we work within our neighbourhood teams, across our larger Place partnerships and the wider health and care system.

We will focus on prevention and tackle what will make the most difference to people’s lives over the next three to five years by continuing to integrate the four pillars of primary care services; bringing together general medical practice, community pharmacy, general dental care services and optometry, alongside other health services and personalised care for people and families, where they live.

Above all, we need to be bold in our approach, leveraging our collective efforts as partners to transform what, where and how we provide care and work with local communities so they can take more control of their own health and wellbeing. 

The deliverables set out in this plan are based on what needs immediate attention, and for which funding in the coming year has been identified. Therefore, the first two years of the plan contain the most detail. Other schemes may require business cases to be developed, to seek additional funding, before they can be delivered. We describe longer term aspirations (3-5 years) as ambitions. These will be reviewed each year when this plan is updated, and future funding allocations are confirmed.

Our wicked problems

We are operating in a financial landscape that is challenged and is not likely to get easier in the near future. We consider the most effective way to address these financial constraints and improve outcomes is the closer integration of health and social care, with less reliance over time on large hospitals and traditional care models, to sustainably address health inequalities.

• How we focus activity and funding on prevention and tackling health inequalities in a challenged operational and financial landscape.
• Social care demand and complexity has overtaken funding levels – resulting in higher acuity for those admitted and greater difficulty in discharging from acute settings.
• An older population – Surrey has 20% more people aged 80+ than the rest of England meaning a large frail population with greater needs and complexity.
• Service recovery – high volumes of planned and emergency care, including delays in care and presentation continue following the pandemic and significant industrial action by clinicians during 2023 and early 2024.
• Sustainability – achieving local financial sustainability, with sufficient revenue and capital to deliver and transform services, and maintain quality, workforce and operational performance across providers.
• Over reliance on private sector – high number of non-NHS independent providers undertaking high margin cost activity, removing private revenues from the ICS.
• Lack of specialised care, compounded by proximity to London – a large proportion of activity occurs outside the ICS (£247m London spend 2021).
• Funding for increased mental health conditions prevalent locally – we receive less funding from national allocations, based on assessment of low complexity and need in our population, due to focus on psychosis, and less consideration for other conditions (like eating disorders) where we have higher prevalence.
• Supporting other areas – providers serve multiple ICSs including Frimley, Kent and Sussex.
• Our workforce capacity is concentrated in acute settings, with more scarcity in community, primary care and social care partners – meaning we don’t have the right people in the right place to deliver the models of care we aspire to.
• Surrey cost of living, access to affordable accommodation, variable education provision within the county and inflexible working options – adds further hurdles to building an effective workforce supply.
• System Flow – high levels of demand and reduced capacity in care settings and effective discharge result in longer patient journeys through our system and challenging environments for our workforce.
• System maturity – whilst we have good relationships across our partners, and bold ambitions, we have variable maturity in how we work together to transform, integrate and manage our services day to day.
• Addressing access and continuity of care – we continue to see service users experiencing challenges and delays in accessing some services and fragmented care. 

Building on our success

We have seen many improvements and achievements in year one of this Joint Forward Plan, despite the challenges of the pandemic recovery, industrial action by clinicians and financial constraints.

• Prevention – A range of projects are being delivered through the No One Left Behind Skills and Employment Network to provide targeted support those furthest from employment and Local Area Coordinators are active in a number of Key Neighbourhoods
• Keeping well – Short term extension of Changing Futures funding until 2025 allowing further delivering and good outcomes being delivered for those experiencing multiple disadvantage
• Aging well – Neighbourhood teams have developed further support for people living with frailty, ensuring those who are ageing and living with long term conditions have a Personalised Care Plan based on what is important to them utilising the wider community assets.
• Primary Care access – Patients can submit online requests to 97% of our GP surgeries via the NHS App
• Carers – In 2023/24 the number of carers assessments completed by Surrey County Council has increased by 29%, carers support plans created increased by 40% and carers support plans revies increased by 23%.
• Children and young people – Growth of voluntary sector support for children’s emotional wellbeing and mental health including to Young Carers and new crisis care support pilot for children with a learning disability or autism
• Cardiovascular Disease – Learning from our system partner’s Healthy Heart Project (which was part of wider NHS Health Checks service commissioned and led by Public Health), an outreach project delivering free blood pressure and atrial fibrillation checks for those aged 35+ and no known CVD diagnosis
• Diabetes – Increased referrals and uptake in NHS Diabetes Prevention Programme.
• Developing fulling careers – 38 prospective volunteers have started our volunteer training programme, 41 international Allied Health Care Professionals have been recruited and 6 new candidates have started the nursing associate training programme for developing community nursing.
• Quality of care – Continued improvements for all our providers who require support to achieve regulatory assurance.

Using our collective strengths and assets, we will measure success through our achievements, performance measures, plus patient and user experience.  This Joint Forward Plan (JFP) sets out how we will deliver our strategic ambitions by 2028:

• Introduction         About Surrey Heartlands
• Chapter One       Ambition 1: Prevention and Keeping People Well
• Chapter Two       Ambition 2: Delivering Care Differently
• Chapter Three    Ambition 3: What we need to deliver these ambitions

Introduction

About Surrey Heartlands

Surrey Heartlands Health and Care Partnership is an ‘Integrated Care System’ (or ICS for short). That means we take collective responsibility for improving the health of the local population, managing resources (including money) and making sure services are high quality.

Our partnership covers most of Surrey, with a population of around 1.05 million of the 1.2 million Surrey residents, as shown in the map below. The rest of Surrey (including the borough of Surrey Heath and parts of Farnham) are covered by the Frimley Health and Care system.  We have long standing partnerships and collaboration with neighbouring health and care systems, from Southwest London to Hampshire.

As a partnership we want to create a health and care system that builds on the amazing community spirit we witnessed during the pandemic.  One that builds trust and relationships with communities and supports people to take more control in their lives and in their communities, with easy access to high-quality care when it’s needed. 

With an important role in the community as the largest employers, major purchasers of goods and services (sometimes called ‘Anchor institutions’) and recognising our duty towards addressing climate change, we want to create opportunities for people to work and volunteer with us. Making sure we involve our workforce and local people in co-designing services so that together, we continue to support and empower the people of Surrey Heartlands to live healthier lives.

You can read more about how we developed leadership and accountability across our system partners in the Surrey Heartlands Development Plan (2022) and governance in Appendix 1: Accountability and Leadership.

The Population we serve

The health of people in Surrey is generally better than the England average.  Surrey is one of the 20% least deprived counties in England, however about 9.1% (18,310) of children live in low-income families.  Life expectancy for both men and women is higher than the England average. 

We know that in our community we still face challenges.

• Implications of covid has impacted on school readiness including speech, language and communication and increased anxiety.
• We know that there are health inequalities in Surrey, where not everyone shares the same advantages. Those living in the most deprived areas can expected to live approximately 6 years less compared to those living in the least deprived areas. We have a clear ambition that ‘no one is left behind’ so that we can help everyone reach their full potential and set a level playing field.  Access to care is not always the same for our communities.
• Surrey is rural place with limited transport links therefore access to care is not always the same across our communities.
• We have an aging population. 2018 predictions estimate the population in Surrey will increase from 1,189,934 in 2018 to 1,227,467 in 2043. This prediction suggests the older population will increase. The increase in the population groups aged 45 and over in Surrey is likely to impact more on health and social care services due to increased risks of developing long term conditions and other needs.
• We have more people than we have seen before living with ill health and conditions such as dementia, and loneliness together with higher acuity.
• Our populations have told us that the Cost-of-Living Crisis is a significant cause of concern which has the potential to lead to poor health outcomes for them, such as the impact of social isolation on mental health or not having a warm place of residence impacting on long-term condition management.  Just over a quarter (26.4%) of the population are economically inactive, of which 2% are long term sick or disabled and 12.9% are retired.

Drawing on our Joint Strategic Needs Assessment (JSNA) and population health management approach, we will focus in prevention and support where it’s most needed. We have recently published an updated JSNA chapter on housing and related support and a new chapter on screening, which are being factored into our transformation plans. 

The Pandemic highlighted the urgent need to prevent and manage ill health in groups that experience health inequalities – differences in health that are avoidable - and the unsustainable increase in demand on public services.  We know that delays in presentation, postponement of elective care and screening will have led to later presentation of non-Covid illness because of the Covid19 pandemic.  The Surrey Community Impact Assessment in 2020 found:

• health impacts were greatest for people aged over 80 and those in care homes
• those that are not used to needing support have started to struggle
• there are significant impacts on those already using mental health services,
• more people are participating in unhealthy behaviours such as smoking and alcohol consumption,
• more people felt more isolated.

We will deliver these ambitions through our Surrey Health and Wellbeing Strategy implementation plans and the CORE20PLUS5 adults and children programmes, which are described later.

Population insights

We have backed up these insights by engaging with Healthwatch Surrey, our local providers and the wider community, voluntary and faith sector to understand what local people are telling them directly.  People told us about challenges experienced and opportunities to make a difference to the health and care support received:

• Access: People continue to struggle with making contact with or accessing services.  It can be confusing or a barrier, particularly when directed to online services with long waiting times.
• Continuity: Too often care is fragmented and has to be repeated or delayed. There is a strong desire for greater service integration and coordination. More direct and frequent communications from service providers (e.g. hospitals) can help people navigate through pathways and support a greater sense of agency and control over their health journey. Greater investment in the frontline workforce is also seen as key to driving positive patient experience and health outcomes.
• Approach: People agree that proactive, personalised care supports their longer-term health and care needs.

Alongside these conversations, we have engaged with local people directly on specific topics and where we can use the public’s opinions and insights across various related work programmes.

Case Study

Draft Clinical Strategy

Through this project we carried out focus groups with members of the public, recruited via our citizen panel, as well as conducting in-depth interviews with individuals from our key priority populations, including service users, people with lived experience, key workers and people with a strategic oversight role.   The key themes and recommendations were:

Prevention: People report feeling most confident in managing their physical health however feel the least confident in self-managing their mental health.

Out of hospital care: A preference for online appointments is highest when it is a routine appointment, where can be offered quicker than an in-person appointment and / or will save on time or travel costs. Patients report low confidence in how appointments are booked and managed. However, the increased use of virtual appointments needs to ensure the patient still remains feeling heard.

Specialist services: People report feeling either unaware of or overwhelmed by the healthcare services available to them. Patients would like to have increased awareness of options, with signposting from their healthcare professionals. 

Research and data: People report feeling uncertain around the use of AI technology. To build familiarity and trust AI should be introduced slowly into patient facing healthcare settings. Furthermore, people voiced concerns on personal data use across the wider healthcare system.

Working with people and communities

As we work together to deliver our priorities, we are focusing our approach on the strengths of individuals, community networks and other assets to focus on outcomes rather than a focus on services.  Local people have told us they want services that are responsive to their needs and put them at the centre of decision making. Our new model of care can only work if our communities and our staff are able to be equal partners in how services are shaped, designed and delivered.

We will continue to identify specific cohorts (as highlighted in our 2023 Population Health Summit) who would benefit from proactive care in the community and working with Primary Care Networks (PCN) to refer them to social prescribing or multidisciplinary teams.  Our response to the needs of our populations is primarily through these local places; supporting people to become expert patients, developing confidence and responsibility for their own care.

The national programme CORE20PLUS5 is aimed at reducing healthcare inequalities for adults and children and young people. We have aligned our response to Surrey's Health and Wellbeing Strategy to meet local needs. Our CORE20 population is made up of four Key Neighbourhoods - the four electoral wards that include areas of deprivation in the national top 20 percent, while our PLUS population is composed of two groups; the Key Neighbourhoods and our communities of identity with the poorest health outcomes.

Underpinning this work, we will focus on specific population groups, including the most deprived 20 percent of our population and those people, families and communities experiencing poorer-than-average health access, experience or outcomes, alongside five national clinical areas - pregnancy, severe mental illness, chronic respiratory disease (COPD), early cancer diagnosis and hypertension - which we know significantly contribute to life expectancy gaps in more deprived populations.

We are clear that what might work in one neighbourhood may not work in another and we will be guided by clinicians, professionals, voluntary, community and faith partners and the wider community in shaping what each neighbourhood offer looks like.  Our Involvement and Participation Framework sets out our strategy for working with people and communities.  The implementation of the ‘Next steps for integrating primary care: the Fuller Stocktake’ Report and the development of Place and Neighbourhood teams will drive how care is delivered working with communities in towns and villages across Surrey Heartlands.

Shaping our approach with our communities

Building together – Engaged to build our approach and plan

• In depth qualitative research into access to general practice
• citizen panel surveys and qualitative research
• Talked to people in their communities
• Engaging with health and primary care teams for example Guilford
• COVID-19 community impact assessment

Innovating locally – Enabled local exemplars

• Growing Health Together in East Surrey
• Guildford and Waverley Alliance appreciative inquiry approach
• Equity development officers in East Surrey
• Working with Citizens Advice to better understand financial challenges in our communities
• Social prescribing in some of our communities

Leads to: Hardwiring this approach – Supporting places to

1. Develop and launch full partnership engagement programmes in the next 12 months
2. Deliver more community projects supporting local well-being and prevention
3. Share learning and best practices for people involved in community development and health creation

Communication and engagement

Involving, listening to, and supporting the ongoing participation of local people and staff in the work of the ICB – and our wider health and care partnership - is critical in meeting the health and care needs of our population and tackling the healthcare gaps and inequalities we know exist. 

In our Involvement and Participation Framework we set out our commitment to this, describing how we will consistently listen and collectively act on the experience and aspirations of local people, communities and staff.  This includes supporting people to sustain their health and wellbeing, as well as involving people and communities in developing plans and priorities and continually improving services. 

As a system, we have a solid foundation of involving and engaging local people; from strong community relationships, positive stakeholder relationships – with the community, voluntary and faith sector, local borough partners, Patient Participation Groups and elected representatives – and involvement in service redesign, to our citizen engagement programme, cited nationally as good practice in developing our citizen’s panel. Our system-wide Involvement and Participation Group, which includes VCSE partners, Healthwatch Surrey, Place representation, members of Surrey County Council’s Adults and Health Select Committee, and other patient and partner representation, provides independent support and oversight for our involvement work and the sharing of best practice.

Involving people and communities across our system

Neighbourhoods

Working with communities at the most local level, creating opportunities for collaboration between all our people with health and care partners.

Working across Places

Developing a local approach across each of our four place-based partnerships including support to work at neighbourhood level and working collaboratively with local partners including health and care partners, the boroughs and the voluntary, community and faith sector.

System

Setting a strategic approach across Surrey Heartlands with key principles to guide good practise and ensuring the public voice influences and shapes work across our system and is heard at both ICB and ICP level, with overall responsibility for meeting our statutory engagement and consultation duties.

We are moving our overall approach away from the more traditional model of engagement to enable genuine co-production and personalised care – tailored to local needs and preferences – as well as a strong reliance on social research and insight to inform decision-making. Working within our Place-based Partnerships and local Neighbourhoods, we are supporting local people to develop a ground-up approach to healthier communities, empowering people to take more control of their health and wellbeing.

Case Study

Communities programme

In Surrey Downs a strong thriving communities programme is focused on redefining how the local partnership works with communities to support people living healthy, fulfilling lives and addressing health inequalities. The local ‘Pulling Together’ programme has brought together staff and citizens from across the local area to explore the importance of citizen involvement in service design and the opportunities for developing local communities in partnership. Via a series of workshops, the programme has looked at the practical steps of how staff and citizens can work together to deliver change and has embedded citizens as part of the programme governance.

We have common involvement principles that we work to across the whole of Surrey Heartlands, actively enacted at local levels through our Place Based Partnerships and local Neighbourhoods.

Key involvement principles

• Putting the voices of people and communities at the centre of health and care decision-making.
• Developing trusted relationships to understand people’s experiences and aspirations, particularly those most affected by health inequalities.
• Building a culture of co-production, insight and involvement – that is meaningful and demonstrating clearly where actions have been taken.
• Involving people and communities at an early stage when developing strategies and plans.
• Avoiding duplication by understanding and building on insights we already have.
• Working in partnership with local communities and going to where people are.
• Providing clear, accessible communication/public information.

In developing our plans we have listened to what local people are telling us; through ongoing engagement and conversation, targeted engagement programmes which have supported the development of service-specific strategies and through a wider engagement programme during the autumn of 2022 which included a total of 188 in-depth qualitative conversations to understand more about what matters to local people, followed up by a survey of our citizen’s panel which generated over 1,000 responses for analysis. Over the next five years we will continue to involve local people as we develop our health and care plans, ensuring their voices are heard and that services are developed around the needs of local people, particularly those experiencing inequalities in care and access. 

We recognise the importance of health and care organisations complying with the Accessible Information Standard. We have established an Accessible Information working group to share and encourage good practice within Surrey Heartlands to ensure organisations meet their obligations under the Standard. We greatly value the input of community and voluntary sector partners and our residents in continuing to evaluate accessibility of services and ensure that services are able to meet the information and communication needs of patients and carers with a disability, impairment or sensory loss.

You can find out more about our engagement programmes and how to get involved on our website.

The way we will work

Since 2017, Surrey Heartlands ICS has been strengthening relationships, promoting equality, diversity, and inclusion and consolidating partner organisation ambitions so we can focus on the wider causes of poor and ill health. 

Essentially this is about improving the way public agencies work together, alongside communities, to address priorities in very local areas; including reducing health inequalities, improving equality of opportunity and access to services, regeneration, and the stimulation of local economic activity, all of which require a multi-agency approach.  Partners are working with communities in towns and villages to make sure that no-one is left behind – the overall aim of the Health and Wellbeing strategy – and with our ICS strategy.

To date there has been a focus in five towns in Surrey where significant regeneration was already happening – Horley, Caterham, Weybridge, Staines and Farnham (in the Frimley system) – with more recent work taking place in Leatherhead, Sunbury, Ashford, Addlestone and Chertsey. Fantastic examples to build on include community listening in North Guildford, the Sheerwater Together partnership in Woking, and the Pulling Together programme in Surrey Downs.

Based on learning so far, rather than continuing to progress this by periodically focusing on additional towns, the intention now is to use a framework of three tiers. Firstly, growing a stronger foundation of enhanced partnership working in each of the 29 towns/villages areas. Secondly, from that base there will be a handful of towns where, right now, there are a coinciding set of specific medium-scale initiatives that require coordination. Then a third tier of those towns where there are significant large scale transformation programmes and regeneration that require deeper collaboration given the scale of investment, change and opportunity to enhance public outcomes. This three-tier approach represents a measured and realistic approach. 

The development of our local Integrated Neighbourhood teams and other work within our Place partnerships are essential components of this overall approach and we are already seeing the benefits this local partnership approach can bring. It’s vital we work alongside local communities - rather than ‘doing unto’ – offering the required support and acting in ways that can carefully facilitate and catalyse further mobilisation of local communities under their own steam.   

Place-Based Approach

We are taking an increasingly Place-based approach to commissioning, partnerships, and design of health and care services in order to reflect the unique qualities of Surrey’s different towns and villages. Places are not statutory organisations, but a way of working with increased collaboration through shared goals.

Our Place-based partnerships cover most of Surrey (Figure 4) and involve the NHS, local government and other local organisations such as voluntary, community and social enterprise sector organisations and social care providers.

We have an ambitious programme to drive improved health outcomes for people through the development of strong local partnerships and working with people where they live.  We have four Place-based partnerships or Alliances – Guildford and Waverley, East Surrey, North West Surrey, and Surrey Downs bringing together health, local government, the voluntary, community and charity sector with wider partners across local populations.  Using their local knowledge and relationships, they aim to reduce health inequalities and support delivery of local services across smaller geographical footprints. 

Working at a Place level, we use opportunities for our residents, their families, and their communities to be at the centre of our integrated working. Our Place-based partnerships are an invaluable generator of ideas and considerations. In addition to our ‘working with communities’ commitment, we are committed to developing community assets – using the skills, knowledge, facilities and social networks – to build positive, trusted and enduring relationships with communities.

Case Study

Spelthorne Healthy Communities Partnership Board

This partnership was established in October 2022 to explore new ways of delivering services and identify interventions that address the wider influences on health and wellbeing in Spelthorne. The group determine spending on the health and wellbeing priorities in conjunction with stakeholders across the health care system, as well as communicating health and wellbeing information. It also aims to give a voice to residents on health and wellbeing issues to deliver services which truly meet the needs of local people.

Since March 2023, the partnership’s achievements include:

• opening of 27 warm hubs across the borough
• delivery of 15,916 subsidised meals with associated welfare checks
• commitment of £1m for home adaptations to help residents live independently
• establishing personal budgets for green social prescribing
• provision of 750 health and wellbeing activity sessions

Each of our four Places has identified its local priorities to deliver the ICS ambitions.Thesereflect the diverse needs of their specific populations and thinking about how they will work differently in the future to achieve.  You can read more about how we will locally deliver the One System, One Plan in each Place on our Surrey Heartlands website.

Key combined place-based focus and outcomes over the next two years

Key delivery focus

• Establishment and embed neighbourhood teams where multi-agency teams come together to build on the work of primary care networks.
• Implementation of viable community based urgent care response as an alternative to Emergency Departments.
• Simplifying and enabling navigation of services to ensure people receive continuation of care thereby improving access and patient experience.

Outcomes

• Increase in joined up, proactive and personalised care.
• Reduce demand and waiting times in Emergency Departments.
• Expedient community-based resolution to urgent care need.
• Care will be delivered closer to home.
• Care will be received in the right place, at the right time and ‘not bounce’ around the care system.

Neighbourhood teams

We are making neighbourhoods ‘real’ for residents.  This is critical to the establishment of all neighbourhoods. It is where communities will come together at a local level to shape and integrate services which address both the wider determinants of health and health delivery. These include community organisations and primary care services which work together in a small local area with Primary Care Networks to form Integrated Neighbourhood Teams (INT).  Each of these INTs are best equipped to understand and drive the changes that our communities want and need by bringing together professionals across Health & Social Care and Voluntary, Community and Social Enterprise.

Partner strategies                               

Surrey Heartlands Provider Partners each have strategies which support delivery of their organisational, NHS and ICS objectives to meet the physical and mental health needs of our populations.  You can read more about these on our providers’ websites.

• Ashford and St. Peter’s Hospitals Strategy 2022-2025
• St George's, Epsom and St Helier University Hospitals & Health Group Strategy 2023-2028
• Royal Surrey Strategy 2022-2025
• South East Coast Ambulance Service Improvement Journey Autumn 2022
• CSH Surrey
• First Community's Vision, Values and Strategic Approach 2020 - 2024
• Surrey and Borders Partnership Strategy
• Surrey and Sussex Healthcare

Provider Collaboratives

The Surrey Heartlands Trust Provider Collaborative (TPC) is the three acute trusts and the mental health trust working collaboratively as the experts in service delivery, to address immediate challenges and deliver longer-term service transformation to ensure future quality, workforce and financial sustainability. Each Trust will retain its own identity, support development and delivery of Place strategies, and within the collaborative lead on specific clinical services to optimise patient outcomes through delivery of operational excellence and value for money.

The TPC will focus on agreed priorities which need to be addressed as a provider system rather than at organisational level.  The agreed priorities are seven clinical transformation programmes and one efficiency at scale programme: Maternity and Neonates, Paediatrics, Stroke, Systemic Anti-Cancer Therapy, Endoscopy, Mind and Body (Mental Health), the Elective Care Centre and Corporate Services.

Our TPC programmes are based around improving outcomes by addressing equity of access across pathways, addressing unwarranted variation in care quality, improving service resilience and developing innovative ways of working with other local partners. 

Case Study

The Mind and Body Programme is one of the 7 key workstreams sitting within the Surrey Heartlands Trust Provider Collaborative to:

• develop better wrap around support to people presenting with Mental Health issues or crisis in an acute hospital setting in Surrey, and
• better integrate physical and mental health presented by patients attending A&E with a Physical and Mental Health need, and the subsequent admission onto an Acute Ward

The aim of Mind and Body is to drive forward the integration of physical and mental health pathways to improve outcomes, flow and experience of people with mental health needs, their carers and families. 

It has brought together partners from across health and social care, including commissioners, Surrey and Borders Partnership (the Mental Health Trust), adult social care, VCSE partners, and acute hospitals - including Royal Surrey, Surrey and Sussex Hospital, Ashford & St Peters, Epsom General and Frimley Park*. 

The programme has developed a standardised framework to improve support across all Acute Trusts and work is currently underway to localise and implement at each Acute Trust with the aim of better patient experience, improved outcomes and more effective use of resources.

*Epsom General and Frimley Park are not formal partners within the Surrey Heartlands Trust Provider Collaborative, however their inclusion is essential due to patient flows across Surrey.

The TPC will focus on transformation that needs to be undertaken across the providers at scale, while continuing to play a key role in working with colleagues at Place to deliver the agreed local priorities that recognise that neighbourhood needs are unique and varied. 

Programmes will be structured with Multi-Professional Clinical Leads to ensure there is coproduction of the underpinning principles to innovate, and to optimise opportunities.

Building on the work of the Trust Provider Collaborative, Surrey Heartlands partners are beginning to scope the potential benefits of establishing a Community Provider Collaborative with the aim of:  

• accelerating integration between local services
• reducing duplication of work and provide more sustainable support services
• targeting support to those most in need based on population health outcomes, and
• making it easier to access help when needed by better co-ordination of support based on need rather than referrals and diagnosis.

Social Care

Social Care in Surrey is delivered through a number of different routes. There are statutory services provided directly by Local Authorities, provision supplied by the VCSE, independent Care Providers and of course, the vast amount of care provided by unpaid carers which is often unseen and unrecognised.  Social care, unlike health care, is means tested and this creates an additional layer of complexity in Surrey given that approximately two thirds of Surrey residents fund their own care.  In many instances, those who self-fund their care will need to arrange it for themselves, often navigating a complex system at a point of crisis.

People at the Heart of Care set out the 10-year vision for adult social care. From this we have shaped three-point vision for Surrey, so that our people:

1. Are informed and able, or have the support, to make decisions about their lives
2. Are enabled to be active, independent and have good wellbeing
3. Are connected to their communities

Our social care strategic priorities reflect our commitment to a modern service promoting people's independence, wellbeing and fulfilling lives.

• Developing an innovative, high-quality prevention approach, underpinned by an accessible digital offer for those residents who are able to self-serve to access information and advice on demand and personalised support for those who need it.
• Transforming Surrey’s reablement offer to support all people, from the community and following hospital discharge, who would benefit from personalised support to achieve their goals and to gain or re-gain skills, confidence and independence.
• Improving mental health outcomes to maximise independence for Surrey's people through better early intervention, prevention, targeted and long-term support.
• Delivering with partners modern, technology-enabled homes and accommodation models with the right care and support to enable people to live as independently as possible.
• Working together as an effective and financially sustainable system, with place-based partners and residents to co-produce services, to deliver good outcomes for people, support them to access health and social care at the right time and in the right place.
• Working in partnership to improve outcomes for young people in transition to adulthood to maximise their independence and live their best life.
• Enhancing our commitment to consistent strengths-based approaches to prevent, reduce and delay reliance on, and demand for, long-term care.
• Creating the environment for staff to develop, progress their careers and thrive in a respectful, inclusive workplace with a supportive culture.

Carers

A carer is anyone, including children and adults, who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or addiction and cannot cope without their support.  The care they give is unpaid.

Surrey Heartlands will be a place where carers are recognised, valued and supported as pivotal to the ambition of the system, both in their caring role and as an individual.  We want to do everything we can to enable carers to live well.  It is crucially important that carers are identified at the earliest opportunity.  Carers will be respected as partners in care, will have a strong voice that influences improvement, and will be able to access responsive support they need, when they need it, and in the way that works best for them.  This support will be available equally to all carers.

Our vision is that young carers feel supported and confident to say that they are a young carer. They are identified, recognised, valued, and supported, and protected from providing inappropriate care, to achieve their full potential, and to have equitable access to the same opportunities as their peers.  They have a strong voice that results in services that work for them, and we hear their voice when the responsibility of caring is not their choice.  Across the system, staff will have the tools, skills and know ledge to increase identification of young carers, enable young carers to self-identify and provide the right support to young carers and their families.  We will develop an ‘All-Age Carers Strategy’, aiming for publication in 2027.

Our work includes the following priorities for young people.

• Increased awareness visibility and support of young carers in education, health and social care:
  • Training for improved identification of young carers and a whole family approach.
  • Improved transfer of information.
  • Consider young carers in any system change.
• Staff have a good understanding of young carer’s rights and young carers, and their families have the tools they need to advocate for themselves:
  • Ensuring that young carers and their families feel able to request a young carer’s assessment and staff have the skills to put them in place.
  • Championing young carer’s rights.
  • Transition to adult services.
• Young carers safeguarding needs are identified and supported.
• Appropriate referrals made for early help to avoid any escalation and preventing the threshold of ‘significant harm’ being reached.

Our work includes the following priorities for adults.

• Place based carer action groups.
• Personalisation (Social Prescribing and Carers Personal Health Budgets), Carer Passports.
• Hospital Discharge and Community Support Guidance Hospital discharge and community support guidance.
• Inclusion of carers in the co-design of virtual wards in Heartlands and the implementation of the wards at Place. Surrey Independent Carers Lead appointed to the Virtual Ward Programme Board.

You can read more about our delivery plans in our adult carers and young carers strategies and find out helpful information on our Carers page on the Surrey Heartlands website.

The following chapters describe how our strategic priorities will be delivered by the Integrated Care Board (ICB) and its partners.

Our Health and Wellbeing Strategy based on our JSNA focuses on three linked priorities:

1. Supporting people to lead healthy lives by preventing physical ill health and promoting physical well-being
2. Supporting people's mental health and emotional well-being by preventing mental ill health and promoting emotional well-being
3. Supporting people to reach their potential by addressing the wider determinants of health

Most people in Surrey lead healthier lives than the average UK citizen. However, this strong average performance often masks areas of underperformance, inequality or where additional focus is required.  We will focus on delivering reduced health inequalities for our priority populations including people in our  inclusion health groups – most likely to experience  the poorest health outcomes - through the CORE20PLUS5 programmes for adults and children.

Surrey Heartlands’ Prevention Principles

Overarching Prevention Principles

• Investing in and building thriving communities, fostering cohesion and reducing inequalities
• Supporting people to lead physically health lives, to have good mental health and emotional wellbeing
• Targeting investment to have the most positive impact on people’s wellbeing
• Managing cost and demand sustainably, and anticipating future challenges
• Creating a healthy, safe and sustainable environment, both natural and built for the wellbeing of all

Prevention as a System Tool

• Evolution and Insight & Measuring Outcomes

Outcomes

• Sustainable natural and built environment
• Great individual health and wellbeing
• Safe and cohesive communities
• Thriving social and economic environment

You can access quarterly highlight reports which provide an overview of the progress of local shared projects supporting the delivery of the Health and Well-being Strategy on the Healthy Surrey website.

1.1. Supporting people to lead healthy lives by preventing physical ill health and promoting physical well-being

We are participating as one of only fifteen areas in the country operating a National Changing Futures Programme to support the most vulnerable individuals in our communities with multiple disadvantages and help them achieve their goals. The Changing Futures Programme in Surrey explores gaps in care, unwarranted variation and disparities in health and care outcomes for this population and challenges opportunities where the system could be effective in improving the outcomes through the power of co-production.

Surrey’s Changing Futures Programme has introduced Bridge the Gap Trauma Informed Assertive Outreach alliance of homeless, mental health and domestic abuse providers to support optimal outcomes for people with multiple disadvantages. The alliance is a group of third-sector providers delivering a specialist, relational model of trauma-informed outreach for adults with multiple disadvantages, supported by clinical psychologists who are trauma specialists. Resolution of these issues offer not only the prospect of reducing offending and reoffending rates, but significant societal benefits and a reduction in costs for the health service, social care, police, and criminal justice systems.  We will continue to collaborate as partners through programmes such as ‘Making Every Adult Matter’, Surrey Police’s ‘Checkpoint Plus’ scheme and piloting community-based outreach services to improve outcomes for those experiencing multiple disadvantages.

Another example, is our system approach to physical activity, including improving use of green spaces, transport initiatives, and healthy planning to enhance the preventative aspects of wellbeing.  Since the development of our Long Term Plan, the number of adults classed as inactive in Surrey is the lowest ever, at 19.5% (people who do less than 30 minutes of activity a week (www.activesurrey.com), England average 21.4% (18/19)) however over 50% of young people are still not meeting Chief Medical Officers’ physical activity guidelines. We will continue to develop the range of support such as nutrition, physical activities and children’s healthy weight on our Healthy Surrey website.

Prevention of ill health includes screening and Health Protection activities, which encompass a set of public health activities protecting individuals, groups and populations from infectious disease such as childhood vaccines for preventable diseases and seasonal influenza, incidents and outbreaks - managed by our system Emergency Preparedness processes, all help people to stay well for longer.

Our ambition is that everyone in later life can experience good physical health and emotional wellbeing, have a sense of meaning and purpose, social connectedness, and better resilience.  We will achieve healthy aging and care through improving our integrated health and care services to provide seamless treatment and support when needed, promoting good health and wellbeing, early intervention and prevention, in a way residents and patients can control and plan in our towns and through neighbourhood teams. 

Over the next 10 years, the number of people aged 65+ living in Surrey is expected to rise by 19.6%.  As this population grows, there is will be a rise in the number of people with multimorbidity, such as dementia and diabetes alongside frailty which is associated with increasing age.  We know that being active can increase the amount of time that people can stay independent and healthy.

As we age, it is common to have a growing number of health issues. Over time, this can affect our ability to bounce back after an illness or other stressful events, as well as our ability to live independently or keep in touch with family and friends. 

Our Living Well in Later Life Strategy sets out the support for people in Surrey.  It is shaped from the views of hundreds of residents, carers, staff, and care providers.  This is our plan for how we will help residents to have more choice and control over the care and support they need, when and where they need it.  We will change how we design and buy services and work with partners to make these changes.

CASE STUDY

Live Longer Better

This pilot through Active Surrey in Elmbridge is focused on helping people stay healthy, happy and independent for as long as possible.  Its mission is to change the culture surrounding ageing, replacing the concept of care with the concept of enablement.  It includes improving physical ability and resilience, preventing and coping with disease, understanding and changing how people think about ageing.

By 2028 our population will benefit from:

• People have a healthy weight and are active.
• Substance misuse is low (drugs/alcohol/smoking).
• The needs of those experiencing multiple disadvantages are met.
• Serious conditions and diseases are prevented.
• People are supported to live well independently for as long as possible.

1.2 Supporting people's mental health and emotional well-being by preventing mental ill health and promoting emotional well-being

This priority is about enabling the emotional wellbeing of our citizens by focusing on preventing poor mental health and supporting those with mental health needs, so people have access to early, appropriate support to prevent further escalation of need, including parents and care givers.

We have a strong and growing social prescribing network and expanded green social prescribing initiatives across our Places which are a collaboration between health, social care, district and borough councils and a range of voluntary sector organisations in our Neighbourhood Teams.  These provide proactive, personalised support such as healthy lifestyles and physical activity, debt and benefits services and mental health & emotional wellbeing.

CASE STUDY

Social Prescribing in Guildford and Waverley Neighbourhoods

Mark is a veteran with Post Traumatic Stress Disorder (PTSD), depression, anxiety and chronic pain from a back injury. Mark receives some practical support from adult social care.  Mark wanted to have more interaction with other people as he was limited to small amounts of employment due to his injury. Through social prescribing Mark was put in touch with Welcome Buddies and Welcome to Volunteering (supported access to a volunteer placement). Although Mark was referred as a client, he was more interested in becoming a volunteer buddy to support others. He is now working towards becoming a buddy and mentor for people with mental health issues as part of the Welcome Buddies project.

By 2028 our population will benefit from:

• Adult, children and young people at risk of and with depression, anxiety and other mental health issues access the right early help and resources.
• The emotional wellbeing of parents and caregivers, babies and children is supported.
• Isolation is prevented and those that feel isolated are supported.
• Environments and communities in which people live, work and learn build good mental health.

Our NHS delivery priorities to achieve these successes are described in chapter 2 - Delivering Care Differently.  You can read more about our work to improve health and wellbeing through social prescribing on the Surrey County Council website.

1.3 Supporting people to reach their potential by addressing the wider determinants of health

We will support our citizens to reach their potential by helping them to develop the skills needed to succeed in life and flourish in a safe community.  This is not only about making sure people's basic needs are met but also about skills development, training and employment, involvement in life-long learning and in their own communities and considering the impact of community safety and the built/natural environment on health.

CASE STUDY

Preventing the ‘revolving door’ between services

Our Sheerwater (high health deprivation area) team alone has mobilised 17 projects involving 1,400 residents, including cost of living support, digital inclusion, new youth clubs, exercise/leisure access.

One former resident of Sheerwater regeneration area accepted help from the team as her home was being demolished as part of the regeneration scheme. She is divorced and has two sons, one of whom she has lost contact with. She had not been registered with a GP since 2016, hadn’t claimed benefits for over three years and had accumulated various debts as she was not in work. Previously she refused to engage with professionals and was known to be unpredictable. She was isolated, anxious, would rarely leave her flat and neglected most aspects of basic self-care.

Over regular visits, the team built a trusting relationship with the resident and pulled together a variety of professionals to help her. She was supported to find a new home she was happy with and bought furniture and essentials through her relocation package and a local charity. She accepted help to register with a GP. The team helped her to claim Universal Credit enabling her to budget and keep her flat clean and tidy. She receives community meals and feels confident enough to walk to the supermarket to buy essentials. She also found a new love for knitting and was helped to reconnect with her son, all of which is having a profound impact on her mental wellbeing.

We aim to improve the perception of disability and increase expectations for everyone. Our Physical Disability and Sensory Impairment Strategy aims to remove barriers and support people with disabilities to become well informed and expert in their own needs and better able to exercise their rights, choices and life opportunities.

By 2028 our population will benefit from:

• People’s basic needs are met (including food security, poverty, housing strategy).
• Children, young people and adults are empowered in their communities.
• People access training and employment opportunities within a sustainable economy.
• People are safe and feel safe (community safety including domestic abuse, safeguarding).

The benefits of healthy environments for people are valued and maximised (including through transport/land use planning).

 

Our populations have told us they want a model of care which is responsive to their needs and puts them at the centre of decision making.  To enable this, we have determined two main aims as we transform how we deliver care:

1. making it easier for people to access the care that they need when they need it
2. creating the space and time for our workforce to provide the continuity of care that is so important to our populations.

We are putting delivery of joined up health and care services at the heart of our approach – integrated care – enabling ‘Making Every Contact Count’ to provide proactive and personalised care through our Place and Neighbourhood teams.

We will enable people to easily access high quality care and focus on support where it’s most needed to access care through our commitment to improving the navigation and information relating to health and care services ensuring:

• proactive access, joined up health and care support
• digitally advanced services
• nobody is left behind.

We need to manage rising demand, on behalf of patients and staff, at the same time as recovering our system post-pandemic and industrial action, reducing waiting times and transforming how we provide care and support people in their communities.  We are moving away from reactive treatment of illness to proactive and preventative care promoting health and wellness.  We aim to ensure every person can access care easily, efficiently and receive the help and support of their choosing and when people want personalised care, receive it through multi-disciplinary teams and care coordination.

2.1 Making it easier for people to access the care that they need

We will move patients safely and efficiently through our clinical pathways, delivering high quality care based on the ‘Get it Right First Time’ principles.

This chapter focuses on improved access – including service navigation – and integrated care pathway developments, ensuring healthcare works effectively when needed and movement through health and care services known as ‘system flow’ improves.

We are proud to have showcased how we are enhancing access to primary care and joining up services for patients to Amanda Pritchard, Chief Executive of the NHS in March 2023.

“The team here are showing the benefits that can come through embracing the power of technology, making best use of the skills of a wide group of clinicians and other professionals, and forging strong links with communities and other services – and it is exactly these benefits which the NHS is working to ensure people across the country can enjoy.”

We will deliver this integrated system working through our collaborative organisation partnerships focusing on the needs of the patient. This is not just about transforming how services are delivered on the front line, it’s also about realigning our functions and re-imagining how they can enable our teams to work together.

2.1.1. Primary Care

Good primary care is the foundation of an effective health system for patients. When working well, it supports the early identification of serious illnesses and the management of chronic conditions, while also helping people to live healthier lives. To achieve this, two defined areas aligned to the ‘Next steps for integrating primary care: the Fuller Stocktake’ and the delivery plan for recovering access to primary care, have been identified.

1. Personalised Care for the who need it: delivering care from a named health or care professional (using all disciplines in Health & Care).
2. Streamlined Access: Expanding MDTs and providing flexibility to tailor services to local demands. Optimising data and technology to integrate siloed same day urgent care services.

Access challenges are being caused by an increased demand for services - both volume and complexity - combined with ongoing workforce pressures and reduced numbers of GPs. Our system has a clear support offer to general medical practice which aims to provide insight in addition to radically transforming general medical practice and wider Primary Care services. We strongly believe that patients should always be able to receive the same, or an equivalent service, however they access their GP practice - be that digitally, by telephone or by walking into the surgery.

General Practice Development Toolkit key components to transform the models of care and streamline the patient journey

Access – An integrated approach to improve patient access

• Improving patient access by creating a model that allows an agnostic front door and uses the skill mix of the full team to effectively triage patients to the right person or service.
• Using local knowledge and data to spot areas that may require more support.

One system, one plan – Delivery of the ‘Next steps for integrating primary care: the Fuller Stocktake’

• One system, one plan.
• Shaping our approach within our communities.
• How the new model works.
• Creating the right space for our teams.
• Building expertise, developing talent, transforming recruitment.
• Transforming digital infrastructure and data accelerating change.
• Sustainability and future access.

Quality improvement – Promoting relationship-based care models to enhance quality

• Relationship based care continuity toolkit.
• Integrating teams (PCN and INT).
• Patient experience.

Modernising access – Improving patient access to the most appropriate care channel

• Data into action.
• Patient initiated contact (GP access).
• Practise initiated contact (Reaching into populations).
• Cloud based telephony (Seamless service transfer).
• NHS app (Driving efficiency).
• E-hub (Back office).

Staff safety and experience – Improving understanding

• Moving from anecdotal to evidence based of abuse to our staff in general practice.
• Gaining an understanding of staff experience to inform support packages.

Metrics – ensuring practices achieve KPIs to receive financial compensation

• List of outputs and jobs.
• Finance schedule.
• Reporting metrics (We will never externally report lower than PCN level).

2.1.2. Improving Patient Access

We have designed our patient-initiated and practice-initiated models to find the most efficient and effective way for patients to access and be contacted by General Medical Practice.

The models will incorporate technologies such as advanced telephony - cloud based systems with clinical system integration – and the NHS app to ensure our population is able to access a wide range of services and support when they need.

Patient and Practice initiated contact models

Patient initiated contact models

Defining the model – The patient-initiated contact model is designed to look at the most efficient and effective way for a patient to access general practice and to ensure a consistent response, no matter how contact is made. This model utilises best practice from across the country and incorporates best use of technology in Surrey.

Where we want to get to – Enabling access to care in a way that suits people best.

Benefits for general practice and patients

• Access to wider alternative health and care support, such as NHS Pharmacy First advanced  service.
• Clinical preparation and administration is completed prior to patient attendance.
• Clinical navigators and triage direct patients to the most appropriate care setting.
• Follow on care can be better managed for patients using digital support tools.

Practice initiated contact models

Defining the model – The practice-initiated contact model is designed in two parts:  i. Proactive case management of long-term conditions  and ii. Preventative care for general and targeted ‘at risk’ populations

Where we want to get to

• Primary care workforce roles and skills increased and utilised.
• Reduced local health inequalities through targeted interventions.
• Reduced unplanned health and care contacts.

Benefits for general practice and patients

• Care coordinators case managing people with long term conditions
• Proactive, holistic patient assessments through a versatile team including social issues and medication reviews.
• Targeted support for those not routinely accessing primary care
• Improved use of clinical time, increasing capacity.

CASE STUDY

Primary Care Networks

Growing Health Together works across East Surrey has seen primary and community health care workers, social prescribers, the county council, borough and district councils, VCSE groups and others collaborate - getting alongside communities to support, enable and promote citizen-led action and projects that create social connections and improve health and wellbeing - this includes, for example, community gardens, arts and music events and peer support groups.

Through the Community and Mental Health Transformation (CMHT) programme we are implementing General Practice Integrated Mental Health Services (GPIMHS). We have embedded teams into primary care networks through the NHS England early implementer CMHT funding, with full coverage achieved across Surrey Heartlands in 2023/24.

Within each primary care network an integrated multi-agency GPIMHS team is deployed, including representation from health, social care, the third sector and people with lived experience of mental health needs.  As well as supporting people to stay well and out of hospital, the programme supports people currently in secondary care mental health services who are stable and would be well placed to alternatively receive recovery focused and integrated mental health care services in primary care, with seamless ‘easy in’ and ‘easy out’ as required, and with a potential shared care arrangement.

Our key delivery priorities to achieve our aims include:

• Continuity of Care – Reducing fragmentation and promoting joint up pathways including expanding MDTs in community pathways
• Patient Experience – Gathering regular feedback to promote a proactive approach to the improvement in the ease of access to general practice
• Professional Integration – aligning teams between PCNs and INTs

Our workforce will be supported by the Surrey Training Hub to develop, retain, and attract the primary care workforce through education and training opportunities to achieve our key delivery priorities.

2.1.3. Community Pharmacy, Optometry and Dentistry

Giving ICSs responsibility for direct commissioning is a key enabler for integrating care and improving population health in line with the NHS Long Term Plan. It provides the flexibility to join up key pathways of care, leading to better outcomes and experience for patients, and less bureaucracy and duplication for clinicians and other staff. Therefore, as part of empowering local decision making, NHS England (NHSE) set out the intention to delegate commissioning functions of Community Pharmacy, Optometry and Dentistry (POD) to all ICSs from April 2023; Surrey Heartlands became an early adopter and transitioned the services in July 2022.

By co-designing additional support and services we will better deliver the national contract, expedite recovery, and aid retention issues in our dental practices and professionals.

Community Pharmacy transformation focus

Community pharmacists will provide an expanding range and supply of medicines optimisation services into local care pathways.

By 2028, patients will benefit from:

• Community pharmacies being the preferred NHS treatment location for appropriate minor health conditions.
• Timely, convenient access to care, medicines and advice.
• Community pharmacists becoming integral to helping people stay healthy and identifying those at risk of disease.

Optometry transformation focus

NHS funded sight tests for eligible patients will be managed and procured by local teams who understand their community and equality needs for general ophthalmic services.

By 2028, patients will benefit from:

• Special School Eye Care service.
• Homeless and asylum seekers access.
• Access to sight tests for adults with learning disabilities.

Dentistry transformation focus

NHS funded services including specialist, community and out of hours managed by local teams who understand the community and equity needs.  This work has been supported by an extensive engagement strategy ensuring our population and health and care colleagues are involved in the co-design, development and delivery of dental services. We have commissioned additional dental appointment capacity, starting in Guildford and Waverley and Reigate and Banstead to address underserved areas and expanded the Dental Clinical Assessment Service, supporting patient access and direction to urgent services following needs assessment.

In line with the publication of the Government’s Policy paper published in February 2024, we want everyone who needs NHS dentistry to be able to access it.  Entitled, “Faster, simpler and fairer: our plan to recover and reform NHS dentistry” the plan confirms recovering dentistry is a priority for the NHS and heralds an important step towards transforming NHS dental services for the better.  Supported by £200m of government funding, the investment is poised to deliver more than 1.5 million additional NHS dentistry treatments or 2.5 million NHS dentistry appointments for patients across England. 

Our service transformation will build on the work already started in 2023, focusing on the 3 core areas of prevention, access and workforce to recover, modernise, support and integrate our Dental pathways into our health and care community.

By 2028, patients will benefit from:

• Improved general access through primary care integration and urgent access for those without a regular dentist.
• Reduced oral surgery hospital waits for treatment.
• Enhanced general dental service access for vulnerable groups, with priority access to hospital based dental care for special needs and paediatric cases.

Primary Care transformation focus

By 2028 our population will benefit from:

• Improved telephony and triage to helping practices manage demand.
• Enhanced booking and triage capabilities to local walk-in sites.
• Local service provision to meet identified challenges in our neighbourhoods.
• Expanded primary care offer at our walk-in sites, including same day emergency care pathways.
• Freeing up GP appointments so that people who need to receive GP advice are able to see their GP more quickly.
• Integrated urgent care pathways such as virtual wards as part of care pathways

2.1.4. Community Care

We know that integrated care teams in the community reduce the likelihood of emergency care needs, enabling people to live in as good health and where appropriate, as independent as possible. Our Community Transformation comprises of five workstreams:

1. Urgent community Response (UCR) aims to expand and improve the Reablement, Intermediate, Virtual Ward capacity and ensure a two hour urgent community response service is available 7 days a week.
2. Community Health Services workstream focuses on pathway redesign and improvement for community-based services and initiatives including Long Covid, Population Health Management, Carers and Children and Young People community services.
3. Integrated Community Pathways focusses more on safe and effective discharge using ‘discharge to assess’ models, trusted assessors, Personal Health Budgets (PHB) and expanding multidisciplinary teams in the community.
4. Care homes and Domiciliary Care aims to further integrated Health and Social care, linking PCNs, Care homes and the Enhanced Health in Care Homes model.
5. Prevention and independent living includes the vaccination programmes, further digital tools and services such as virtual wards and ‘Making Every Contact Count’.

Our proactive and preventative care is delivered in many ways across our communities, such as offering blood pressure and atrial fibrillation screening to eligible patients following Covid19 vaccination.  Clinicians with a special interest, such as in frail elderly people, lead our complex care function, acting as the link between the integrated neighbourhood team and complex care function in each Place to co-ordinate integrated decision making and care. INTs will identify patients through clinical judgement, conversations with patients, and risk stratification enabled by population data.  We will continue support those through NHS Continuing Healthcare or Continuing Care Packages for children (where eligible) to enable people with long term complex health needs, receive care outside of hospital such as their home or care home to aid improvement in the quality of life.

We will better support people by having in place a community-based falls response service in all systems for people who have fallen at home including care homes and providing additional support for care homes through reducing unwarranted variation in ambulance conveyance rates.

We will maximise the use of virtual wards as an alternative to admission or earlier safe and supported discharge seven days a week, 8am to 8 pm.  By supporting acute capacity management, virtual wards add value in making our services more sustainable and provide care closer to home.  Our model brings together primary care, secondary care, and community services to support patients who would otherwise be in hospital. We are expanding our step-down capacity and we’ve developed a step-up model that will operate at place level and evaluating the establishment of an Acute Respiratory Infection (ARI) hub to support same-day assessment. 

Our Better Care Fund (BCF) supports people to live healthy, independent and dignified lives by joining up health, social care and housing services. Surrey County Council, Surrey Heartlands Integrated Care Board and Frimley Integrated Care Board agree a joint BCF plan for Surrey which is owned by the Surrey Health and Wellbeing Board (HWB).  It is aligned with the Surrey HWB strategy delivery and governed to tackle pressures faced across the health and social care system and drive better outcomes for people.

The BCF programme underpins key priorities in the NHS Long Term Plan, joining up services in the community - such as support for unpaid carers, housing support and public health and supporting ‘Next steps to put People at the Heart of Care’. Our BCF programmes will begin to support prevention programmes and continue to facilitate the smooth transition of people out of hospital, reduce the chances of re-admission and support people to avoid long term residential care by acting on the plan to recover urgent and emergency services.

We are working closely with colleagues across other parts of Surrey, including the Frimley Integrated Care System and Southwest London Integrated Care System, to ensure our ambitions for high quality, compassionate, person centred, co-ordinated palliative and end of life care to meet people’s wishes and choices (dying well), are aligned across the whole county.  Our Palliative and End of Life Care strategy is being led at a local level by our Place partnerships.  You can read more about the improvement ambitions and support information on the Surrey Heartlands website.

By 2028 our population will benefit from:

• A workforce that works around the child, from buildings which are local to families and within communities
• An increase in personalised care provided by multi-agency, multidisciplinary teams with care coordinators, enabling patients to see the same clinicians or teams
• Targeted support where there is clear inequality in terms of life expectancy, immunisation, screening in populations who aren’t routine health seekers
• Relevant services are part of Surrey Family Hubs and Frailty Hubs support adults and children close to home
• Digitally shared care records to support individuals get the care and support they need
• Support for all care home residents requiring frailty and enhanced health care
• Seamless urgent community response and virtual wards provision for people with escalating health and care needs, ensuring access to timely support and early interventions in their place of residence
• Increased opportunities to access immunisations and vaccinations for adults and children

2.1.5. Urgent Care

Our urgent and emergency care (UEC) system is challenged across both our local practices and the wider care system.  Unless we work across the traditional boundaries of primary and urgent care as one system using one plan, the relentless pressures on our health and care system that have become commonplace will not go away.

Central to our approach, we are developing effective, resilient, neighbourhood-based same-day access to urgent care that can serve as an easily accessible first point of contact for patients with routine issues. This sits as part of our integrated urgent care pathway, which ensures clarity for patients and referring clinicians.

Our ambition is to improve access to same day urgent care for those who need it, free up capacity to enable continuity of care and test and learn to shape new approaches that work locally.  There will be separate emergency and urgent care services, which are clearly defined purpose, appropriate access and care provided for adults and children.

We are developing proactive models that work to allow same day urgent care access directly to our local communities across digital, innovation and hub models. These include:

• Enhanced access hubs – same day urgent appointments that can be accessed digitally and include multidisciplinary teams that work until 8pm weekly and across the weekends
• Urgent community response – for our more complex and frail patients we will provide a multidisciplinary rapid response approach to help patients avoid the need to be transported away from their home and into an acute hospital
• Urgent children and young people response – many children and young people attend A&E with minor complaints that could have been treated in the community. We are exploring ways in which children will be treated closer to home in a more appropriate settings such as virtual wards.  This includes some elements of care that have historically been given in hospital
• Community diagnostic hubs – working across Place we have developed models of diagnostics that are placed within local communities, including outreach models such as working with the homeless communities who can now access mobile Hepatitis C screening and liver testing as well as Covid vaccinations from an outreach community team
• Care homes – we have implemented a multidisciplinary approach to the management of care for these residents, particularly those who are more complex requiring extra support to avoid hospital admission
• Frailty models of care – we have developed key ambitions for frailty services that work with our local communities and carers to deliver urgent care in frailty that allow people to stay at home for longer safely
• Anticipatory care models – using our new digital risk stratification we can better target those most at risk of admission and attendance into the urgent care system
• Triage improvements – in referral processes are proving effective in enabling the ‘right care, in the right place’ and we are now looking to extend these models across practices.

CASE STUDY

Surrey Downs Urgent Care Coordination Centre

A single point of access for all referrals (including from health and social care colleagues, 111 and self-referral).  The single point of access will allocate referrals to the appropriate team within the place-based urgent care pathway - whether it is urgent community response, virtual ward, Homefirst+ or primary care network hubs.  It aims to streamline and support greater clarity in navigating the system for all and can provide care coordination as patients move through the pathway ensuring continuity of care.

Same Day Emergency Care (SDEC) is a service that provides emergency care to people without the need for an admission to hospital and can provide direct referral into mental health services, dentistry, community pharmacy and services such as ophthalmology. We will ensure:

• SDEC operates 7 days a week for 12 hours daily
• enhanced diagnostic access and referral routes with an increase in the number of Advanced Practitioners
• Surrey Heartlands meets the core service provision set out in the Long-Term Plan, including community child and adolescent mental health services and 24 hour a day crisis teams

Our NHS 111 service supports people who need urgent but not life-threatening emergency care.  It provides advice and signposts to treatment if your GP or Dental practice is closed or if people are injured or ill and are unsure what to do. Work is on track to be extend bookable appointments into other alternatives to Emergency Departments  such as SDEC.  In Surrey Heartlands, NHS 111 forms part of our Integrated Urgent Care service which also comprises Clinical Assessment Services (CAS) and GP Out of Hours provision (including clinical contacts, base visits, and home visiting). 

Surrey Heartlands, in line with national ambitions, is continuing to develop this service to make it easier for people to access the care that they need and support emergency departments to work more effectively.   This includes dedicated paediatric advice and guidance for families to support decision making around care options. You can find out more about how our NHS 111 service works on our website.

2.1.6. Ambulance

Our ambulance services are under extreme pressure resulting in slower call response times and fewer resources available.  We know that handover delays – the time from arrival to transfer to a clinician at hospital – are not the only cause of slower ambulance response times.  Our ambulance trust, South East Coast Ambulance (SECAmb), like many across the country, has experienced increases in sickness and other staff absence, along with the complexity of ambulance crews’ work increase meaning each incident is taking longer. 

Surrey Heartlands ICS and SECAmb are committed to getting ambulances to patients more quickly and in turn support recovery of patient flow.  We will improve ambulance response times for Category 2 incidents to under 30 minutes on average, with further improvement towards pre-pandemic levels.

SECAmb has established the following 2023/24 strategic objectives to achieve our collective aims: Quality Improvement, Responsive Care, People and Culture, and Sustainability and Partnerships, which are underpinned by strategic goals and in-year objectives, as part of the current Improvement Journey. These are reviewed for assurance by Trust and Commissioning Boards

The developing SECAmb long term strategy has completed an options appraisal process both internally and with system partners; and further to agreement from the Trust Board, SECAmb will be pursuing ‘option 2’ which focuses on the enhanced ability of the Trust to clinically assess and navigate patients to the most appropriate care pathway whilst also delivering optimal response to the most time critical patients, significantly improving clinical outcome as a result. 

The approach and priorities for 2024/25 are being finessed and finalised in preparation for the start of year 1 delivery. Under this model the expectation will be to deliver improvements in the ability to triage and clinically differentiate callers, enabling a physical ambulance response for those that need it or a more tailored response for our urgent patients, ensuring they are seamlessly connected to the most clinically appropriate service.

Delivery of this model will require collaborative system working alongside our UEC pathway providers. Together with all 4 ICSs in its catchment, the Trust aims to provide safe, effective, and timely response times for patients and to become a sustainable provider by optimising referral pathways and avoiding inappropriate conveyance to emergency departments.

The Trust Board priorities and aspirations align with the Integrated Care System's Joint Forward Plan and demonstrate the Trust’s commitment to improving patient outcomes, delivering high-quality and responsive care, developing sustainable healthcare provision, building a culture of continuous improvement, and promoting a positive and inclusive culture.

2.1.7. Emergency Care

Surrey Heartlands ICS experienced exceptional pressures throughout 2022 and into 2023. Unlike previous years, this has not been wholly created by increases in demand, increased ambulance conveyances and NHS 111, but exacerbated by high number of patients who no longer need to reside in hospital severely constricting patient flow into and out of hospital.

Our  primary focus is delivering the NHS recovering urgent and emergency services two year plan to regain improved waiting times and patient experience.  The integrated system working described earlier will enable us to support people access the care they need and alleviate continuation of care delays to recover patient flow.  We are committed to the ambition to improve the percentage of patients being admitted, transferred, or discharged within four hours by March 2024 to the national 76% target, with further improvement in 2024/25.

2.1.8. Managed Discharge

We know that long stays in hospital, through delayed discharges, are not good for patients and significantly impact how hospitals are able to provide services. We will focus on improving discharge processes – sometimes known as ‘flow’- between hospitals, community services, local authorities and social care to improve health and care outcomes plus patient experience.

Surrey Heartlands will deliver health and care discharge services seven days a week for people ready to leave an acute hospital bed. Surrey Heartlands will continue to build on personalised health and care initiatives that focus on people leaving the hospital, including interim care support packages coordinated across health, social care and voluntary sector partners. Getting discharge planning right is a crucial component of our process for managing surges in demand. 

The NHS delivery plan for recovering urgent and emergency care services encourages us to centre our improvement work on joint discharge processes, intermediate care and social care services. We will focus our efforts on embedding discharge planning at the point of admission with an estimated discharge date and identifying those with complex discharge needs by working with families and carers.  We will use our ‘Discharge to (Recover and) Assess’ (D2A) to facilitate care closer to people’s homes, with increased health and care agency coordination for intermediate care and domiciliary care, and supported by the Better Care Fund.

CASE STUDY

In-reach community nursing

A pilot for in-reach community nursing within the Royal Surrey County Hospital was launched in January 2022.  The adult community discharge senior nurses work to review all Guildford and Waverley community nursing caseload admissions to the hospital prior to their discharge home.  The nurses are made aware of any patients on the district nursing caseload attending A&E and assist with preventing unnecessary admissions.

In the first six weeks community nurses received 165 referrals, promoting self-care in 21 patients, facilitating four early discharges and referring five high risk patients who were previously unknown to the community matrons, in the hope of preventing avoidable admissions.  The self-care instruction to insulin dependent patients alone avoided costs of estimated £93,447 per year.  Feedback from staff within the hospital Trust was extremely positive and the decision was taken to provide Better Care Funding to expand and extend these roles.

By 2028 our population will benefit from:

• Providing clear relevant information to ensure patients can access alternative services for urgent same day care.
• Providing access to online resources 24/7, in a variety of formats, so that support can be given more quickly for many conditions.
• Neighbouring partners working together for walk-in sites booked appointments and Same Day Emergency Care (SDEC) pathways.
• Providing greater opportunity for care and support to be tailored to the individual’s own support network and community.
• Urgent and emergency care services are consistently rated as good or outstanding.
• Our urgent and emergency care system is attractive to staff to work in
• Linking care records, with consent, so that the person is able to 'tell their story once’.
• Providing more direct appointments with many local services, considerably reducing wait times.
• Ensuring that the Emergency Departments are better able to meet the needs of people who require emergency care due to suffering a life-threatening health event.
• Reducing wait times within the Emergency Departments; and increasing timely discharge from hospital.

2.1.9. Maternity and Neonatal Care

The best start in life begins well before birth. The NHS Long Term Plan national set the ambition to halve the rates of stillbirths, neonatal mortality, maternal mortality and brain injury by 2025.  Within Surrey Heartlands we seek to ensure patient safety and go further to achieve sustainable, high-quality physical and mental health care for women, birthing people and babies that meets the wide range of needs in our communities.

This means increasing choice, personalisation and continuity of carer, listening to women and birthing people, improving access to maternity and perinatal mental health services and improving uptake of prevention activities.  Our local maternity and neonatal system seek to provide women, birthing people and their partners with a positive, supportive experience from conception through to caring for their baby after the birth.

We know from the Independent Reviews of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust (Ockenden, 2020 and 2022) and Maternity and Neonatal Services in East Kent: ‘Reading the signals’ we need to develop multi-professional training, recruitment and retention.  We are proactively focusing on safety, positive cultures, and future workforce concerns within our Maternity Services.  We will align our work with NHS England’s three year delivery plan for maternity and neonatal services, including achieving the national ambitions by 2025.

We will prioritise improving and co-designing maternity and neonatal services in collaboration with pregnant women and birthing people through our local Maternity and Neonatal Voice Partnership (MNVP), to ensure maternity equity and meet the needs of communities.  Our key provision priorities include personalised care, continuity of carer and establishment of community hubs, improved postnatal care and appropriate bereavement care services for women who suffer pregnancy loss. 

To improve outcomes for women, birthing people and babies, we have a number of priorities including:

• To halve the rates of stillbirths, neonatal mortality, maternal mortality and brain injury by 2025 – Our collaborative Maternal Medicine Network with Southwest London LMNS will improve outcomes for women and consequently babies and referral criteria will reflect the increased vulnerability of women from ethnic minorities and those who are socially deprived.
• Addressing health inequalities – Our 5-year perinatal equity strategy.
• Physical health – to work with Southwest London Maternal Medicine Network to develop pathways for maternal medicine and we will scope services for pelvic health following birth. 
• Emotional wellbeing: Perinatal Mental Health – ensuring that every woman:
  • has access to services to during the antenatal period for 2 years after birth.
  • is able to access quality perinatal mental health care and treatment at the right time, at the right level and at the right location
• Public health – We are working on pathways for smoking cessation during pregnancy in collaboration with Public Health. We also have public Health campaigns such as Ready for Pregnancy and Ready for Parenthood.

CASE STUDY

Maternity and Neonatal Voices Partnership

The Maternity and Neonatal Voices Partnership (MNVP) is a national initiative that brings women, birthing people and families together with NHS staff and other stakeholders in an equal partnership to coproduce improvements to local maternity services. NHS Surrey Heartlands has four MNVPs; one for each of our maternity provider trusts. The MNVPs are led by a team of local parents with lived experiences within each trust.  Our MNVPs will continue to lead on gathering feedback from women and families in a variety of ways (from ‘Walking the Patch’ at the maternity unit, to visiting toddler and community groups), and work with staff to keep women and families’ voices at the heart of maternity and neonatal improvements and developments. 

MNVP activity includes building relationships with local faith groups, food banks and charities, attending and presenting at Trust quality & safety meetings, co-producing bereavement pathways and literature, social media engagement with the public, contributing to strategies, and co-producing information and communications literature.

By 2028 our population will benefit from:

• Services co-designed with pregnant women and birthing people.
• Improved culture within services will support safety
• Digital strategy will support interoperability across the system
• A reduced rate of still births, neonatal and maternal mortality and morbidity.
• Feedback from women and birthing people demonstrating that they are listened to, have a choice and are the key decision maker for their care.
• Pregnant women and birthing people offered continuity of carer.
• Whenever possible, care closer to home.

2.1.10. Children and Young People

High quality services for children and young people are essential to improving whole of life health outcomes and reducing health inequalities. Poor health outcomes can become embedded early in childhood, so children and young people access a wide range of services during this life phase affords many opportunities to tackle this and make improvements.  We are focusing on supporting children effectively in primary care or community settings to improve opportunities for prevention as well as the quality of care for acute and longer-term illness.

The NHS Long term plan sets out key aspirations which consider the diverse and complex needs of children. The focus includes improving the quality of care for children with long term conditions such as asthma, epilepsy, diabetes and, more recently, long covid; right-sizing paediatric critical care and surgical services to meet the changing needs of patients, ensuring that children and young people access high quality care as close to home as possible and selectively moving to a ‘0-25 years’ service which will improve children’s experience of care, outcomes and continuity of care.

The national programme, Core20PLUS5, enables and emphasises the need to reduce health inequalities for children and young people. These concentrated efforts run through improvement work, such as Improving Children’s Emotional Wellbeing and Mental Health for children and young people with a Learning Disability or Autism.

CASE STUDY

Mental health inpatient unit for young people

Surrey and Borders Partnership NHS Foundation Trust and Elysium Healthcare have come together in partnership to build and manage a brand-new, dedicated mental health inpatient unit for young people.

The unit offers 12 inpatient beds for young people and a therapeutic, safe, and nurturing environment to support and aid recovery. There will be a variety of communal living and outdoor spaces to give young people the opportunity to socialise with their peers and be as independent as possible. There will also be an Ofsted registered school set up on-site to enable young people to continue with their schooling whilst receiving treatment.

Joy Chamberlain, Chief Executive Officer of Elysium Healthcare said, “Partnership working to deliver services in this way will create a new benchmark for the future, and we look forward to continuing to work with Surrey and Borders Partnership on this exciting journey.”

Supporting this ambition, our Joint Commissioning Strategy outlines how our system architecture, will commission services for children and young people – for Surrey services, neighbourhood and individual level. Our vision is to support children and families holistically to live healthy and fulfilling lives’, using improved understanding of needs across health and care services, hearing children and families’ voices and managing our resources together.

The strategy focuses on three main theme areas.

1. Promoting and facilitating good health, emotional wellbeing, and healthy relationships
2. Recognising and promoting the importance of development and early learning; enabling partnership working and collaboration
3. Recognising the benefit of fully inclusive services, communities, and neighbourhoods

This strategy builds on work taking place and supporting strategies including the Best Start for Surrey Strategy (2022 – 2027), Additional Needs and Inclusion and Emotional Wellbeing and Mental Health and Family Resilience. In response to what children, young people and families tell us about their experiences and as part of our system ambition to improve outcomes a Care and Health Transformation plan has been developed in collaboration with partners across the Surrey system. This 5-year transformation plan focuses on 5 key pillars: Prevention, Access, Assessment, Statutory / Specialist, Integration.

We will continue to use our learning from the development of current services such as Mindworks Emotional Wellbeing and Mental Health services for children and young people, the iThrive approach, HOPE service and independent review improvement recommendations, to continue strong partnership working to achieve our ambition.  The Helping Families Early Strategy, Children’s Community Health Services re-commissioning, maternity transformation, improving support and diagnostic access for neurodiverse needs, statutory improvement for Early Help and for children with Additional Needs (SEND) and the Children’s Digital Programme are significant enablers of this strategy and transformation plan.

Our vision for Children’s Community Health Services is to meet the needs of children, young people and their families at the earliest opportunity, through providing timely support, advice and specialist delivery at home, within local communities and across the county’s geographies.  We aim to ensure healthy lives and a brighter future supports children to grow up safe and resilient by prioritising prevention, early intervention and addressing health inequalities, enabled by designing and delivering integrated services across Surrey and at Place.

As a partnership, our improvement priorities include:

• Children with Disabilities – Social Care alignment to health services, including continuing care, speech and language therapy, occupational therapy, physiotherapy, community paediatrics, and child and adolescent mental health services (CAMHS).
• Personalisation – including increasing take-up of and streamlining personal budgets, direct payments and personal health budgets.
• Health of Looked After Children and Care Leavers – better use of health assessments and understanding of the mental and emotional health of these children and young people.
• Ordinarily Available Provision – services to support children with additional needs in schools enabling those that work in universal services to know what is available in their communities.
• Community Health Services – making sure waiting times are reduced, workforce issues are addressed, and services are more impactful on shared outcomes.
• Diagnosable eating disorders – Children and Young People (CYP) with a diagnosable eating disorder receive timely access to treatment, irrespective of severity and maintain the delivery of the 95% achieving the national waiting times standards of 4 weeks for routine care and 1 week for urgent care.
• Vulnerable Adolescents – Anxiety and Suicide Prevention to address the rising numbers of young people who are experiencing mental health crises, heightened through the pandemic, particularly through our Targeted Youth Offer.
• Neurodevelopmental Pathway – ensuring practitioners and services come together around a family at every stage of their journey.
• Post Adoption and Special Guardianship Order (SGO) – support ensuring therapeutic provision to prevent adoption or SGO family breakdown.

To ensure that children with additional needs and disabilities can access the right support at the right time, from local, high quality health services, we will deliver an integrated system across Health, Social Care and Education.  As well as providing appropriate and easy transitions for young people into adult services, we are committed to developing a transition to adult services that is seamless.  We will increase use of digital technologies and multidisciplinary teams within clinical pathways as the normal way of working to ensure we make the best use of our resources.

CASE STUDY

Supporting children and young people

Surrey Minority Ethnic Forum (SMEF)  have co-produced support and direct interventions with women and families from ethnic minorities, including women and families from refugee and asylum-seeking hotels. This includes:

• Peer support: To empower women from ethnic minority communities and provide psycho-social perinatal mental health support.
• Increased engagement with services to enable improved health outcomes: Community Development Workers (CDWs) provide outreach into local communities, linking into health and public services, to provide a network of support.
• Cultural awareness: CDWs work with children's and maternity services to improve cultural awareness and promote inclusive environments and services.
• Personalised care: The CDWs follow the women through their perinatal and mental health journey, facilitating personalised and continuity of care alongside healthcare professionals.

For children and young people with complex needs and special educational needs and disability (SEND), our ambition is that Surrey children and young people aged 0 to 25 years will lead the best possible life. They will be able to access health information and will understand the services available when they transition into adult healthcare provision as part of ‘Preparing for Adulthood’ in higher education or employment, independent living, participating in society, and being as healthy as possible.

By 2028 our population will benefit from:

• Better managed long-term conditions with reduced unplanned hospital attendances and admissions plus reduced co-morbidities later in life.
• Improved health and wellbeing including improved school attendance for children and young people, breastfeeding rates, healthy relationships with secure attachment and early learning.
• Children will be seen in a more appropriate community setting instead of an emergency department whenever possible.
• Children’s critical care will be provided closer to home whenever possible.
• Each child or young person with an Education, Health and Care plan will have high quality health provision to ensure their health needs are met in alignment with their educational outcomes within statutory timescales.
• Under school age children with Special Educational Needs, will have their health needs identified early.
• Children and young people, parents and carers will be able to access clear health information.
• Young People in Surrey will have access to the Health Services they need as part of Preparing for Adulthood.
• Health interventions in Non-Maintained Independent Educational Provision will meet standards in line with National guidance and expectations.
• Medical needs of Children and young people in Educational Provision will be met.
• All young people with learning disabilities and/or autism in Surrey who are aged over 14 and over will have an annual health check.

You can read more about our children’s services, young carers in the introduction, strategy for looked after children and children’s social care priorities in the Corporate Parenting Strategy on our websites.

2.1.11. Mental Health

We know that self-reported wellbeing has decreased significantly over the last three years; the combination of the impact of the Covid19 pandemic and cost of living has affected many people in Surrey and across the country.  There is around a 20 year gap in life expectancy for people with Serious Mental Illness (SMI) and notably excess mortality (the number of deaths above the five-year average) for those under 75 years is significantly higher in Surrey for SMI than the England average. In Surrey the percentage of citizens reporting high anxiety levels is 22.5% which, while better than the England average (24.2%), is higher than the reported best (15.9%).  This correlates with the increase in demand and use of all age mental health services in Surrey Heartlands. 

Our ambition is that we will achieve the national mental health deliverables informed by the NHS Long-Term Plan and deliver the recommendations from the local Surrey Mental Health Improvement Plan.  Through the Surrey Heartlands Trust Provider Collaborative, we will develop an integrated approach to manage the interrelationship between physical and mental health, especially for those experiencing a mental health crisis.

Mental health provision is a priority in Surrey. System partners are working together to deliver the Health and Wellbeing Strategy (Priority 2), NHS Long Term Plan and the Mental Health Improvement Plan. The overall focus is on prevention, expanding community services, removing barriers, and enabling people to become proactive in improving their emotional health and wellbeing.

We have made progress on delivery objectives with the aim of continuous improvement and using new information such as the Joint Strategic Needs Assessment 2023 to enable the drivers of change. The mental health System governance has been updated with the Mental Health System Committee driving improvements throughout the system.

Shared outcomes – all services aim to achieve the following:

• Reduce health inequality so no one is left behind:
  • give people a better network of support so they don't feel alone
  • help people feel more independent
  • improve people's feelings of self-worth and confidence
  • people feel positive about the support they receive
  • contribute to people recovering from a period of ill health
  • improve people's mental well-being.

Emotional Wellbeing and Mental Health of Children and their Families is a priority that cuts across education, health and social care. The iThrive model of support promotes emotional wellbeing as being everyone’s business. Our recent CYP Emotional Wellbeing, Mental Health and Suicide Prevention Strategy (Children and Young People’s Emotional Wellbeing and Mental Health Strategy 2022-2027) includes 6 priority areas that were coproduced with children and young people.

By 2028 our population will benefit from:

• Increased access to evidence-based care to an additional 24,000 women with moderate to severe perinatal mental health difficulties and personality diagnosis each year until March 2024.  Care provided by specialist services will be extended from preconception to 24 months after birth and access will also be expanded to psychological therapies in services.  A key priority was the development of a Maternal Mental Health Service, which was launched in December 2022.
• 24/7 psychiatric liaison in all emergency departments.
• 60% of people with a diagnosed severe mental illness receive an annual physical health check in a primary care setting.
• Increased access to psychological therapies.
• Implementation of actions from the Suicide and Prevention Strategy 2022.
• A tailored service to young people between 18 and 25 years old who are experiencing mental health challenges and transitioning from children to adult mental health services.
• Working towards eliminating all inappropriate out of area placements.
• Supported the creation of an Adult Mental Health Alliance, which will help facilitate voluntary sector engagement with the health and social care system in a more strategic manner.
• Implementation of actions from the EWMH strategy, which provides the strategic framework for all partners in Surrey to improve EWMH of CYP and ensures commitment to the implementation of the iThrive framework.
• A much stronger focus on early intervention, with mental health support for children and young people embedded in all our schools and colleges.
• Implementation of Community Transformation and One Team approach for adult community services.
• Implementation of integrated commissioning arrangements.
• Improving accommodation with care and support for people with poor mental health, led by SCC with ICS partners.
• Improving access to employment support for people with a serious mental health illness.
• CYP experiencing a mental health crisis able to access the support they need.  This will be achieved by 100% coverage of 24/7 age-appropriate crisis provision for CYP which combines crisis assessment, brief response and intensive home treatment function as well as being supported to prevent a crisis occurring again by being connected to support from early intervention offers.

You can read more about our mental health programme on the Surrey Heartlands website and Joint Forward Plan Fact File.

2.1.12. Dementia

In Surrey, people with dementia have a higher number of hospital admissions with longer lengths of stay and higher emergency admissions compared to people the same age without dementia.  Whilst Surrey performs similar to or better than the England average on the majority of the dementia care indicators, to meet the health and wellbeing strategy target of reducing emergency admission rates of people with dementia from 3,272 to 2,496 per 100,000 we must do things differently.

Our Joint Health and Care Dementia Strategy for Surrey sets out the collective ambitions we want to achieve across Surrey to improve the dementia care pathway in five parts:

1. Preventing people from getting dementia
2. Helping people who have just been diagnosed with dementia
3. Helping people with dementia to live well
4. Supporting the care of people with dementia
5. Supporting people with dementia to live for as long as possible 

By 2028 our population will benefit from:

• People can make good decisions about when to consider care and how to find the best choice for them, shown through improved outcomes.
• Information, advice and guidance offered ensures everyone accessing care and support for themselves or for someone else, can have the right information at the right time.
• People to know about the different options available to them locally in the community and how to get support to live independently.
• Increase in Surrey residents accessing day services and activities within their local communities to stay independent for longer.
• Understanding that technology is not a preference for all residents and ensuring that other options are available to support, ensuring no one is digitally excluded.
• Continued research and development of initiatives to provide access to trials of new medications and treatments.
• Progressing actions from the Joint Health and Care Dementia Strategy for Surrey 2022 to 2027.
• Using new and existing technology to improve people’s care choices and independence.

You can read more about the work to support these improvements in our Dementia Strategy.

2.1.13. Learning Disabilities and Autism

We are using the national policy drivers to optimise outcomes for those with Learning Disabilities and Autism (LDA), including Building the Right Support Action Plan.

Our ambition is to make sure no one person is left behind for those with Learning Disabilities and/or Autism.  We are using our local drivers including the Surrey All Age Autism Strategy,  LDA Three year delivery plan, Joint Commissioning Strategy for Children and Young People, Children and Young People with Additional Needs & Disabilities: 2022 -2030 Sufficiency Plan and Surrey Accommodation Care and Support Strategy which outline the local response and actions to meet the national drivers and Surrey 2023 community vision. 

People with a learning disability tend to have worse physical and mental health than the general population.  We know that women with a learning disability live 20 years and men 14.7 years less than their counterparts.  We will focus on specific and measurable actions that reduce the health gap between people with a learning disability and autistic people and the wider population, with the aim of achieving equivalence of care.

CASE STUDY

Addressing life expectancy inequalities

Surrey Heartlands ICS and the Public Service Consultants (PSC) undertook a project to respond to the significant life expectancy gaps faced by people with Learning Disabilities (LD).  The PSC analysed data to identify causes of death, risk factors, and inequalities. The project team combined data analysis carried out by the PSC with the NHS’s understanding of those challenges being faced on the ground, day-to-day, and as a collaborative they were able to provide a holistic overview and a series of recommendations.

The project has been a success in pinpointing causes of death and associated risk factors for LD individuals, informing targeted interventions. Notably, we were able to see significant disparities in obesity, Type 2 diabetes, and high blood pressure, and higher mortality rates for women with LD.

The project has provided a strong foundation for further replication in addressing health inequalities for other underserved or vulnerable populations. It has also been an opportunity to empower people with LD and give them a voice to influence healthcare policies and approaches and ultimately improve lives. One of the biggest endorsements of this great work has been the recent shortlisting for an HSJ award. The joint team’s hard work has been recognised for the ‘Most Impactful Project Addressing Health Inequalities’ Award.

Good quality healthcare and effective access to Primary Care services are key to how we are tackling such inequalities.  As some health problems experienced by people with a learning disability are simple to treat once diagnosed, a GP can often prevent a serious health condition with early identification.  To this effect, an Annual Health Check is offered to anyone aged 14 or over who is on their GP’s learning disability register.

By 2028 our population will benefit from:

• Delivering the workstreams in the All-Age Autism Strategy 2021 to 2026.
• An increased the number of people with learning disabilities on general practice register, receiving an Annual Health Check and effective Health Action Plan to prevent physical ill health and promote physical well-being.
• Numbers of individuals in inpatient settings reduces and stays below national targets:
  • no more than 3 children or young people at any one time.
  • children and young people (up to 25) will be supported by key working service.
  • no more than 21 adults at any one time.
• People at risk will be supported by a digital dynamic support register and intensive support services to prevent admission.
• Increase in Supported Independent Living (SIL) options, meaningful activities in the community and numbers of people in employment.
• We will have a workforce trained in learning disability and autism in line with the Health and Care Act 2022.
• Proactive Public Health targeted interventions to reduce health inequalities to decrease disease burden and prevent premature mortality.
• Reasonable adjustment digital flag will be in place across the system .
• All regulated providers are compliant with the Oliver McGowan Mandatory Training requirement under the Health and Care Act 2022.
• Autistic people without learning disabilities will have access to an annual health check and health action plan from age 18 onwards (anticipated from 2025).
• Following publication of the statutory guidance of the Down Syndrome Act (anticipated Spring 2024) we will ensure that people with Down Syndrome have their needs met by all 'relevant authorities' as defined in Schedule 1 of the Act including health, social care, housing, education and youth justice.

You can read more about our Learning Disabilities and Autism work on the Surrey Heartlands website.

2.1.14. Elective Care

Our ambition following a significant reduction in elective services during the emergency phases of the pandemic, is that elective services recover to pre-pandemic levels. National data shows that the recovery rate for children’s elective care has been at a slower rate than for adults and Surrey Heartlands replicates this.

Our aim is to reduce the volume of patients waiting long periods for admitted care and that they ‘wait well’ with the following objectives: no patient waiting over 52 weeks for elective care by March 2025; 95% of patient waiting six weeks or less for a diagnostic; and 75% of patients referred for a suspected cancer be diagnosed or have cancer ruled out within 28 days by March 2025. 

We understand the impact longer waits have on our patients and their families.  The safety of our patients is our top priority, and we will prioritise the most clinically urgent patients.  We will continue to share information on a range of conditions to enable a better understanding of supporting your own health while on the waiting list – known as ‘waiting well’.  It is a key system priority to progressively reduce the volume and length of elective care waiting lists. 

Delivering such a high volume of activity is costly and puts significant strain on an already pressured workforce.  Surrey Heartlands will implement robust pathway changes that improve efficiency to deliver the same patient care across fewer episodes and with less cost. 

We have continued to focus on reducing the longest waits over the last 18 months. We are now working to achieve no waits over 65 weeks by September 2024.  However, our plans will need us to do things differently, creating additional capacity within our system and changing for the better the way services are delivered, while giving patients more choice and control over their experience in the NHS. 

Delivery of our elective recovery plan includes several initiatives:

• Significant investment in and reconfiguration of our diagnostic services, including standardisation of referral pathways and clinical criteria.
• Collaborative system wide working to reduce variation and standardise referral pathways into Single Points of Access (SPOA) models where appropriate in specialties such as Ophthalmology, MSK and Dermatology.
• To identify opportunities to consolidate services in order to improve clinical outcomes, reduce variation and improve efficiency
• Develop digital technology to support operational delivery of elective care, including integration of patient-facing digital technology with the NHS app.
• Development of care models to consolidate attendances, provide flexibility to arrange own follow-up appointments and expand capacity to deliver high-quality care.

Services for people with a range of rare and complex conditions, often involving treatments for those with rare cancers, genetic disorders or complex medical or surgical conditions known as Specialised Services, has a large Clinical Transformation Programme in line with national Long Term Plan and strategic priorities.  As part of the development of a 3 year Forward View and Strategic Plan for specialised services during 2024/25, a strategic review of our Clinical Networks will be incorporated to establish and manage the Specialised Services Operational Delivery Networks (ODNs) across South East England. 

From 1^st April 2025, NHSE aims to delegate some specialised services commissioning responsibility to ICBs such as critical care, neonatal care, cardiac care, renal dialysis, and some cancer care. This will enable a real opportunity in Surrey Heartlands to join up specialised and non-specialised patient pathways to truly improve the health of local populations and integrate care pathways – from prevention to primary care, through to secondary and highly specialised care. 

Our outpatient services provide the greatest volume of hospital services. Demand for these services continues to increase with improved care treatments reducing the need for admission and waiting lists created because of the pandemic.  We will continue to improve demand management to reduce the volume of patients being seen in an acute setting unnecessarily. We will redesign care pathways to include opportunities for patients to seek support and guidance from appropriate alternative health and care professionals, such as optometrists with more effective and timely advice and guidance (A&G) to primary and community care services.  In addition,  we are reducing the number of follow-up appointments patients receive, with the help of technology and Patient initiated follow-ups.

Surrey Heartlands has already made significant progress improving cancer services. We have met the cancer 28 day Faster Diagnostic Standard (FDS) during 2023/24 and are committed to deliver the core cancer waiting time standards: 28 days faster diagnosis standard ; 31-day decision to treat  to treatment standard; and 62-day referral to treatment standard. Maintaining excellent cancer pathways is one of our key aims, supported by the Cancer Centre at Royal Surrey Foundation NHS Trust and the Surrey and Sussex Cancer Alliance. 

Through our Cancer Centre and Surrey University, we aim to deliver research and innovation in cancer, offering patient trials and new technologies where available.  By implementing new technologies, changes to screening protocols and best practice timed pathways will all enable Surrey Heartlands to continue to deliver one of the best cancer performances in the country.

We are increasing diagnostic provision to meet the needs of the population and transform services to ensure patients are diagnosed faster, earlier, more efficiently and are able to be prescribed the most appropriate course of treatment, thereby improving patient experience and outcomes. 

We developed our Diagnostics Strategy in 2023, with the expectation to develop an annual implementation plan focusing on the recommendations from the Diagnostics: Recovery and Renewal. We continue to expand existing Community Diagnostic Centres to ensure patients can access a range of diagnostics closer to home, ensure effective collaboration between different workstreams such as cancer diagnostics and NHS@home, and develop a sustainable and resilient workforce.

By 2028 our population will benefit from:

• Improved access to specialist advice – providing greater flexibility in how advice from clinicians is accessed by patients, enabling more timely, convenient and appropriate care and avoiding the need for unnecessary appointments.
• Improved patient pathways – reducing avoidable delays by ensuring we are making the best use of the latest technology, clinical time and expertise.
• Expanding community diagnostic centres – focusing on ease of access and convenience for patients.
• Care is more personalised – more choice and options to reflect patient preferences and needs.
• Targeted support for patients – patients are informed, supported to wait well and co-develop personalised plans to prepare for treatment.

You can read more about the planned care delivery plans in our Joint Forward Plan Fact Files on our website.

2.2. Delivering NHS Long Term Plan Priorities

We know that life expectancy has increased over the years since the NHS was founded, and different types of diseases are becoming more common.  Mortality from heart and circulatory diseases has declined by more than three quarters over the last 40 years. But we have seen an increase in the number of long-term conditions – illnesses which last longer than a year, often worsening with time – which are responsible for a substantial amount of poor health and demand on health and care services.

There have been slower improvements in the number of years of life lost particularly for cardiovascular, stroke, respiratory conditions and diabetes.  The NHS Long Term Plan (LTP) set out a number of improvement priorities which we have been working on and achieving over the last five years. There are still improvement ambitions we want to achieve for our population; some going beyond what is required, to ensure no-one is left behind. 

Our Medical Directors and professional clinical body are developing an ICS Clinical Strategy, which we expect to publish in Summer 2024.  This will align with organisation clinical strategies and support the delivery ambitions of the Provider Collaboratives, through the coordination of care into a single, coherent process and clinical integration.  As part of this focus, we are leading specific work to reduce clinical unwarranted variation - variation that cannot be explained by illness, medical need, or the dictates of evidence-based medicine – to realise optimal health outcomes.

In this chapter we describe our delivery and outcome ambitions for these LTP priorities.

2.2.1. Cardiovascular

The NHS Long Term Plan’s national ambition is to prevent 150,000 strokes, heart attacks and dementia cases over the next 10 years and has agreed a set of ambitions which seek to improve the detection and treatment of the high-risk conditions including Atrial Fibrillation (AF), Blood Pressure (BP) and Cardiovascular Disease (CVD).

Our ambition for the Cardiovascular programme is to support National Core20PLUS5 priorities and local population health data through our local priorities:

• Improved AF detection and management
• Hypertension detection and treatment to target
• Cholesterol (lipid) management
• Heart failure management
• Cardiac rehabilitation

Cardiovascular disease contributes to more preventable deaths than any other disease. Up to 80% of premature CVD deaths are preventable. CVD overlaps with both diabetes specifically and multimorbidity (the presence of two or more long-term health conditions) generally. Modifiable risk factors – such as high blood pressure, high cholesterol, diet, obesity, physical inactivity, smoking and air pollution - explain the vast majority of CVD.

The CVD Prevention Plan has been developed jointly between the ICB and Public Health to support delivery of targeted interventions to optimise care by maximising diagnosis and treatment to minimise both individual risk factors and population risk. This aligns with the 10-year cardiovascular disease ambitions for England, which are underpinned by the need to do more to reduce health inequalities by focusing on atrial fibrillation, high blood pressure, and high cholesterol.

By 2028 our population will benefit from:

• 85% of the expected number of people with AF are detected (national ambition by 2029)
• 90% of people with AF who are at high risk of a stroke have adequate anticoagulation (national ambition by 2029)
• 80% of patients with high blood pressure to be identified and of those 80% to be treated to target
• 75% of people aged 40-74 to have received a formal validated CVD risk assessment and cholesterol reading recorded (national ambition by 2029)
• 45% of people aged 40 to 74 without established CVD who are identified as having a 20% or greater 10-year risk of developing CVD in primary care are treated with statins (national ambition by 2029)
• 25% of people with Familial Hypercholesterolaemia (FH) are to be diagnosed and treated optimally
• Increase identification of heart failure (HF) diagnosis
• Reduction in the prevalence of hypertension in our population
• An embedded multiple long term conditions approach that delivers effective primary and secondary prevention and early diagnosis and enables people living will multiple long-term conditions to manage and live well.

You can read more about our cardiovascular delivery plan in our Joint Forward Plan Fact File on our website.

2.2.2. Stroke

The NHS Long Term Plan’s ambition for stroke care includes developing improved post-hospital stroke rehabilitation models, delivering a ten-fold increase in the proportion of patients who receive a thrombectomy after stroke and delivering improved thrombolysis performance with access to all patients who could benefit. 

Integrated Stroke Delivery Networks (ISDN) are an integral part of delivering the LTP commitments for stroke.  The Frimley and Surrey Heartlands ISDN aims to improve the quality of stroke care, through improving clinical outcomes, addressing areas of unwarranted clinical variation, excellent patient experience and patient safety.  The ISDN brings together key stakeholders and partners to collectively agree a strategic plan of work to facilitate service improvements across the whole stroke pathway, ensuring a patient centred, evidence-based approach to delivering transformational change.  Stroke, alongside paediatrics and maternity, are being reviewed across Surrey Heartlands as part of the provider collaborative discussions.  The Frimley and Surrey Heartlands ISDN will support and inform any end-to-end stroke pathway transformation discussions providing subject matter knowledge and expertise.

The ISDN has three key workstreams:

1. Prevention – The development of a stroke prevention strategy is linked with the cardiovascular disease programme.
2. Acute and Urgent Care – This workstream brings together clinicians (including Stroke Consultants, nursing and therapy staff) and service managers working across the acute hospitals within the ISDN, representatives from SCAS and SECAmb, nursing staff within the Early Supported Discharge Teams, GP leads and the Stroke Association.  Key priorities include SSNAP Performance, Transient Ischaemic Attack Pathways, Pre-hospital pathway and Thrombectomy Pathway.
3. Rehabilitation and Life after Stroke – delivering the Integrated Community Stroke Service Model (ICSS), improving the intensity and access to rehabilitation across the geography and ensuring the integration of social care in the delivery of stroke rehabilitation.

By 2028 our population will benefit from:

• As part of the joint CVD / stroke prevention strategy, significant and sustained improvements will have been made in the identification and treatment of hypertension and atrial fibrillation within the population.
• Thrombolysis and thrombectomy rates will have increased significantly and the LTP ambitions for thrombectomy achieved.
• Pre-hospital video triage will be ‘business as usual’ within the Stroke pathway.
• Computed Tomography Perfusion will be available across all Acute Stroke Centres within the ICS and the National Optimal Stroke Imaging Pathway (NOSIP) fully implemented.
• Development of 7-day Consultant and therapy team working within the hyperacute phase consistently across the ISDN.
• Routinely admitting stroke sites will consistently achieve SSNAP ‘A’ ratings.
• Agreed rehabilitation data sets will ensure that quality and quality measurement is at the heart of the stroke rehabilitation model.  They will enable ongoing service evaluation, performance review and outcome measurement, thereby supporting continuous service improvement and development.
• Quality equitable care will be delivered across the Stroke pathway, including sustainable stroke specific rehabilitation with opportunities for mutual aid in times of need.
• Patient and carer experience will be embedded as an integral element informing and developing ongoing pathway development and quality improvement.

You can read more about our stroke delivery plan in our Joint Forward Plan Fact File on our website.

2.2.3. Respiratory

The NHS Long Term Plan’s ambition is to improve treatment options and reduce the impact on those with the condition through prevention and self-management developments.  Our ambitions for those with respiratory conditions are for:

• appropriate treatment and support, enabling self-management and access to services when needed. Through this, we will transform our outcomes so that they are equal to, or better than, our international counterparts.
• people admitted to an acute or mental health hospital who smoke will be offered NHS-funded tobacco treatment services. The model will be adapted for expectant mothers and their partners.
• transform Pulmonary Rehabilitation services by increasing capacity, improving accessibility, and to enable patients to be empowered to self-manage their condition by working with system health and care partners and voluntary organisations.
• improvements in experience and outcomes and achieve economy of scale with ensuring developments are made jointly with cardiovascular disease and cardiac rehabilitation, prehabilitation and moving from reactive treatment post event to prevention.

Around a third of people with a first hospital admission for chronic obstructive pulmonary disease exacerbation have not had a previous diagnosis.  Surrey Heartlands has commenced a programme of reducing variation in quality of spirometry. We are re-introducing access to training and reviewing locally commissioned services to enable consistent provision.

Asthma is the most common long-term medical condition in the UK, with around 1 in 11 children and young people living with asthma, with outcomes exacerbated when living in the most deprived areas.  We know that the UK has one of the highest prevalence, emergency admissions and death rates for childhood asthma in Europe.  Surrey Heartlands is acting to improve early diagnosis such as improving access to diagnostics, implementing breathlessness pathways, using medicines optimisation and improving the asthma pathway for children, young people and adults through implementing the national bundle of care objectives.

Smoking rates in Surrey are below the national average and are continuing to fall.  But we know that smoking rates are much higher among our more deprived communities, having a significant impact on increasing health inequalities by reducing life expectancy by up to 20 years and that smokers are 36% more likely to be admitted to hospital.  Research from Action on Smoking and Health (ASH) estimates there are about 35,000 smoking households living in poverty in Surrey Heartlands. Our smoking rates for substance misuse service users (69.5%) and people in routine and manual occupations (30%) sit above the South East and national averages. Surrey Heartlands will implement the tobacco prevention model for inpatients (acute and mental health patients), adapted for expectant mothers and their partners.

By 2028 our population will benefit from:

• More patients will have access to testing, such as spirometry testing, so that respiratory problems are diagnosed and treated earlier.
• Patients with respiratory disease receive and use the right medication, including educating patients on the correct use of inhalers, with increased numbers of people switched to low carbon inhalers.
• Expanded rehabilitation services, including pulmonary rehabilitation and digital tools so that more patients have access to them and have the support they need to best self-manage their condition and live as independently as possible.
• Improved treatment and care of people with pneumonia.
• Smoking prevalence in the adult population to below 9%.

You can read more about our respiratory delivery plan in our Joint Forward Plan Fact File on our website.

2.2.4. Diabetes

Our ambition is to improve the lives of people with or at risk of developing diabetes across Surrey Heartlands. Identifying people earlier and providing equitable access to education and services.  We will empower our citizens to manage their diabetes or reduce their risk by raising awareness, providing quality education programmes and by reducing variation in care provision and clinical outcomes.

We will achieve this by working together across healthcare, social care, and voluntary sector ensuring the care we provide meets the needs of our population and is of the highest quality.  We aim to improve experience and outcomes by ensuring developments are made jointly with other long-term conditions (e.g. cardiovascular disease and respiratory disease) as we move towards an approach that better supports managing and living well with multiple long-term conditions (in line with the national Major Conditions Strategy), shifting from reactive treatment to prevention, proactive care, early detection and diagnosis. Around 50,000 people in Surrey Heartlands are diagnosed with diabetes, with approximately a further 66,118 people at a higher risk of developing type 2 diabetes.

The Surrey Heartlands Diabetes programme sets key ambitions to drive an improvement:

• Improve performance in the annual National Diabetes Audit for people with diabetes receiving all eight NICE Care Processes (8NCP) and achieving the three Treatment Targets (3TT) across our lowest 50% of practices.
• Reduce hospital admissions for cardiovascular and renal disease.
• Work with system partners to ensure equitable access to inpatient specialist nursing teams in hospitals to improve the quality of care, 7-days a week.
• Develop diabetic foot care services, increase capacity to reduce waiting times and reduce rates of lower limb amputations.
• Ensure people newly diagnosed with diabetes attend structured education within one year of diagnosis.
• Early identification of non-diabetic hyperglycaemia (NDH) and referral to prevention and weight loss programmes such as the NHS Diabetes Prevention Programme (NDPP).
• Support people with diabetes to use existing and emerging technology to support their diabetes care and self-management.
• Development of diabetes care for children and young people, especially at the point of transition from paediatrics to adult services.

By 2028 our population will benefit from:

• An increase in earlier identification of diabetes, and an increase in the number of people taking part in prevention programmes focused on reducing the risk of developing type 2 diabetes.
• Reduction in unwarranted variation including access to services and achievement of treatment targets across the ICS.
• An increase in people taking an active role in managing their condition.
• Reduction in development of diabetes related complications such as number of major and minor lower limb amputations.

You can read more our diabetes delivery plan in our Joint Forward Plan Fact File on our website.  

By reducing pressure on our health and care services over time, we create the space for our workforce to provide care quality with continuity of care and do much more on preventative care to support people to stay well for longer.  The following chapter focuses on care quality, safety, personalised care plus equality, diversity and inclusion.

2.3. Providing Quality, Safety and Continuity of Care

“I am able to access care in an environment which is appropriate to my needs with the right facilities and supporting information both I, and my clinician or care professional, need.”

Core to our ICS strategy are the principles of quality and equitable care, patient safety and tailored care that supports patient choice, whenever possible in line with the National Quality Board principles.  Quality threads through everything we do an ICS.  This section summaries our approach.

Our ambition is to improve quality by creating a culture that is focused on continuous improvement and learning, ensuring that our health and care services provide people with safe, effective, responsive, caring, well led, and compassionate services, where innovation is encouraged and is safe.

In Surrey Heartlands, we are strengthening partnerships with staff, local communities and people using services to deliver higher-quality care and tackle health inequalities and ensuring that decisions are taken closer to the communities they affect, so that they are more likely to lead to better outcomes.  We strive to provide people with an improved experience of health and care, as services are more coordinated, focused on addressing health inequalities and based on the latest evidence, learning and best practice. 

All of Surrey Heartlands NHS provider trusts are rated ‘good’ or ‘outstanding’ overall.  80% of Care Homes are rated ‘good’ or ‘outstanding and 95% of GP Practices are rated ‘good’ or ‘outstanding’.

We are committed to continuous care quality improvement at every level of our system and have established the Quality Improvement Collaborative (QIC) to drive our quality governance model across Place-based areas and the ICS.  Surrey Heartlands’ Quality Management System Framework has been developed with partnership organisations building on existing quality governance principles, delivery mechanisms and the joint commitment to the delivery of care that is effective, safe and provides as positive an experience as possible.

We will continue to use our System Joint Intelligence Group (JIG), formed from ICB, Trusts, Public Health and Regulators, to provide a strategic, integrated forum to inform decision making and risk management to improve quality of care for those who use our services.  You can read more about our care quality improvement monitoring and management on our Joint Forward Plan Fact File.

The Surrey Heartlands Quality Improvement team support the system to use improvements approaches where quality improvement is required either from across the system - trusts, place or neighbourhood level.  By learning from patients, staff, and partners we aim to ensure high-quality governance, patient safety, and risk mitigation.  We will continue to utilise the national Commissioning for Quality and Innovation (CQUIN) approach to embed sustainable care quality and patient safety improvements in Surrey Heartlands.

2.3.1. Patient Safety

We will build into our care quality, a patient safety culture and a patient safety system with three strategic aims:

1. Insight – improving understanding of safety by drawing intelligence from multiple sources of patient safety information.
2. Involvement – equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system.
3. Improvement – designing and supporting programmes that deliver effective and sustainable change in the most important areas.

Nationally there are over 700 Patient Safety Specialists, including at Executive level. Within our NHS trusts and through the ICS, we are providing leadership and support to patient safety activities across their organisation.  We will provide mandatory patient safety training for all staff in conjunction with Health Education England in collaboration with Academy of Medical Royal Colleges (AoMRC).

We will continue involving patients, families and carers in their own safety through our Patient Safety Specialists.  We will work with our providers and system stakeholders to support all our providers transitioning from the serious incident framework to the new national Patient Safety Incident Response Framework and continue to engage in the national plans for the rollout of the Patient Safety Incident Response Framework to Primary Care.  Our Patient Safety Specialist Network will continue to provide the opportunity to share concerns and sharing learning across the whole health and care system to work more collaboratively through regular workshops.

2.3.2. Infection and Prevention Control

Our overarching aim is to continually improve quality of care by reducing the risk of avoidable harm from Health Care Associated Infections (HCAI) and other communicable diseases.

To achieve this, we will have in place governance oversight processes to monitor and receive assurance on the following strategic objectives:

• Being person-centred: listening to our service users.
• To build ICS specialist IPC workforce capacity to collaborate and support provider services to deliver safe care.
• To support health and social care providers to maintain compliance with the code of practice on the prevention and control of infections and related guidance, to deliver safe and effective and reduce risk associated with HCAI.
• To capture and share meaningful system wide learning from incidents and outbreaks, to drive IPC quality improvements across all health and care settings.
• Maximising financial capacity.

2.3.3. Medicines Optimisation

Medicines optimisation looks at the value which medicines deliver, making sure they are clinically effective and cost-effective. It is about ensuring people get the right choice of medicines, at the right time, and that they are engaged in the process by their clinical team.

Our medicines optimisation goal is to help patients to improve their outcomes, take their medicines correctly, avoid taking unnecessary medicines, reduce wastage of medicines and improve medicines safety.

We have identified key priority areas of work from a pharmacy and medicines optimisation perspective to support the organisation in delivering its strategy and overarching key ambitions including the Critical Five, implementation of the recommendations from the ‘Next steps for integrating primary care: the Fuller Stocktake’ report next steps for integrating primary care and include:

• Workforce – The overarching ambition is to develop a collaborative pharmacy workforce with the ability to provide integrated pharmacy services to patients across Surrey Heartlands.  This will ensure that we provide high quality medicines related care for those who need it, in the right place, at the right time, by the right person; working innovatively and in partnerships across our services to better serve the population and make Surrey Heartlands the best place to work (for the pharmacy workforce) in line with the NHS people plan and NHS Long Term Workforce Plan.
• Medicines Safety – Developing an open, learning, and safer culture locally is a high priority across Surrey Heartlands. This aligns with the aims of the Medicines Safety Improvement Programme (MedSIP), one of the workstreams within the wider National Patient Safety Improvement Programme, which is to reduce severe avoidable medication-related harm by 50% by 2024 and the third WHO Global Patient Safety Challenge: Medication Without Harm.
• Antimicrobial Medicines Optimisation – with a focus on reducing unwarranted variation in prescribing, improving prescribing standards and reducing harm from inappropriate antimicrobial use aligned to the UK five-year national action plan.  Priority areas of work include management of UTIs, review of Co-amoxiclav and Fluoroquinolone  prescribing, length of antibiotic courses alignment of secondary care clinical guidelines.
• Community Pharmacy – to fully embed all services included in the national Community Pharmacy Contractual Framework with a focus around the successful launch of NHS Pharmacy First advanced service. The ambition is for community pharmacies to:
  • be the preferred NHS location for treating and where appropriate testing for minor health conditions, promoting patient self-care.
  • be taking pressure off our local urgent care, out of hours services and GPs, reducing waiting times and offering convenient care for patients (including NHS Pharmacy First advanced service ).
  • become established as healthy living centres, helping local people and communities to stay healthy, identifying those at risk of disease and reducing health inequalities.
  • support key local and national NHS targets and quality improvement initiatives such as tackling antimicrobial resistance, improving vaccination uptake rates.
  • continue to ensure patients can safely and conveniently access the medicines they need as well as doing more to improve patient and medicines safety.

Dispensing doctors and dispensing appliance contractors form part of our delegated responsibility for Primary Dental Services and Prescribed Dental Services, Primary Ophthalmic Services and Pharmaceutical Services.  Work will be undertaken with Pharmaceutical Services providers to support integrated, collaborative working in order to deliver a more joined up preventative and personalised care for the population of Surrey Heartlands.

2.3.4. Supportive Learning Culture

We are working together in complementary ways through our joint commitment to the delivery of care so that it is effective, safe and provides as positive an experience as possible. This will demonstrate improvements in both population and clinical outcomes and provide clarity on roles, responsibility, and accountability.

Key to this approach is ensuring subject matter experts from all sector partners are given the platform to collaborate to work together, agree quality outcomes, intelligence requirements, support innovation and standardise good practice.

You can read more about the monitoring and metrics used to assure our delivery in appendices 1 and 3.

2.3.5. Safeguarding and Domestic Abuse

The safety and welfare of children and adults, alongside the protection of those with care and support needs from abuse and neglect is of paramount importance to Surrey Heartlands ICS.

Our safeguarding teams provide strategic leadership, expert advice to our partner organisations and ensures all services provide high quality, safe and effective care. Using the NHS Safeguarding Accountability and Assurance Framework ensures improvements in health outcomes for those with support needs.

A significant proportion of adults who need safeguarding support may be experiencing domestic abuse (DA).  Our vision is for every adult and child experiencing domestic abuse to be seen, safe and heard, and free from the harm caused by perpetrator behaviour.  As a partnership, we will focus on preventing domestic abuse and ensuring all children, young people and adults affected across their lifespan:

• Can access the right information, services and support, at the right time in the right place.
• Are empowered to live lives free from domestic violence or abuse.
• Gain the personal confidence to build healthy relationships for themselves and their dependants.
• Perpetrators are held to account and change their behaviour.

Our priorities are threefold:

1. Community – To break the silence about domestic abuse within our local communities and remove the barriers that make it hard for survivors and perpetrators to reach support.
2. Professionals – To maximise every opportunity to identify and respond to domestic abuse for survivors and perpetrators.
3. Expert support – To empower specialist expert support to work with survivors, children and perpetrators in a way that achieves safety, with minimum reliance on external resources.

You can find out more information about domestic abuse on Surrey County Council, our joined-up approach to tackle Violence Against Women and Girls in Surrey and support on Healthy Surrey websites.  To find out more about our safeguarding work, visit the Surrey Heartlands’ Safeguarding webpages.

2.3.6. Equality, Diversity and Inclusion

Surrey Heartlands aims to be a leader in promoting equality, diversity, and inclusion (EDI).  We believe that our organisation must reflect the full diversity of the communities and people it serves, both in employment and service delivery. 

Public sector organisations have specific duties that need to be fulfilled.  The general duty has three aims:

1. Eliminate unlawful discrimination, harassment and victimisation.
2. Advance equality of opportunity between people from different groups; and
3. Foster good relations between people from different groups.

Our duties relate to:

• Equality – we want everyone to have equally good health and care.  However, the term ‘equality’ is sometimes used to describe equal treatment, care, or access for everyone regardless of need or outcome.
• Equity – we want fair outcomes for everyone.  What is important is addressing avoidable or remediable differences in health between groups of people.

To achieve equity, some groups may need more or different support or resources to achieve the same outcomes.  Ideally, the barriers would be removed for everyone, so adjustments wouldn’t be required. However, this is not always possible.

We are seeking to gain insight and research from local communities and support in developing culturally appropriate interventions through the use of Equity Development Officers and programme leads.  We will enact the targeted actions to address prejudice and discrimination as set out in the NHS equality, diversity, and inclusion improvement plan.

CASE STUDY

Perinatal Equity Project

Perinatal Equity Project is being led by Surrey Minority Equality Forum in Woking, Spelthorne, Reigate and Banstead focusing on pregnancy and the first two years of a child’s life to provide information and support to families, pregnant people and new parents to improve their experience of pregnancy and parenthood in Surrey.

Community Activity Champions are working to remove barriers preventing women from being active.  Through trusted community leaders, women are taking up activities benefiting their wellbeing, families and community.

Our ambition for our Contingency, Asylum, Refugee, Evacuee and Migrant Service that it is equitable, agile, and coordinated for all the different schemes to enable the most effective support for these vulnerable people across the health and care system. This starts with GP registration and initial health care check to assess the level of health needs following entry into the country, with appropriate follow up and support.

You can read more about our Equality, Diversity and Inclusion workforce approach in chapter 3 and more about our Equality, Diversity and Inclusion work on our website.

2.3.7. Personalisation and Patient Choice

Surrey Heartlands believes that personalised care and patient choice are fundamental to helping people to stay well for longer as part of a joined-up approach to health and care support. This gives people the same choice and control over their mental and physical health that they have come to expect in every other aspect of their life.

Our ambition is to ensure our citizens have choice and control in the way their care is planned and delivered, building skills, knowledge, and confidence to support them to live independent lives and improve outcomes.  That they can access outstanding quality and tailored care and support and find adult social care fair and accessible with a workforce that is enabled to deliver these commitments.

Our work will continue to assure and enforce patient choice principles across all our partners and through our professionals by ensuring:

• patients are aware of their choices, including their legal rights, and actively seek and take up the choices available to them
• GPs and referrers are aware of and want to support patients in exercising the choices available to them
• patients, GPs and referrers have the relevant information to help patients make choices about their care and treatment
• choice is built into service development plans, contracting arrangements and provision
• choice is embedded in referral models, protocols and clinical pathways.

By 2028 our population will benefit from:

• Our providers retain CQC ratings of ‘good’ or ‘outstanding’ across our system.
• An integrated population outcomes and clinical outcomes dashboard.
• Delivery of our ambitions against the Patient Safety Strategy and Infection Prevention and Control Strategy.
• Improvements in Quality Improvement methodologies are equitable and embedded across the system.
• Social prescribing link workers are part of admission and discharge pathway to enable post discharge support.
• Being connected to non-medical, community- based activities and support to build networks and resilience, tackling loneliness and isolation.
• Supported referral into services offering help on social determinants of health, for example housing, homelessness, energy, debt and welfare.
• Being safe and feel safe (community safety including domestic abuse, safeguarding).
• Greater choice and control of the care and treatment.

You can read more about Personalised Care on NHS England’s website.

To enable us to be a mature, productive and effective system and deliver our ambitions, we need a number of other functions to be working well.  This chapter presents our priorities to enable achievement of our ambitions.

3.1 People and culture

We know that building a sustainable workforce is one of the greatest challenges facing our organisations and the integrated systems we are developing with partners today.  There are well documented challenges – high waiting times from stretched capacity, falling retention and staff satisfaction, a difficult labour market, declining public satisfaction and a worsening financial environment.  Our ambition is to address these problems in ways which also enable the improvements and developments in care described in this plan. 

‘Next steps for integrating primary care: the Fuller Stocktake’ called for new ways of bringing our people together – through integrated neighbourhood teams that organise themselves around local population health needs – so we can provide more holistic care for the most vulnerable members of our community. Meanwhile, developments in elective care will require a more mobile and shared workforce.

The publication of the NHS Long Term Workforce Plan in June 2023, set out the future demand and supply requirements for the next 15 years.  It underpins our ongoing programme of work to deliver an integrated approach to planning and delivery, bringing together workforce planning with service and clinical strategies and financial planning.

At the heart of our vison is a ‘united team’, aiming to share ways of working (a shared system culture), which connects us more and better and drives better connected resourcing, sharing talent and expertise across partners and sectors.  Our United Surrey Talent strategy describes how we are utilising six change levers to transform ways of working and career development in Surrey Heartlands through a series of process and collaboration changes.

Six levers for change (ICS United Surrey Talent Strategy)

1. Modernise and integrate recruitment – unite recruitment efforts with talent sharing top class labour marketing analytics and diverse, effective recruitment channels.
2. Build new capabilities – Health and Care Academy for learning and education. Strategic education and training partnerships, focusing on values as well as skills.
3. Develop fulfilling careers – integrated, attractive careers across health and care. Introduce career guarantees with two job offers in one.
4. Establish a Surrey Offer – level up experience with innovation in incentives and retention to build productivity, satisfaction and cost control.
5. Enable the United Surrey team - one governance vehicle. Mobility across partners, systems access, and shared spaces to connect. Digital enablement and building our neighbourhood teams.
6. Build our expertise – leading expertise in workforce development and management.

Delivering the fundamental step-change of this nature will require considerable scale and expertise. The right type of vehicle for our collective efforts is key; the  essential parts of our change vehicle are:

• Recruitment and Onboarding
• Workforce and Market Analytics
• Education and Training
• Employment Coordination
• Retention and Talent Development
• Joint ICS/SCC funding agreed.
• ICS and Place partnerships
• Education Partnerships - University of Surrey, Royal Holloway University of London, Nescot College, Bourne Education Trust

The scale and pace required of these changes will only be possible through a connecting culture that speaks to the ‘how’ and ‘why’ and not just the ‘what’ we do together, to drive innovation, shared learning and spread across our partner organisations and local people.  We have launched a workforce innovation fund to stimulate change and test ideas for scaling across our system, with over 30 pioneer projects in place.

Fundamental to the integrated neighbourhood teams is ‘how’ they connect. We are helping to shift the focus from services, systems and diseases to local population health needs and human connection through our cultural development work, ‘Connecting Surrey Heartlands’. Working at neighbourhood, Place and ICS levels, we are focusing our attention on those things that are already working and using a systematic and science-based methodology, social research, to understand what and why people connect well and the conditions that enables and breeds success for effective change.

3.2 Developing our future workforce and Team of Teams

With over 40,000 jobs in the county, we can offer local talent a whole range of opportunities and career pathways across different settings with flexible work to suit individual needs.

We should not over-rely on overseas recruitment and as living in Surrey is expensive, we need to grow our own talent.  This includes offering more opportunities to students at local education providers and reaching out to wider talent pools such as helping people with disabilities, armed forces backgrounds and those from care to support them find new careers in our services.

CASE STUDY

Inspiring students to take up NHS careers

150 students and parents from local secondary schools and colleges were given behind the scenes access and expert demonstrations from teams at East Surrey Hospital in an inspiring careers event.

Local students in year nine or above were invited to our ‘meet the practitioner’ careers event.  They were able to watch demonstrations from doctors, nurses and therapists in the simulation suite, learn life-saving CPR techniques in ‘re-start a heart’ style workshops and attend a range of presentations about different careers in healthcare.

The event was delivered together with Surrey Heartlands Health and Care Partnership, and First Community Health and Care with support from London Southbank University and University of Surrey.  Students from 29 schools and colleges attended.

With Surrey County Council, we have established the Surrey Heartlands Health and Social Care Academy to help build, develop, share, and nurture talent across all settings incorporating social care sector staff. As an example, the Academy will help equip staff better to look after residents and patients at home.  This is a win-win; helping people stay well at home whilst professionalising this important staff group with skills and better reward. With changes in care models, there will also be significant increase in academy types of support, such as diagnostics and frailty, where coordinated and focused support will be created for these priority pathways.

CASE STUDY

Nursing Associates in Social Care

Surrey Heartlands Health and Social Care Academy is supporting a programme to introduce Trainee Nursing Associate roles into Care Home Social Care settings. Additional funding is enabling 41 individuals who are currently in support worker roles to progress onto an education programme to become a Registered Nursing Associate. By January 2024 15 individuals have joined the programme so far with a further 26 expected to join by the end of 2025

This initiative helps our Surrey residents remain well at home or somewhere like home whilst also supporting professionalisation of Social Care roles.

Such is the scale and breadth of opportunities across our organisations, we are trialling a career guarantee by offering two jobs at the same time in some career pathways – your first role and a conditional offer for your next move.

Both provider and Neighbourhood Teams are being enabled to form teams of teams so they can work across settings.  Digitisation and data are key; we will draw on the National digital staff passporting developments to help easy mobility of teams between organisations, we will increase access to shared care data and implement the required deployment systems, such as rostering and temporary staffing solutions.

We are building on our collaborative with Frimley ICS and Buckinghamshire, Oxfordshire and Berkshire ICS to unite temporary staffing across Surrey, with fair pay and access to work, whilst incentivising the take up of permanent careers with our partners.

Access to our one public estate and related digital infrastructure will continue to augment – helping staff with more flexible working, getting the job done wherever they are and increasing opportunities for our teams of teams to come together physically.

Examples where increased mobility will be prioritised include elective and diagnostic activity across our provider collaborative, integrated neighbourhood teams and temporary staffing across all providers.  We are developing our ambitions for workforce transformation in community and acute settings as the ICS clinical strategy emerges.

3.2.1. Looking after our people

Health and care is about teamwork.  We want to see Surrey develop a core offer for our people, where everyone on the team has access to the same or equivalent support and reward.  We have established a mental health support hub and are finding innovative ways to ensure this can be accessible to the many small VCSE organisations as well as the larger NHS Trusts. 

CASE STUDY

GP supervision programme

Working with NHS Practitioner Health and Doctors in distress, Surrey Heartlands offers a supervision programme to support for GPs who are having mental health issues.  General Practitioners, who often work on their own for long hours, need to be able to share issues that they are dealing with in a safe and blame free environment, so they are not reliant on family members or colleagues who may have burdens themselves and might be conflicted.

The programme is designed to improve GPs’ wellbeing, offer a confidential safe place to help prevent escalation of mental problems and reduce the risk or suicidal thoughts.  Over time the programme could be rolled out to wider groups of staff across primary care and beyond.

The cost of living has hit staff hard. We struggle to attract and retain staff in a county which is beautiful but expensive.  We are working with Surrey County Council on its housing strategy for more affordable accommodation and on ways to improve the pay for social care workers.  Meanwhile, the NHS continues to rely on recruiting international workforce and Surrey Heartlands ICS has invested significant amounts on recruiting world-wide. 

The benefits of a diverse workforce cannot be overstated, especially as it provides opportunities to recruit from a wider pool of candidates and projects a positive image of an inclusive organisation.

A corresponding investment in training, resources and awareness on Equality, Diversity and Inclusion to support its diverse workforce will contribute to additional recruitment, support the retention strategy and lead to increased productivity.

3.2.2. Leadership and health and care professional development

Surrey Heartlands’ ambition is to create a diverse range of multi-professional leaders and representative professional leadership model that reflects our clinical and care professionals, and the diversity of our population across the full range of partnerships, health and caser services through the commitment to improvement on behalf of residents and partner organisations.  This is central to designing and delivering integrated care and meeting the complex needs of people, not conditions.

CASE STUDY

New medical school

The University of Surrey is partnering with the University of Exeter, to support the development of this new and innovative curriculum for a new medical school.  It will offer a four-year, graduate-entry bachelor’s degree medical programme and expects to welcome the first cohort of 40 students in 2024.

We will provide improved and integrated services to Surrey residents by having effective and integrated system leadership that enhances capabilities of all partners.  This will be achieved by bringing together quality and safety, system leadership and improvement focusing on improving health and care quality and safety through multi-professional involvement and engagement.

To drive the changes described in this plan, our leaders need to work across organisational boundaries at both local and county levels.  We are pioneering a “Growing System Leaders” programme to help key people develop their stewardship skills across Surrey Heartlands.  We are also building maturity in how organisations shape and deliver transformation as a system, recognising the needs for more effective change capability, capacity and governance.

CASE STUDY

Growing System Leaders Graduation Event

The first cohort of Growing Systems Leaders attended a graduation ceremony at Woodhatch Place to celebrate their achievements in December 2023.  Launched as a proof-of-concept in East Surrey Place, as a new approach to systems leadership development, the programme was designed to equip colleagues working at every level and from all organisations to feel empowered, initiate change, be inspired and courageous and to have a voice across organisational boundaries. The programme's emphasis on breaking down silos has not merely encouraged collaboration; it has actively dismantled organisational boundaries, paving the way for cohesive teamwork across sectors.

People from a wide variety of organisations such as social care, District Councils, Surrey County Council, community transport, the NHS and voluntary sector demonstrated exceptional dedication and commitment throughout their journey. 

Due to the success of the programme in East Surrey Place, it will now be rolled out across all of Surrey Heartlands Integrated Care System. It is hoped the next cohort will commence in May 2024.

Transparent, continuous cyclical shared learning with delivery examples

System Quality Group: Improvement

• Patient involvement and engagement
  • Building and nurturing a learning culture
  • Supporting and enabling quality improvement and transformation at all levels
  • Ensuring staff have the right capabilities and skills for quality improvement
  • Sharing best practice
  • Informing pathway design
  • Systems for spreading learning skills and knowledge
  • Embedding change expertise in the system
  • Clinical networks
  • Patient safety collaboratives
  • Improvers network
  • Communities of practice
  • Health and Care Professional Committee
  • Transformation boards

System Quality Group: Surveillance and control

• Patient involvement and engagement
  • Processes to identify and manage risk and drive improvement
  • Providing a stable basis on which to improve
  • Objective and subjective views
  • Early warning systems

System Quality Group: Planning and assurance

• Patient involvement and engagement
  • Strategy and policy development
  • Establishing systems and processes
  • Monitoring hard and soft data points
  • Understanding priorities
  • Internal and external reporting
  • Developing system assurance and risk identification

By 2028 our population will benefit from:

• More staff looking after people in out of hospital settings, either at or near home.
• A professionalised care workforce, with accredited skills, qualifications and better pay, terms and conditions.
• More “home-grown talent”, with disadvantaged job seekers provided better access to employment and more degree education provision in Surrey for professional roles.
• A corresponding investment in training, resources and awareness on Equality, Diversity and Inclusion to support and attract a diverse workforce.
• Targeted increases in roles in non-medical primary care, community nursing, diagnostics and social care.
• A more mobile workforce, able to share data and work across settings.
• A “go to” digital academy for access to diverse opportunities to earn and learn across health, social care and VCSE sectors.
• Clear and accessible career structures enabling staff to have greater control over their future.
• More clinical apprenticeship and degree courses running at Surrey institutions.
• Supporting staff with better access to affordable housing and equitable, universal provision of physical and mental health services.
• Many more multi-professional teams in place who are supported to collaborate, learn and improve together to consistent standards.
• United temporary staffing services across partners.
• A leadership more representative of the people it serves and with the skills and tools to lead effectively across traditional boundaries.
• Trialled, researched and evaluated methods for securing the best culture to thrive.

3.3 Estates

Estates can be a catalyst for integration, particularly when approaching the delivery of neighbourhood teams and same-day urgent care.  As a system, we can develop spaces and establish the conditions for communities to improve their wellbeing, on their own terms, in non-clinical ways.

The developing Surrey Heartlands Infrastructure (Estates) Strategy represents the partnership working between Surrey County Council (SCC) and Surrey Heartlands Integrated Care System to re-set and re-commit to the delivery of a more efficient and effective public sector estate, specifically NHS Estate. 

Our ambition is to make it easier to provide and support great health and social care, in the appropriate property, in the right place, fit for purpose, available at the right time and support communities and partners to deliver more effective ways of tackling health inequalities and the wider determinants of health.  Our strategy therefore considers both the current population needs and how the capacity, type and utilisation of spaces will need to change in the future to meet the needs of our population.

Our strategic aims are to:

• have a meaningful strategy that is understood and owned by all
• ensure delivery of an integrated, cohesive engagement programme that reaches across our Place and Neighbourhood areas
• optimise our Core estate and progressively move out of Tail (poor quality estate that is not fit-for-purpose and should be phase out when alternative estate is available) estate
• continue collaborative working to allow Place area to develop estate plans
• facilitate an estate that delivers excellent patient care.

CASE STUDY

Expanding diagnostic services in Woking

A new community diagnostic centre at Woking Community Hospital will prevent the need for 30,000 hospital visits outside of Woking annually, providing residents with a vibrant, modern health facility.

Currently, Woking residents need to travel to Ashford, Camberley, Guildford or Chertsey for the majority of diagnostic outpatient appointments. 

This project is part of a wider community diagnostic hub programme across Surrey Heartlands, helping to reduce waiting times and expedite treatment for local people.

The centre will expand the vast range of diagnostic services already provided at Woking Community Hospital to include computerised tomography (CT), magnetic resonance imaging (MRI), extra ultrasound capacity and improved access for the mobile breast screening unit.

The centre is funded by NHS England and will be developed by Ashford and St Peter’s Hospitals NHS Foundation Trust, working in close collaboration with CSH Surrey, primary care and Alliance Medical Ltd.

By 2026 our population will benefit from:

• Close work with community and social care services, teams, and others to identify and support delivery of priority schemes which help reduce health inequalities including supporting the creation of community diagnostic and maternity hubs.
• Delivery models for new health delivery pathways, for example, ‘health on the high street’.

By 2030 our population will benefit from:

• Flexible integrated health and care estate that enables the right services to be delivered and empowers communities to support each other in the places that need them.
• Estate supporting the changes in the way services are provided relieving pressure on acute settings, provide a new more agile way of working for staff, and help to reduce inequalities and improve access to the right settings across the system.

3.4. Net Zero

No one can solve climate change in isolation, so Surrey Heartlands’ net zero strategies show how public sector, businesses, residents and communities can work together to bring about faster change.

In 2020, Surrey's Climate Change Strategy was published in response to Local Authorities declaring a climate emergency and setting a target for Surrey to become net-zero carbon by 2050. The delivery plan identifies actions which will be taken to support those who live, work and visit Surrey to reduce carbon emissions and adapt to the impacts of climate change.

Surrey Heartlands’ NHS ambition is to align ICB, Acute, Mental Health and Ambulance trusts’ ambitions with the wider NHS goal of becoming Net Zero Organisations. Starting during the life of this plan, NHS England aims to reduce the emissions we control directly (the NHS Carbon Footprint) by 2040, with an ambition to reach an 80% reduction by 2028 to 2032.

We are looking across our estates, housing, and transport programmes to progress our net zero policies across our System and Place geographies.

In our ICS Green Plan we identify the four local priorities for the NHS in Surrey Heartlands:

1. Inhaler Project aimed at achieving a transition of prescribing to dry powder inhalers within Acute and Primary Care resulting in reduction in emissions as well as better health outcomes (See section 2.3.3 Medicines Optimisation).
2. Innovation Programme aimed at supporting innovators with implementing sustainability within their own developing programmes (see section 3.11 innovation and research).
3. Engagement Strategy within the ICS and public to cultivate sentiment towards sustainability and increase understanding (see section working with communities).
4. Funding support for Providers to bid for funding for sustainability projects within their organisations.

You can read more about our sustainability work including Green Plan actions on our website and each of the NHS Trusts and Foundation Trusts have published Green Plans on their websites.

CASE STUDY

Greener NHS

Since the launch of Ashford and St Peter’s Green Plan in 2022, the Trust has taken action to reduce its carbon footprint in areas such as transport, estates and facilities, clinical models and practices, waste and recycling, and greener outside spaces.

Work to achieve this has included introducing electric vans to replace the majority of our existing fleet, introducing electric bicycle charging points, and increasing the number of electric vehicle charging points.

Ashford and St Peter’s Hospitals is leading a pioneering project to reduce the usage of aerosol inhalers where clinically safe in both the hospitals and primary care partner organisations across North West Surrey. This project alone has led to an annual saving of 104 tonnes of CO2e – roughly the same as taking 51 cars off the road per year.

Other innovative initiatives to reduce the Trust’s carbon footprint include reducing food delivery miles by 20% (438 truck-miles per week), and no longer using desflurane anaesthetic which is a major greenhouse gas.   ASPH in Bloom launched in 2023 and provided teams with the opportunity to bid for charitable funds to enhance existing outdoor spaces and bring more nature back to the sites.

3.5. Digitally Enabled Care

Our ambition is to improve how teams use and share data to create better and healthier lives empowered by digital and data.  We have a vision to increase staff capacity by removing cumbersome manual administrative tasks and eliminating costs through use of automation and artificial intelligence.  In this section we cover the Digital Strategy, Data Strategy, Personal Health Record, Digital First Primary Care, Information Governance and Data Protection.

Our Surrey Digital and Data Strategy is being developed by bringing together existing separate Data and Digital strategies to provide a single integrated Surrey wide strategy to help deliver better care and services to our residents now, and in the future.  We have categorised three key categories – i) Digitise ii) Connect iii) Transform – and seven strategic capabilities – i) well led and delivered ii) smart digital foundations iii) secure safe care iv) connected workforce v) personalised care vi) improved care pathways vii) population data and health – that are being delivered, following the NHSE design principles for the development of the digital strategy.

• Put people at the heart of everything you do
• Design for the outcome and be inclusive
• Design for context and Trust
• Test the problem and clarify assumptions
• Make, learn and iterate
• Do the hard work at the beginning to make it simple
• Make things open. It makes things better

3.5.1 Category 1: Digitise our services

An aligned digital and data infrastructure to create a consistent secure agile foundation for future digital transformation and tools:

• Cyber – A single cross organisational strategy and plan to manage cyber risk across Surrey.
• A single system wide Data Architecture – A shared data ecosystem (a data MESH) used for public services across health, social care and voluntary care.
• The Integrated Digital and Data Platform (IDDP) – will meet this system integration need by providing an integrated central system, to drive Population Health Management (PHM) goals, deliver the Surrey Care Record (SCR) and Personal Health Record (PHR), a Secure Data Environment (SDE), Operational Planning and Reporting, including workforce, and state of the art business intelligence and advanced analytics.  We expect the IDDP to go live from January 2024.
• Surrey Care Record – by connecting data from our many providers we can understand current and future health care needs and trends. We will also need to ensure our hard-to-reach populations are not digitally excluded.
• Electronic Patient Records – Implementation and optimisation of new EPR solutions e.g. Oracle Cerner and System 1.
• Digitising Social Care and Care Homes – Supporting the digitisation of 600 local health and care settings to improve citizens outcomes.

3.5.2. Category 2: Connect our different services and organisations

We undertook a listening project to look at ways in which digital technologies might better support patients.  We spoke to patients, clinicians and the wider public to truly understand how digital technologies might support people’s health needs.  We particularly wanted to hear from under-represented groups and from people who do not normally use digital technologies.

• Personalised Care e.g. Patient Portals – Using these insights and acknowledging concerns raised during engagement sessions with citizens and staff, we are building safe and secure online access to your health records, whenever you need them and to help better manage care.  Using the NHS App and healthcare provider systems, people will have 24-hour access to their health care information and records to make, change or cancel appointments, check test results, contact their health and care professionals and submit test results.
• Connecting our Workforce – Digital Passport: Improve retention through Surrey Professional Development platform and Resilience Hub; improve recruitment through Surrey-wide temporary staffing and recruitment platforms; embed digital literacy into Core Training and focus on digital passporting.

3.5.3. Category 3: Transform our current service and clinical pathways to deliver better care and outcomes

• Elective Care – working with colleagues to transform the Diagnostics digital capability using new technology and AI to support demand and capacity management. The creation of a single cross provider patient treatment list, implementation of improvements in theatre utilisation and prioritisation of out-patient cohorts and lists.
• Urgent and Emergency Care – optimisation of system control centres and further embedding the use of SHREWD - real-time operational management tools - to provide a system wide view of capacity and demand.
• Virtual Care - Working with colleagues to support the procurement and implementation of a system wide platform to support monitoring of patients outside of hospital.
• Digital First Primary Care – The development of digital tools to help patients easily access the care they need, such as receiving advice, booking and cancelling appointments, consulting with a healthcare professional, receiving a referral and obtaining a prescription.  Expanding the capabilities most GP surgeries, dental practices, hospitals, mental health services and community care services offer with video consultations, enabling contact with patients via a video call to their smartphone, tablet or computer, to talk to and see the patient.
• Mobile first health and care applications – we will continue to use and scale the use of remote monitoring tools and applications such as blood pressure monitoring service ‘BP@Home’, urine tests, Children’s e-Red book, My COPD. This means that patients no longer need to visit their GP surgery or health care facility to have their readings taken. Patients will be able to submit their results via digital App, text, email or even by phone.

Not everyone wants to or can use digital technologies.  However, we want everyone to have freedom of choice in accessing their care and that digital technologies complement rather than replace existing ways of working.  Our Digital Inclusion approach ensures that no one is left behind for example, we deliver digital skills training to people who have experienced domestic abuse in refugees across Surrey Heartlands and the Surrey Coalition for Disabled People project Tech to Community Connect, provides people with access to technology and advice.

We estimate that around 30% of the Surrey population do not have access to digital technologies or choose not to use them if they do.  We also know that this is broadly linked to deprivation, which in turn is broadly related to poorer health outcomes.

We have created a targeted programme of action to identify those most at risk of exclusion from digital NHS services and ensure they have the support they need to access healthcare services.  That means individuals being able to use computers and the internet (digital skills), being able to access to the internet (connectivity) and services designed to meet all users’ needs, including those dependent on assistive technology to access digital services (accessibility).

3.5.4. Information governance (IG) and data protection

Information governance (IG) and data protection is all about how to manage and share information safely and securely.  It provides a consistent way to deal with the many different standards and legal rules that apply to information handling.

Our ambition is to create an integrated information governance function for the ICS, ensuring the safe and appropriate use of personal data on behalf of our citizens and supporting information sharing arrangements between our organisations.

Organisations within Surrey Heartlands are now working more closely together as part of the Integrated Care System, within our Places and Primary Care Networks.

ICS, Places and PCN partner organisations need to share and use personal confidential data in order to take forward key transformational activities and achieve planned improvements in care delivery and financial efficiency.  To ensure there is a protocol for these activities, the Surrey Heartlands Health and Social Care Information Sharing Agreement (ISA) has been established. 

The aim of the Agreement is to:

• Provide a clear framework for the secure sharing of personal confidential data for the delivery of care and for the management of the health and social care system.
• Accelerate the pace with which regional and local sharing requirements can be agreed.
• Reduce the costs of developing and agreeing individual sharing requirements.

The ISA is now being used to support safe and effective sharing between around 150 separate organisations (including NHS organisations, independent providers, local authorities, and Voluntary Sector organisations) for Direct Care and other activities (such as Population Health Management and Integrated Neighbourhood Teams).

By 2028 our population will benefit from:

• Aligned data and digital platform to create a consistent foundation for future digital tools - simplifying access to the right information at the right time and by standardising the quality of data we will improve the available intelligence and insights for care pathway redesign, workforce prioritisation, and targeted treatment for those at high risk.
• A data governance function and data management team to support the new data platform, ensure that citizen’s information related rights (including opt-outs where applicable) are applied appropriately, and the delivery of further integration of additional information sources, to support health and care partners plan and deliver improved services.
• An integrated Information Governance function.
• An increase in digital capability maturity through delivery of key digital roadmap initiatives such as the Children’s eRedbook (personal child health record), the Collaborative Bank (staff), Virtual Wards, Population Health Management and the Digital Social Care record.
• Access to health and care information from more partner organisations through the Surrey Care Record including Hospices and the Voluntary sector, supporting efficiencies of workflow and improvements in care transfer and delivery for better outcomes for our citizens. Implementing single-sign-on from Acute Trust electronic record systems to improve access, experience and efficiencies for health and care professionals. 
• Improved quality of information held by care providers to support better care planning, decision support, improved outcomes for those in care. This will also support efficiencies in transfer of care, by assisting community and local authority partners to implement electronic records (Care homes and domiciliary) with a target of achieving 80% of providers having an electronic record by March 2024.
• Partners attaining Healthcare Information and Management Systems Society (HIMSS) level 5 Digital Maturity for comprehensive, secure electronic information available to support health and care professionals’ decision making, for improved patient outcomes: acute hospitals and our mental health trust by 2024 (funded), with the ambition of supporting Community providers to do so by 2026.
• Provision of an integrated personal health and care record, providing people of Surrey with easy access to a combined view of their health and care information held across all partner organisations from one place (NHS app). People will be able to view and change appointments, communicate with their health and care professionals and engage with their health and care plans.
• The new national Electronic Staff Record solution will be available, including increased self-service availability for managers and staff – reducing waste and improving data quality.  The solution will improve our ability to ensure the right skills are built and deployed as care models improve.

You can read more about our Information Sharing Agreement on the Surrey Heartlands website.

3.6. Finance

We are operating in a financial landscape that is challenged and we consider the most effective way to address these financial constraints is closer integration of health and social care as described in this strategy, with less reliance over time on large hospitals and traditional care models, to sustainably address health inequalities and the likely needs of our population in the future.

Surrey Heartlands ICS faces a significant financial challenge.  In 2022/23, the ICS reported a deficit of (£33.6m) which represents (1.5%) of the total allocation it received for healthcare services of £2.213bn.  Achievement of the deficit (£33.6m) was in part achieved using non-recurrent means; on an ‘underlying’ basis (excluding the impact of the non-recurrent benefits), the ICS deficit position is closer to £100m.  High-level modelling indicates the deficit would increase in 2024/25 and beyond in a ‘do-nothing’ scenario, in which cost and pay inflation would outstrip underlying allocation growth, and that significant recurrent savings and efficiencies need to be identified to enable the system to operate sustainably.

Recognising the extent of the underlying financial deficit in 2022, the ICS developed a five-year ‘sustainability plan’ which sought to both improve patient outcomes as well as place the system on a more sustainable financial footing. Framed round the 'Critical Five’ strategic objectives, a series of interventions and transformational programmes of work were developed which identified almost £100m of financial benefits over a five-year period and which would support a balanced ICS system over time.

Work identified in the five-year sustainability plan is underway. Examples include a common approach to the management of agency staff across the secondary acute system, which has realised significant benefit in 2023/24  and the Surrey Heartlands Elective Centre, where additional capital funding was received via a successful bid to streamline the delivery of lower complexity, higher volume surgical activity. Drawing on the themes of the five-year sustainability plan, priority programmes of work for efficiency and transformation for 2024/25 are being developed and agreed between system partners.  The headline programmes are:

• Large Procurements – for key pathways to put in place a single pathway and contractual framework to optimally configure the market.
• Voluntary Sector – introduction of a single Community Investment Framework that sets a fixed budget for devolution to each Place for investment in the voluntary and community sectors aligned to key priorities and with confidence in return on investment
• Small Contracts – review of all small contracts
• Medicines – system partners’ pharmacy & medicines optimisation across all care settings
• Continuing Health Care – process and policy review
• Procurement & Back Office – streamline and/or consolidate corporate infrastructure across organisations
• Core Provider Cost Improvement Plans - tracked through normal financial monitoring processes
• Deep Dive Benchmarking – analysis and action to benchmark operational variation across organisation e.g. bed base, WTE staff

The ICS continues to work on the detail of Provider Collaborative arrangements and delegations to Place, in order to support the principles of subsidiarity.

The Better Care Fund programme is enabling Surrey Heartlands to pool money to address the strategic ambitions of the fund.  This is one financial approach we’re taking to better integrate health and social care in a way that supports person-centred care, sustainability and better outcomes for people and carers. 

The Surrey All Age Mental Health Investment Fund (MHIF) initiatives aim to support the emotional well-being of our citizens by focusing on preventing poor mental health and aiding those with mental health needs. This gives people access to early, appropriate support, preventing further escalation of their needs. The MHIF also supports projects that work with communities to tackle isolation.  £530,000 was granted in 2023 to 9 projects, in addition to the granted funding of £3.6m funding grants across 13 projects in Surrey.

The ICS plans an income and expenditure plan for 2024/25 in line with its statutory obligation and is planning to manage its capital spend within the operating capital envelope allowable by NHSE. On an underlying basis, the ICS is a ‘deficit’ healthcare system – that is where planned expenditure is greater than planned income. 

It is acknowledged all partners have areas where clinical outcomes can be improved, staffing may be fragile or there is provision duplication that could be delivered collaboratively to contribute to system efficiency.  Appendix 2: Strategic Delivery Contributions, details productivity contributions from services featured in this Joint Forward Plan.

Like all parts of the NHS, Surrey Heartlands’ procurement is subject to a number of key legislative requirements when determining the provider of a contract including the principles of transparency, equal treatment and non-discrimination.  When awarding public contracts, we are expected to achieve Government objectives, including value for money, maximising public benefit such as tackling climate change and integrity.  The introduction of the Provider Selection Regime (PSR) requires public sector buyers to take a broad view and take account of the national strategic priorities set out in the National Procurement Policy Statement (NPPS).

3.7 Integrated Commissioning

In 2019, Surrey Heartlands made the decision to integrate commissioning across health and care, beginning with Children’s services and Learning Disability and Autism, Continuing Health Care, Carers and moving to adult mental health.

Together we will continue to work in more integrated and collaborative ways for the good of the families living in Surrey.  Across our system, there are several partners involved - including the local authority, health, education, the police and third sector organisations - ensuring that in Surrey people are safe, healthy and can live up to their potential.

Our programme of work aims to:

• Re-affirm the vision and ambition for integrated commissioning – re-committing to and further defining integrated commissioning in Surrey as essential to ensuring good outcomes for residents/patients and value for money.
• Re-affirm a target operating model for integrated commissioning – understanding the gap between the ambition and the current situation to develop, design and implement improvements. This will include around governance, working practices, culture, infrastructure such as IT and building space.
• Improve joint-planning – ensuring a better understanding of existing organisation plans and planning cycles and enable greater joint-planning both in the short and long term.
• Identify initial areas of commissioning/contracts where we can improve our integrated working – understanding what opportunities we have coming up within our commissioning forward plan to improve our integrated commissioning practice (using the target operating model) and improve outcomes and value for money for residents and patients.
• Ensure commissioners are supported to do good integrated commissioning – through a learning, development and networking programme.

CASE STUDY

Joint Commissioning Strategy for Children and Young People

Our Joint Commissioning Strategy for Children and Young People highlights good areas of effective joint commissioning including – the HOPE and crisis intensive support services, Mindworks and community health contracts.

3.8 Governance and System Working

As a mature ICS, Surrey Heartlands is already achieving aspects of thriving system working.  At the same time, it’s clear the scale of the challenges we face, alongside our wider ambitions, mean we will need to work very differently over the next few years if we are going to get services back to where our communities want and need them to be, and create the step-change we want to see for our population.

Working as a system we can accelerate improvement and innovation to ensure investment and support is targeted where it will have the greatest impact.  Developing the principle of subsidiarity is our ambition through the delivery of our ICS strategy.  Strengthening local leadership, supported by continuous quality improvement and a commitment to sustainable primary care provision is at the heart of our approach to governance.

We will continue to develop informed decision making through the incorporation of expert advice such as the Primary Care Advisory Forum and Health Care Professional Committee - and broader engagement including people and communities.

You can find our more information about our board meetings, board members, committees and governance on the Surrey Heartlands website and Appendix 1: Accountability and Leadership.

3.9 System Led Assurance

As the statutory NHS organisation within the Surrey Heartlands Health & Care Partnership (Surrey Heartlands ICS), NHS Surrey Heartlands ICB is accountable to NHSE. The ICB works alongside regional and national NHSE teams to provide effective, streamlined oversight for quality, performance and tackling inequalities.

Assurance arrangements for delivery of the Joint Forward Plan (JFP) and other related plans are set out within a Memorandum of Understanding (MoU) between the ICB and NHS England. It is expected that the MoU will be reviewed in Quarter 1 of each fiscal year to account for the annual revision of the JFP.

Assurance is sought through robust, embedded governance arrangements. The System Assurance and Performance Sub-Committee (SAPS) is the primary sub-committee for overseeing assurance activities for the ICB. Wider assurance is obtained through relevant Committees and Boards at provider, place, and system level, feeding into the sub-committee and onward to Integrated Care Board as appropriate. The ICB provides assurance to NHSE through quarterly Oversight Meetings, with key outputs and actions, which builds towards an annual assessment with NHSE. The current arrangements are set out in the Governance Handbook and assurance processes will continue to adapt in line with any changes.

Assurance and performance monitoring is enacted through a wide range of tools and assurance reports, underpinned by the NHS Oversight Framework (OF) – a national framework encompassing NHS priorities, operational planning and NHS Long Term Plan delivery commitments.

Assurance reports assess delivery of system objectives and plans, including the Joint Forward Plan, annual Operational Plan, and a wide range of quality and performance metrics. Core content includes Oversight Framework (OF) metrics, latest validated and un-validated performance positions, supplemented by expert intelligence, assurance narrative and latest system highlights. This enables the system to identify key issues at a provider, place and system level.

The Assurance, Performance and Quality Teams work together to ensure the inter-dependencies with Quality Assurance are integral to the ICS-led assurance processes. You can read more about the metrics used to assure our delivery in Appendix 3: Metrics and Outcomes.

3.10 Innovation and Research

Through our Innovation and Research strategies, Surrey Heartlands aims to establish itself as a dynamic health and care ecosystem and the destination of choice to trial and scale the latest local, national, and international health and care research and innovations.  

Aligned to the NHS Long Term Plan, we will drive future outcomes improvement through enabling prevention of ill-health, earlier diagnosis, better outcomes, faster recovery and increase the number of people participating in health research.  Our objectives to accelerate development of innovations include:

1. Create, manage, and deliver an effective innovation pipeline prioritised to the needs of the citizens of Surrey Heartlands.
2. Create an internal operating model and methodology to deliver maximum benefits to Surrey ICS.
3. Develop a strategy to attract industry investment and leverage additional capabilities to support delivery and development of novel solutions.
4. Develop a Research Strategy to advocate and establish a mechanism for Research to be scaled at a system level and embedded into “care as usual”.

This will be achieved through the adoption of an influencing model that enables the ICS innovation function to offer services across neighbourhood, place and system. We will cultivate a culture that allows people within and across multiple organisations to co-create, develop, and test new ideas and facilitate turning those ideas into business value.

Our focus will be on guiding the Innovation Strategy at a system level and, through collaborations and partnerships that leverage knowledge and expertise across industry, academia and health and care, we can look to drive exploratory innovation to address unmet needs whilst identifying and implementing those that will deliver the most impact at scale.

Working closely with the University of Surrey, Surrey County Council, the VCSE community and Industry partners, we will look to create the Surrey Academic Care Partnership (SACP). The SACP’s vision and purpose will be to contribute to the health and wellbeing of the population of Surrey by facilitating the delivery of the integrated care agenda, particularly:

• Facilitating delivery of the integrated care agenda by harnessing the full range of expertise across the partnership from community through to laboratory.
• A wish to focus that expertise on projects and initiatives which primarily involve an out of hospital setting.
• Generating greater collaborative and interdisciplinary research to increase both participation and initiation.
• Developing a workforce culture, supporting entrepreneurs, and embedding innovation into practice.
• Enabling economic growth through the development and adoption of innovation across Surrey Heartlands.

By 2028 our population will benefit from:

• Greater use of innovation – for example, to support self-management for citizens.
• Reductions in unwarranted variation – in the provision of care when this is needed.
• Increased diversity of both participation and initiation of Research –
  • targeted engagement with our priority populations to improve involvement and participation for diverse communities
  • improved transparency and connectedness across research active communities at a system level.
• Greater economic growth – jobs and investment measurably leveraged into the local system.

 

Surrey Heartlands Joint Forward Plan 2023-2028 APPENDIX 1 Accountability and Leadership [docx] 489KB

Surrey Heartlands Joint Forward Plan 2023-2028 APPENDIX 2 Delivery Contributions [docx] 230KB

Surrey Heartlands Joint Forward Plan 2023-2028 APPENDIX 3 Metrics and Outcomes [docx] 663KB

Surrey Heartlands Joint Forward Plan 2023-2028 APPENDIX 4 Statutory Requirements [docx] 225KB

Surrey Heartlands Joint Forward Plan 2023-2028 APPENDIX 5 Glossary [docx] 212KB