One System Plan in Surrey Heartlands

One System Plan in Surrey Heartlands

As a system we have one single view of transformation and recovery, known as our One System Plan, which is reflected in the plans and strategies of all partners.  This will help us transform our health and care system and make sure it is sustainable into the longer-term.

One System Plan priorities

To support this One Plan, we have developed a framework with five key priorities that will transform our system and ensure services remain sustainable into the future.

Priority One: Keeping people well

Priority One: Keeping people well

Doing more to promote prevention, stepping in earlier to prevent people’s health deteriorating; and, when people do deteriorate, making sure they understand how and where to get the urgent help they need. 

Priority Two: Safe and effective discharge

Priority Two: Safe and effective discharge

Helping patients, their carers and families understand and safely navigate the options available to them from a much more joined up and improved community care environment and supporting people to leave hospital as soon as they no longer need acute hospital care.

Priority Three: High-risk care management

Priority Three: High-risk care management

Making sure those who are most vulnerable receive the care they need in a coordinated and planned way.

Priority Four: Effective hospital management

Priority Four: Effective hospital management

Making best use of hospital resources to support patients safely and efficiently from the point of admission to discharge; this is also about delivering high quality care based on the ‘Get it Right First Time’ principles (a national programme designed to improve patient treatment and care through in-depth reviews of services and analysis of data/evidence).

Priority Five: Surrey Heartlands-wide efficiencies

Priority Five: Surrey Heartlands-wide efficiencies

System-wide programmes that ensure we are working in the most efficient way – whilst maintaining high quality care – across areas such as diagnostics, clinical networks, more efficient use of our workforce, digital innovation, corporate and clinical support services, financial management and how we use our estates and facilities.

One System Plan key themes

Three key themes run through our plan, in line with the Fuller Stocktake recommendations.

Keeping people well and redesigning urgent care pathways

Keeping people well and redesigning urgent care pathways

Helping people stay well at home, increasing self-care, strengthening urgent community care to provide viable alternatives to A&E.  Creating a more resilient infrastructure around GP practices will enable same-day access to urgent care and greater continuity of care for patients. Separating reactive and proactive care, by providing integrated urgent and episodic care at primary care network level, alongside improved access to urgent care services, are fundamental to helping us do this.

Delivering personalised care for those with complex needs

Delivering personalised care for those with complex needs

By managing urgent care differently and supporting the development of integrated neighbourhood teams, we can create the capacity for team-based continuity, focusing on specific cohorts such as frail elderly people. Patient cohorts will be identified through clinical judgement, conversations with patients, and risk stratification enabled by population data.

Enabling prevention and tackling health inequalities

Enabling prevention and tackling health inequalities

Primary care has a vital role to play in preventing ill health and tackling health inequalities. We will be working with partners to integrate primary, community, public health, and voluntary and community prevention services to target specific health conditions and address the wider determinants of health.