Our work with people and communities

Regularly engaging with the community is a fundamental element of effective service delivery and system transformation.

Consistent engagement helps identify and address barriers that prevent people from accessing services, particularly those in marginalised or underserved communities. It supports the design of inclusive services that reflect the needs of people from different backgrounds, geographies, and experiences.

• Builds trust and transparency – when people feel heard and see their feedback acted upon, trust in services improves. Ongoing dialogue rather than one-off consultations demonstrates that we are accountable, open, and responsive.
• Enables early insight and prevention – community engagement can surface issues before they escalate, providing early warning signs about gaps in provision, rising health inequalities, or emerging community tensions. This supports preventative action, reducing long-term costs and improving outcomes.
• Drives better decision-making – communities hold deep knowledge about what works locally. Regular engagement allows decision-makers to draw on lived experience and co-produce solutions, leading to services that are more relevant, sustainable, and effective.
• Supports statutory duties and best practice – health and care bodies have a legal duty to involve patients and the public in decisions about services. Regular engagement ensures compliance with these duties and aligns with best practice guidance, including the NHS’ Working in Partnership with People and Communities framework.

A substantial programme of community engagement has been delivered across Surrey Heartlands through 2024/2025. This work has involved collaboration with a wide range of voluntary, community, faith-based, and statutory organisations.

Activity has centred on the dissemination of public health information, the gathering of insight from protected and vulnerable groups, the promotion of research inclusivity, and the delivery of health improvement initiatives.

Neighbourhood and network meetings

Over 90 local neighbourhood and network meetings were attended by the community engagement team. These included forums such as the Redhill & Reigate Health and Wellbeing Neighbourhood Network, Guildford & Waverley Patient Participation Groups (PPGs), and the Preston Partnership Forum. These meetings provided opportunities to share service updates, gather insight, and build partnerships at Place level.

Engagement with protected and vulnerable groups

Ethnic Communities

Engagement with groups such as the African Association in Surrey & Sussex (AAISS), SMEF, Guildford Hong Kongers Group, and local Ukrainian Hubs supported the dissemination of public health messages relating to vaccinations, healthy eating, and service access. 

Activities emphasised cultural sensitivity, addressed access barriers, and promoted participation in health and wellbeing events.

Disability Groups

Participation in the Disability Partnership Board, Surrey Vision Action Group (SVAG), Valuing People Groups, and the Wheelchair Service User Forum enabled discussion of key concerns including access to equipment, delays in provision, and the need for accessible communication formats.

Young People and Carers

Forums such as User Voice, along with activities run in collaboration with Mindworks and Action for Carers, helped to identify and explore themes including the experience of neurodevelopmental conditions, school inclusion, young carers’ needs, and access to mental health support.

Case Study: Community engagement in practice – raising awareness of sickle cell through partnership

Working with the African Association in Surrey and Sussex.

Background

Sickle cell disease disproportionately affects people of African and Caribbean heritage, yet awareness, early testing, and support can be limited.

Through our community engagement, we recognised an opportunity to work alongside the African Association in Surrey and Sussex (AAiSS) to improve community understanding of sickle cell disease and promote earlier access to testing and support.

What we did

Ask and listen: Surrey Heartlands ICB engagement team met with representatives of the African Association to understand concerns about sickle cell disease awareness and access to testing.

Clinical colleagues from haematology, the Clinical Lead for Haematology and the consultant haematologist were also engaged to explore service pathways and opportunities for improvement.

Clinical collaboration: It was agreed that, due to clinical and logistical complexities, direct blood testing at a community event would not be appropriate; instead, individuals would be encouraged to request testing through their GP practices.

Options were also explored to enable community members to access sickle cell carrier testing via their GP, supported by the development of an information leaflet to simplify the request process. Advice and best practice were sought from regional sickle cell networks to inform the approach. 

Community event: Plans were developed for a public-facing awareness event, co-hosted by Surrey Heartlands ICB, clinicians, and the African Association.

The event was designed to provide education about sickle cell disease, signpost community members to testing services, and promote new resources, including patient information leaflets and emergency alert cards to support people living with sickle cell when accessing urgent care.

System-wide thinking: Opportunities were identified to extend this approach across Surrey Heartlands following the initial awareness event, embedding learning into future engagement activities across all Places.

In addition, discussions were initiated with primary care colleagues about offering targeted training on sickle cell disease through protected learning time, supporting greater clinical awareness and improved patient care across the system.

What we learned

• Partnership working between community organisations, clinical specialists, and system leaders is essential to addressing health inequalities.
• Listening to the lived experiences of affected communities helps shape more practical, culturally appropriate solutions.
• Community engagement can be a catalyst for wider system change, supporting training and service improvements across pathways.
• Empowering individuals with accessible information promotes autonomy and improves access to preventive healthcare.

Through this work, relationships between Surrey Heartlands ICB, clinical teams, and the African Association were strengthened, helping to build trust and create open channels for ongoing dialogue.

The initiative raised awareness of sickle cell disease among both community members and health professionals, supporting earlier diagnosis and access to appropriate care. It also catalysed the development of practical resources, including GP information leaflets and emergency alert cards for people living with sickle cell. 

Importantly, it established a model for replicating similar community-clinical engagement initiatives across the wider Surrey Heartlands footprint.

Case Study: From listening to action – Identifying health needs through community engagement

Partnering with the Shifa Network

Background

Surrey Heartlands ICB is committed to working alongside communities to ensure services are shaped by the people they serve. A key part of this work involves attending community-led events to listen, build trust, and identify opportunities to address health inequalities.

One such opportunity arose through the relationship built with the Shifa Network, a local organisation supporting women from ethnic minority backgrounds in Woking. 

How engagement identified a need

A community leader from the Shifa Network highlighted a need to the trusted member of the Surrey Heartlands engagement staff relaying health priorities and concerns from community members.

Through informal conversations, a clear need emerged for more accessible information and advice around healthy eating and lifestyle choices, particularly in ways that were culturally sensitive and relevant to the community’s needs.

This insight would not have been captured through traditional methods alone. It was the direct, face-to-face engagement in a trusted environment that enabled participants to express their needs openly.

Collaborative action: planning a health and wellbeing event

In response, Surrey Heartlands worked collaboratively with colleagues at Ashford and St Peter’s NHS Foundation Trust, North West Surrey Alliance and the Shifa Network to co-design a health and wellbeing event focused on nutrition and healthy lifestyles.

The session was delivered by two dietitians from Ashford and St Peter’s Hospitals, one of whom spoke Urdu and was able to run the workshop bilingually. This was extremely beneficial in helping participants feel included and ensuring the content was fully accessible.

The workshop was interactive and practical, with participants making healthy wraps together which the dietitians then cooked on site using dry-frying methods. The session encouraged informal discussion, and participants enjoyed sitting together to share their food and experiences in a relaxed, supportive environment.

Importantly, the session did not just focus on ingredients or recipes. The facilitators also explored emotional and boredom-related eating, opening conversations around the emotional aspects of food, which many participants found particularly valuable. 

This approach supported both learning and wellbeing, helping to build knowledge, confidence, and connection among the group.

What we learned

This case reinforced the importance of direct community engagement in identifying real needs that may not otherwise be captured. It also highlighted those co-producing solutions with community partners rather than delivering pre-set activities ensures interventions are better received, better attended, and more impactful.

What difference it made

The partnership with the Shifa Network led to a successful Health and Wellbeing Event that met a locally identified need. Participants reported increased confidence in managing their diet and health, and the event strengthened relationships between Surrey Heartlands and the community for future collaboration.

Supporting Patient Participation Groups (PPGs) across Surrey Heartlands

We recognise the vital role that Patient Participation Groups (PPGs) play in embedding patient voice into primary care services. PPGs help practices to better understand the needs and experiences of their local populations and support ongoing service improvement.

To strengthen and support PPGs, we:

• Published a comprehensive PPG Handbook to provide practical guidance to PPG members and practice staff, promoting good governance, inclusivity, and effective engagement.
• Delivered tailored 1:1 support to PPG Chairs and Practice Managers to help address specific challenges, such as practice transitions, recruitment, improving representativeness, and managing change.
• Provided ongoing advice and resources to promote good practice in patient communication, feedback processes, and community involvement.

In 2024, Surrey Heartlands provided direct 1:1 support to approximately 10 practices and their PPGs across the system. This work has been vital in helping practices and PPGs maintain strong, trusting relationships with their patient communities, particularly during periods of significant operational change.

Case Study: Supporting Molebridge GP practice through transition

Molebridge GP Practice undertook a review of how it operated to ensure future sustainability and deliver the best possible mix of skills within its multidisciplinary team.

Recognising that such change could raise concerns among patients, the practice sought early support from Surrey Heartlands to ensure communications and engagement were handled sensitively and effectively.

Surrey Heartlands provided direct 1:1 support to the practice leadership and PPG Chair. This included helping the practice develop clear, transparent communications to reassure patients about the reasons for the review, maintain trust, and invite ongoing feedback.

Support was also provided to strengthen the PPG’s role during the transition, ensuring that patient representatives were kept informed, able to contribute constructively, and positioned as a vital link between the practice and the wider community.

Through this collaborative approach:

• Molebridge Practice maintained patient trust and transparency during a sensitive period.
• The PPG was empowered to act as an active partner in shaping future developments.
• Patients were reassured that their voices would be heard as changes were explored.
• Learning from the Molebridge experience informed wider engagement approaches across Surrey Heartlands.

This case highlights how direct, personalised support from the ICB can make a real difference in strengthening local relationships, supporting sustainable service development, and ensuring the patient and public voice remains at the heart of primary care.

All Age Continuing Care Patient Engagement Forum

The All Age Continuing Care (AACC) Patient Engagement Forum provides a dedicated space for service users, carers, and voluntary sector representatives to engage with the AACC team and help shape how services are delivered. Established in 2019, the Forum supports ongoing dialogue and co-production to improve patient and carer experience across Surrey.

The Forum brings together individuals with lived experience of NHS Continuing Healthcare and NHS-funded Continuing Care. It supports people to better understand key stages of the process including the initial Checklist, the Decision Support Tool (DST) assessment, commissioning of care packages, and the appeals process. The format of the Forum includes updates on current service developments, clinical presentations with Q&A, and group discussions to embed co-production into service improvement.

Participation is open to all and reflects a broad range of perspectives. Contributors include patients, family members, carers, and representatives from local voluntary and community organisations. Forum discussions often highlight how complex and confusing the AACC process can feel. Listening to lived experience has helped the AACC team better understand barriers and co-design improvements.

Feedback from the Forum has played a key role in shaping the development of a patient-facing process. This included gathering views on language preferences, references to protected characteristics, and how to support individuals at each stage of the AACC pathway.

Discussions recognise the need to reflect the diversity of care journeys, from straightforward packages to more complex arrangements where individuals may act as employers of their own care staff.

Insights gathered through the Forum continually improve how information is shared, how support is offered, and how care is commissioned. This engagement forum approach ensures that service development remains grounded in the experiences of those who use it.

Ongoing community engagement – next steps for 2025/26

This period of activity has demonstrated the value of co-designed, locality-based engagement in ensuring equitable access and aligning service delivery with lived experience. Our next steps will focus on:

• Awareness of local services has increased, particularly in communities where information was co-delivered with established local partners. Continue to nurture and expand this approach.
• Community insight to inform ongoing communication planning, with a particular emphasis on health inequalities and accessibility.
• A centralised engagement tracker is continually being developed and improved to monitor activity, capture themes, and track follow-up actions.
• Summary reports being shared with commissioners and service leads to support planning and delivery improvements.

Guildford and Waverley

Community Engagement in Cranleigh and Surrounding Villages - Emerging Neighbourhoods

Guildford and Waverley Alliance took part in a health and wellbeing community event hosted by the Cranleigh Villages Group, covering Cranleigh, Alfold, Dunsfold and Ewhurst.

The event brought together residents, voluntary and faith groups, and health and care professionals to explore opportunities for greater collaboration at a neighbourhood level.

The Alliance’s presence supported conversations around integrated neighbourhood working, with a particular focus on how local insight and lived experience can shape the future of health and care delivery. Engagement at the event formed part of wider efforts by the Alliance to build stronger, community-led approaches across the area.

A consultant in social prescribing, shared learning from the Frome model in Somerset, where trained local volunteers known as community connectors help link residents with non-clinical sources of support. Discussions followed around how this model could be adapted for Guildford and Waverley, and a toolkit was introduced to support local implementation.

The East Waverley Primary Care Network and Voluntary Action South West Surrey also shared a case study highlighting the personal impact of social prescribing, reinforcing the value of collaborative, person-centred approaches to wellbeing at Neighbourhood level.

Guildford and Waverley Alliance led an interactive session on the principles of neighbourhood health, inviting attendees to share their views on what matters most to their communities. Residents from Alfold offered insight into local strengths and emphasised a community-led approach based on what is strong, not what is wrong.

The event provided a valuable platform for the Alliance to listen, connect with residents and community partners, and gather ideas to support the development of integrated, neighbourhood-based care. Insights shared on the day will inform future engagement and planning across the Guildford and Waverley area.

Surrey Downs

Community Engagement and Green Social Prescribing – Dorking Hospital Garden

The transformation of the garden at Dorking Community Hospital represents a powerful example of community-led engagement in support of health and wellbeing. The Grow Together – Share Together initiative, delivered in collaboration with local residents and voluntary partners, has created a therapeutic outdoor space that fosters connection, conversation, and recovery.

This inclusive project demonstrates how green spaces can be used to bring people together across generations and cultures, strengthening relationships between the hospital and the wider community. The redesigned garden has been developed as a shared space for staff, patients, carers, families and residents. Key activities delivered through the project include:

• Sharing Stories – Informal conversations and memory-sharing to promote social connection and reduce isolation
• Growing Food – Hands-on learning in sustainability and nutrition through shared gardening
• Intergenerational Connections – Activities that bring children and older people together to support mutual understanding and belonging
• Therapeutic Use – A calming environment that supports patient recovery and emotional wellbeing

Impact and Community Value

This initiative has created a space where wellbeing is supported holistically. Benefits reported by those involved include:

• A safe, welcoming area for patients to relax during or after treatment
• Opportunities for staff to de-stress and reflect
• Increased community ownership and pride in local health infrastructure
• New conversations around health, nature, and sustainability

The project also contributes to broader system goals including prevention, rehabilitation, and the use of nature-based approaches to health improvement.

Neighbourhood fund: Strengthening communities through local grants participation group, investing in health and wellbeing – a partnership approach

Reigate and Banstead Borough Council was awarded £84,100 from Banstead Primary Care Network and Surrey Downs to establish and manage the Banstead Neighbourhood Fund. This initiative was designed to support local projects that improve community wellbeing and address key health challenges.

Community-Led, Locally Focused

A strong emphasis was placed on local engagement and insight, ensuring the grants were widely promoted and accessible.

A participation group of residents played an active role in assessing applications, with final funding decisions made by the Banstead Neighbourhood Board.

Meeting real community needs – 20 local projects were funded, benefiting approximately 2,500 residents across Banstead.

Impact across key health and wellbeing areas

Funded projects tackled a broad range of health and social challenges, including:

• Mental health support
• Youth engagement
• Loneliness and social isolation
• Support for people with vision impairment and life-threatening illnesses
• Physical and mental wellbeing initiatives
• Domestic abuse support services
• Dementia awareness programs
• Children’s fitness and wellbeing
• Bereavement support
• Support for veterans and those facing financial hardship

Emerging Network: Community development – Pulling Together Programme

The Pulling Together Programme was established following engagement about health and care needs and wishes with staff, lay partners and local residents from across the Surrey Downs Health and Care Partnership.

The programme focusses on ‘what’s strong, not what’s wrong’ and aims to identify, grow and lead community development projects by working collaboratively with community partners.

Local Primary Care Networks (PCNs) worked with Districts and Boroughs to identify, grow and lead a series of local community development projects, supported by the Partnership and using community development funding.

These projects might use existing assets within the community, such as skills, spaces and connections and the expertise of local people in the community.

The Pulling Together Programme:

• Understands the needs and priorities of communities by independently engaging with communities and residents. 
• Brings together the NHS, local government, community health services, voluntary sector, and other providers to serve the people and communities in Surrey Downs. 
• Develops targeted programmes that make a difference to our local residents and service users. 
• Shares ideas and resources between projects/programmes through the network of support.

East Surrey

Neighbourhood development through the work of the South Tandridge Health and Wellbeing Network

Over the past year, the South Tandridge Health and Wellbeing Network took a collaborative engagement approach with residents, healthcare professionals, and local organisations to identify and address various health and wellbeing concerns.

The Network has responded to community feedback and successfully addressed numerous issues, leading to the implementation of a variety of initiatives.

Support for local veterans

A dedicated armed forces information page has been added to the Alliance for Better Care website. A veteran’s representative will be joining the South Tandridge Neighbourhood meetings, and the Oxted Legion will host a future meeting to support veteran's mental wellbeing and foster camaraderie.

Community repair and recycling shed in Hurst Green

Workshops focused on teaching repairs, crafting and upcycling are being planned for Hurst Green. Over 40 residents and schoolchildren shared their thoughts in the initial survey, and 10 volunteers have already signed up.

Park Play in Hurst Green

Park Play is a fun way for adults and children of all ages and abilities to get active and meet others. The free two-hour sessions take place every Saturday morning at Holland Junior School, starting at 9:30 am.

The programme is growing, with 13 attendees and one volunteer leader already taking part. It is hoped that more volunteers and participants will join as more people get to hear about the initiative.

Additional initiatives that have been coproduced with the community:

• Private spaces for breastfeeding in GP practices
• More support for volunteers and community groups
• A memory café for people with dementia and their carers
• Enhanced community spaces
• LGBTQIA+ groups for people with disabilities
• Peer support groups for parents of children with SEN
• And much more, all aimed at fostering connection and wellbeing.

Merstham Community Action Group Growing Health Together

The Merstham project, part of the Growing Health Together initiative, is a strong example of community-focused health and wellbeing development. It centres on collaboration between healthcare professionals, local organisations, and residents to address health inequalities and support holistic wellbeing.

Approach to community engagement

The Merstham Neighbourhood Health and Wellbeing Network has undertaken several community-driven actions to enhance local health and wellbeing. These efforts are rooted in collaborative engagement with residents, healthcare professionals, and local organisations.

• Participatory Development – The project actively involves local people in identifying health priorities and co-designing interventions. This ensures that solutions are relevant, responsive, and locally led.
• Local Partnerships – By working with schools, faith groups, and voluntary sector organisations, the initiative builds trust and makes effective use of established community networks to share health information and offer support.
• Accessible Support – The project provides easily accessible resources, such as mental health directories and local wellbeing services, helping residents to find the support they need in a timely and informed way.

Key initiatives in Merstham

These initiatives reflect a commitment to participatory development, where community feedback directly informs the actions taken. The network's approach aligns with public sector objectives of promoting health equity and community resilience through inclusive and collaborative methods.

• Improving Access to Health Support – The network has identified and addressed barriers to healthcare access, aiming to make services more approachable and responsive to community needs.
• Enhancing Antenatal and Postnatal Care – Recognising the importance of maternal and infant health, efforts have been made to improve support for expectant and new mothers, ensuring they receive comprehensive care during and after pregnancy.
• Addressing Antisocial Behaviour – Community concerns regarding antisocial activities have been acknowledged, with initiatives implemented to foster a safer and more cohesive environment
• Promoting NHS App Confidence – To bridge the digital divide, the network has worked on increasing residents' confidence in using the NHS App, facilitating easier access to health information and services.
• Providing Smoking Support – Recognising the health risks associated with smoking, targeted support has been offered to assist individuals in cessation efforts, contributing to overall community health improvement.

Maternity Best Start: Neonatal unit psychological support – workforce engagement for service improvement

The Surrey Heartlands Neonatal Unit Psychological Support initiative aimed to improve early bonding between parents and babies in neonatal care, while supporting staff in providing emotionally responsive care.

The project, initially funded through COVID-19 relief and subsequently by the Local Maternity and Neonatal System, enabled psychotherapists to work directly within neonatal units. Between 2021 and 2023, the service reached more than a thousand families across Ashford and St Peter’s, Royal Surrey, and Surrey and Sussex Hospitals.

Evidence shows that the first 1,000 days of life are critical in establishing a child’s long-term health and development. Babies in neonatal intensive care units (NICU) often require significant medical interventions, which can interrupt bonding and increase stress for parents.

The psychological support offered by this project addressed trauma, strengthened parent-infant relationships, and provided essential emotional support during this critical time.

An evaluation of maternity staff experiences revealed widespread support for the service:

• 82% of respondents requested additional psychotherapist hours in neonatal and special care baby units.
• 78% reported the service changed their thinking and improved understanding of psychological needs.
• 67% felt it reduced work-related stress and increased confidence.

The service also informed the rollout of Family Support Workers across Surrey Heartlands, following a successful bid by Shooting Star Children’s Hospices to the Community Foundation for Surrey Mental Health Scale Up Fund. These workers offer practical and emotional support to families, host weekly coffee mornings to reduce isolation, and assist with bereavement support in the Daffodil Suite at St Peter’s.

Patient experience

Reflections gathered from parents and families demonstrated the positive impact of the project. Many shared feelings of anxiety, helplessness, and disconnection from their babies.

The psychological support helped families process these experiences, build confidence in their parenting role, and feel more emotionally connected to their child during a highly stressful period. Parents valued being heard, supported, and included in their child’s care journey.

Vignettes shared by psychotherapists and insights from parent groups illustrated improved emotional resilience, reduced isolation, and stronger engagement with neonatal teams.

This work highlights the importance of embedding psychological support within neonatal services, recognising the emotional needs of both families and staff as integral to quality care.

Early cancer diagnosis: Improving HPV vaccine uptake among young people with learning disabilities – targeted research

The CORE20PLUS5 Accelerator Programme aims to improve cancer outcomes by increasing early detection.  The target is to diagnose 75% of cancers at stage 1 or 2 by 2028.

A key focus in Surrey Heartlands is boosting participation in the Human Papillomavirus (HPV) vaccination programme, ensuring that all eligible young people, including those with learning disabilities, can be protected.

Research shows that young people with learning disabilities have lower HPV vaccine uptake, but the reasons behind this are not fully understood.

Why this matters

To bridge this gap, Surrey Heartlands conducted a study involving parents and carers. The research activity consisted of one-to-one interviews with parents and carers of young people (aged 14-17) with learning disabilities. Their insights have been invaluable in shaping recommendations to improve access and understanding of the vaccine.

Key findings from the research

The research highlights the diverse perspectives of parents regarding the HPV vaccine which we’ve put into three groups.

Parents who consent to the HPV vaccine

• Proactive consent – Parents who actively support vaccinations and ensure their child receives the vaccine.
• Conditional support – Parents who recommend it but leave the final decision to their child.
• Passive consent – Parents who assume their child gets vaccinated but don’t follow up.

Parents who decline consent to the HPV vaccine

• Perceived lack of relevance – Belief that their child is too young or that the vaccine isn’t necessary and may not have long lasting effects.
• Vaccine hesitancy – Concerns about vaccine safety, myths around side effects, misinformation, or immune system overload.
• Limited awareness – Uncertainty about its benefits, particularly for boys.

Barriers to vaccine uptake

• Missed school vaccination days – Many children miss out due to a lack of alternative appointments, GP limitations, or logistical issues.
• Young person’s refusal – Anxiety, fear of needles, or increased hesitancy post-COVID contribute to refusal.

Engaging the community in open conversations, improving awareness, and ensuring accessibility can help increase HPV vaccination rates.

Maternity: Baby Steps, perinatal support for minoritised communities in Surrey

Baby Steps co-produced support for ethnic minority families in the perinatal period (the period between when a woman becomes pregnant and up to a year after giving birth). This had an aim of:

• Focusing on mental wellbeing, health literacy and accessing services
• Providing creche and transport funding
• Organising and developing peer support groups
• Introducing one to one listening
• Offering Pilates exercise sessions
• Making health education and information available.

Background

Surrey Minority Ethnic Forum (SMEF) worked in collaboration with Surrey Heartlands Integrated Care Board (ICB) and Public Health (Surrey County Council) on their First 1000 Days Programme and Perinatal Equity Action Plan.

This work sets out Surrey's vision to provide every family with the best start in life, with a clear emphasis on closing the gap in outcomes. The early years of a child’s life will lay the foundation for their health, their growth and brain development.

The first 1000 days are particularly important in building happy and healthy children. Sometimes only small changes in the first 1000 days are needed to make family life easier, healthier and more enjoyable. These changes can make a huge difference to a child and the adult they become.

This collaboration has created SMEF’s ‘Baby Steps’ Perinatal Equity Project, that aims to improve equity of access, experience, and outcomes for pregnant women and families from ethnic minority backgrounds.

The Baby Steps mid-term evaluation report details the co-production approach undertaken to design and develop the project. 22 different organisations, groups and services were consulted to give their opinion and feedback on the needs of the minoritised communities in Surrey and what services they would like Baby Steps to provide.

Project outcomes and highlights

Achievement of objectives

The project directly reached 75 women and birthing people across Woking, Stanwell, Reigate and Banstead, providing culturally sensitive perinatal support. The project:

• Increased access to perinatal healthcare services.
• Improved maternal health knowledge and practices among women from minoritised communities through peer support groups.
• High satisfaction rates, with 100% of participants expressing increased confidence in managing their perinatal health.

Unanticipated outcomes

Greater than expected demand for the service, indicating a significant need within the community.

Sustainability and next steps

There are plans to expand the initiative to additional regions within Surrey with additional funding and partnerships. The main needs identified by the professionals are:

• Increased engagement with the minoritised communities
• Access to groups to run awareness sessions about available services
• For communities to understand NHS systems and processes
• Translation services

Feedback

Feedback sessions in areas identified for the project, to consult with the minoritised communities, revealed that women and birthing people wanted:

• Peer support
• Groups with other women from similar communities where they wouldn’t feel the need to ‘explain themselves’
• Light physical activity
• Creche mental health support
• Regular health checks
• ESOL lessons
• Activities for children
• Domestic abuse support
• Advice on what is available to them
• Visits to local places
• Advice on infant care
• Peer support but time for 1-1 as well
• To be involved in a project where they can create something for the professionals to increase cultural awareness.

The Surrey Baby Steps project ran for a 2-year period from March 2022 to March 2024. The service has been completely co-produced and there is now funding for a further 5 years. Read the Midterm and End of Project Reports.

Cardiovascular disease prevention – working with partners to reduce inequalities

Surrey Heartlands is working through VCSE partners across the Integrated Care System (ICS) to address key long-term conditions including cardiovascular disease (CVD), diabetes, and respiratory illnesses. Prevention, early intervention, and equitable access are central to these efforts, with a particular focus on engaging communities most at risk.

Black and Minority Ethnic (BME) communities in Surrey experience disproportionate risks related to CVD and diabetes. Contributing factors include deprivation, cultural dietary patterns, limited healthcare access, and genetic predispositions. Targeted action is essential to close these gaps.

Surrey Minority Ethnic Forum (SMEF) has played a key role in this space through its Health and Race Project, which set out to:

• Promote equitable access to culturally appropriate health information and services.
• Empower BME communities to make informed health choices.
• Strengthen BME engagement in the design and delivery of local health services.

Community-based action

Two health clinics were delivered by SMEF in partnership with NHS Alliance for Better Care in Woking.

These focused on reaching women from Asian communities who had not accessed health checks via their GP.

The clinics offered tailored support including:

• Blood pressure, cholesterol, glucose and BMI checks
• Mental health and smoking cessation advice
• Vaccine provision and weight management guidance

Participants were also referred onwards to services such as GPs, mental health support (Talking Therapies), and safeguarding teams where appropriate.

In addition, SMEF hosted a series of awareness sessions with local women’s groups to promote the importance of NHS health checks and self-care for conditions such as diabetes and hypertension. These initiatives enabled community-led conversations and created more culturally competent pathways into care.

The SMEF End of Project Report outlines the outcomes of this work and sets the foundation for continued collaboration in addressing health inequalities across Surrey Heartlands.

Key Neighbourhoods: Starting Well in Ockford Ridge – Listening to the Needs of Families with Young Children

The findings from this project provided important insight into how services at the new community centre on Ock Way could be more effectively developed to meet the specific needs of families with children aged 0 to 5 in this area.

Located in Waverley and identified through local data as experiencing poorer early years outcomes than could typically be expected in Surrey, the project aimed to provide the data that could help decision makers develop a service offer that was inclusive, co-produced, and grounded in the lived experience of parents and carers.

The research consisted of five semi-structured online focus groups involving a sample of parents, carers, and prospective parents. Three of these groups involved parents from Ockford Ridge, while the other two involved parents from across Surrey to allow for a comparison.

A parent from the Ockford Ridge area was involved in the project as a peer researcher, providing valuable input in the areas of question development, participant recruitment, analysis and reporting, ensuring the voice of parents and carers was a consistent thread throughout the process.

The research sought to understand what kind of services families value, the barriers they face in accessing existing services and their priorities for the future.

Key findings revealed strong community support for a focus on early years support, alongside concerns about unintentionally excluding older children and other community members who have a caring responsibility for 0 to 5s. Families called for a broader offer that could support teenagers, provide affordable activities during school holidays, and offer inclusive services for children with additional needs.

Barriers identified included inconvenient timings of services, inaccessible locations, and the affordability, all of which contributed to low uptake of existing provision. 

Participants consistently emphasised the importance of personalised, welcoming interactions with staff, noting the impact of empathy, cultural sensitivity, and familiarity on sustained engagement. Clear and consistent communication, along with flexible scheduling, were seen as essential enablers.

Families highlighted a need for improved coordination among local providers to reduce duplication and simplify access. A more joined-up approach, supported by better information sharing, was seen as key to improving the overall experience. In relation to future engagement with the ICB on similar topics, community members expressed a clear preference for informal methods, valuing visible follow-up and practical demonstration of how their feedback shaped services.

The findings are being used by decision makers to inform service planning, helping local partners to design a community offer that is more inclusive, responsive, and reflective of the diversity and needs of the local population. Insight from this project also contributed to broader learning across Surrey, supported by comparative feedback from Citizen Panel members in other areas.

Using a range of co-design and insight methodologies we have supported programmes of work to directly improve services.  

Case study: Supporting Young People with Diabetes – The Together Type 1 Peer Support Event

In April 2024, a two-day engagement event was held at the Children and Young People’s Haven in Epsom for young people aged 11–16 living with type 1 diabetes. The initiative was designed to build peer relationships, reduce isolation, and strengthen links between children and young people, their families, and clinical teams.

This programme was developed through a collaborative partnership involving the National Academy for Social Prescribing (NASP), Diabetes UK’s Together Type 1 Youth Programme, Surrey Youth Worker Service, clinicians from the children and young people’s diabetes team, East Surrey Place, and Surrey Heartlands ICB. 

The work of the programme was aligned with the NHS Core20PLUS5 approach to tackling health inequalities, and focused on improving engagement through community-based, youth-led support.

Activities and co-production

The event included a range of creative and therapeutic activities cooking classes, a tree of life exercise, graffiti art, and a co-production workshop.

These created a safe, welcoming space for young people to express their feelings, explore shared experiences, and build confidence in managing their condition.

A central element of the event was the co-production workshop, where participants shared concerns about the challenges of managing diabetes, particularly in school and peer environments.

Key issues raised included:

• Limited access to safe spaces for insulin injections
• Anxiety about nocturnal blood sugar episodes
• Social exclusion due to fluctuating glucose levels
• Difficulties accessing emotional support post-diagnosis
• Parental distress and disruption to family life

Clinicians and youth workers reported strengthened relationships with participants, with feedback indicating increased positivity and confidence following the event.

Impact and next steps

Insights from the event informed the development of a new partnership model in transition clinics. Under this model, Youth Workers provide continuity of support during the move from paediatric to adult services.

Young people are offered the choice of where to meet their Youth Worker and are encouraged to participate in wellbeing-focused activities that promote self-management and social connection.

This approach responds to key priorities including:

• Improving psychological support for children and young people
• Reducing isolation and post-diagnosis trauma
• Enhancing long-term clinical engagement and mental health outcomes
• Preventing avoidable diabetes-related complications in adolescence

The Together Type 1 event demonstrated the value of co-designed, inclusive approaches in shaping services that reflect the lived experience of young people. It also highlighted the importance of integrated, non-clinical support within health pathways for long-term conditions.

Case study: Ashford and St Peter’s Hospitals Surgical Prehabilitation Programme: ‘Prepare to Recover’ Supporting Better Surgical Outcomes

The Prepare to Recover programme is a collaboration between the therapy and anaesthetic teams at Ashford and St Peter’s Hospitals (ASPH), delivering patient-centred, needs-based prehabilitation support within the community.

The programme focuses on early identification and optimisation of perioperative risk factors including chronic health conditions, physical fitness, nutrition, and psychological wellbeing enabling patients to take an active role in their recovery journey before surgery begins.

Why prehabilitation matters

Extended waiting times for surgery can contribute to physical deconditioning, worsening of chronic conditions, and reduced psychological resilience, making recovery more challenging. Prepare to Recover aims to break this cycle by helping patients become:

• Medically optimised for surgery
• Physically stronger and more resilient
• Psychologically prepared for their procedure

Support is delivered through a combination of:

• Structured exercise circuits designed to improve strength and mobility
• Bite-size ‘Surgery School’ sessions providing education, practical advice, and emotional support

Listening to patient voices: Survey feedback

Patient feedback has been integral to the development and improvement of the programme.

All participants are invited to complete a structured survey after finishing Prepare to Recover, focusing on:

• Their overall satisfaction with the programme
• What aspects they found most helpful
• Any barriers or areas for further improvement

Key outcomes from the survey include:

• Overall satisfaction rating: 4.75 out of 5
• 100% of participants who completed the survey would recommend the programme to others

Survey findings have been used to refine session content, identify additional patient needs, and guide future improvements to the delivery model.

Patient experience – real stories, real impact

In addition to survey data, participants were invited to share their personal stories and reflections in more depth. These first-hand accounts provide valuable qualitative insight into the emotional and practical impact of Prepare to Recover.

Participants highlighted benefits such as:

• Regaining a sense of normality and community
• Improved emotional wellbeing and reduced anxiety
• Increased confidence in managing their own health and fitness
• Feeling better prepared and empowered ahead of surgery

Quotes and anonymised case studies are being actively used to inform service development, raise awareness of the programme, and promote the importance of prehabilitation across the wider health and care system.

Examples include:

Coming here made me feel better... I do my work, and it’s all beneficial because I’m not dwelling on the past – it doesn’t worry me anymore.

 

Group sessions made me realise I’m not alone. I thought my pain and mobility problems were worse than they were. Now, I know exercising regularly will help.

 

Thanks to this programme, we feel in control. Even if something goes wrong, we know we have done everything possible. That gives us peace of mind.

Empowering patients to take charge

The feedback and lived experiences of Prepare to Recover participants clearly demonstrate the life-changing impact of prehabilitation. By taking an active role in their health, patients feel more confident, more resilient, and better equipped for both surgery and recovery, ultimately supporting better health outcomes across Surrey Heartlands.

Part of the work supported by the Surrey Heartlands ICB Research and Engagement team has been to shape some of this work across the health and care system, ensuring we are meeting our statutory duties as an ICB but also to spread best practice and innovation.

We have supported several system-wide engagement tools and approaches where it feels appropriate to develop/understand a system-wide view, whilst ensuring our methodologies are robust and representative of the system we serve.

Surrey Heartlands Participation and Involvement Network

The network brings together engagement leads from NHS, local authority, and voluntary sector partners to strengthen how communities are involved in health and care decision-making. The group is supported by a Non-Executive Director, providing a link into the Audit Committee to ensure engagement activity aligns with governance and system priorities.

With a focus on sharing practice, coordinating activity, and learning from public feedback, the group meets regularly to review key engagement work and identify opportunities for collaboration. Members are encouraged to bring reports, plans, and insights for discussion, helping to build a shared picture of what’s working and where improvements can be made.

Recent items have included the CQC Framework for engaging with people and communities and the Winter Engagement Report, both used to reflect on how feedback is gathered and used to address health inequalities.

Participation and Involvement Network

Community insight: Surrey Heartlands Citizens Panel

The Surrey Heartlands Citizens Panel is a standing engagement forum comprising approximately 3,000 residents from across the region. Panel members voluntarily contribute to ongoing service development by taking part in surveys, focus groups, and community events.

The panel supports collaborative engagement between Surrey Heartlands and other public sector organisations, offering a valuable channel for consistent public feedback.

Over the last year, the panel has contributed insights on a wide range of topics, helping to shape service priorities and communication strategies across the system. Surveys conducted between May 2024 and March 2025 covered key areas including pharmacy services, attitudes towards local NHS provision, winter health communications, planning for social care, sexual health, and the development of the Surrey Heartlands Ten Year Plan.

In addition to quantitative surveys, the panel has served as a recruitment pool for several qualitative research projects. Panel members have supported deeper engagement around the Clinical Strategy, early years support services, and long-term strategic planning. Their contributions have ensured a representative voice is embedded in decision-making processes across programmes.

By facilitating broad and inclusive participation, the Citizens Panel continues to play a central role in shaping a health and care system that is informed by the lived experiences, priorities, and expectations of the communities it serves.

Surrey Heartlands Citizens Panel

Embedding Community Voice into the Surrey Heartlands Clinical Strategy

The Surrey Heartlands Clinical Strategy was developed to align with the wider Integrated Care System (ICS) ambitions of prioritising prevention, reducing health inequalities, and delivering care in more accessible and innovative ways.

These priorities, first articulated in the five-year Joint Forward Plan, were further shaped by a commitment to reflect the lived experiences and expectations of local people.

To support this, research was conducted through two phases of public involvement. 

Clinical Strategy public research

Informing the NHS 10-Year Plan

A comprehensive research and engagement programme was delivered locally to inform the development of the NHS 10-Year Plan and align national priorities with the specific needs of the Surrey Heartlands population. The work focused on capturing a broad range of insights from diverse communities, service users, and stakeholders, particularly those experiencing health inequalities.

Context and objectives

The NHS 10-Year Plan called for a transformation in health and care through three strategic shifts: from hospital to community-based services, from treatment to prevention, and from analogue to digital healthcare. Surrey Heartlands undertook a structured engagement initiative to explore how these shifts could be meaningfully applied locally. The programme aimed to:

• Generate robust and representative insights across communities.
• Identify barriers and enablers specific to priority groups, including those outlined in the CORE20PLUS5 framework.
• Inform strategic alignment between local service delivery and national ambitions.

Engagement approach

A mixed-methods research design enabled both depth and breadth in the evidence base. Activities included:

• Focus Groups – Eight structured focus groups were delivered with public representatives, priority populations (including justice-involved individuals and young people), healthcare staff, and service providers. Each session explored perceptions of digital transformation, community care, and preventative health.  These sessions were based on a Surrey Heartlands version of the Workshop in a box material developed by NHS England and Thinks Insight and Strategy.
• In-Depth Interviews – Semi-structured interviews were conducted with individuals from under-represented communities, including carers and people with disabilities, to surface personal experiences and system navigation challenges.
• Survey – A survey was run on the Citizen Panel to capture broad public views on the strategic shifts, particularly preferences and concerns related to digital healthcare, community-based care, and preventative services.
• Community Engagement Sessions – Facilitated discussions were held with selected community groups and networks, including Surrey Charities Forum, SMEF, and GP Patient Participation Groups.

Ethical standards were embedded throughout the process, ensuring informed consent, participant confidentiality, cultural sensitivity, and voluntary involvement.

The findings from the engagement programme were compiled into a detailed report and used to inform the development of the Surrey Heartlands Clinical Strategy, as well as local contributions to NHS 10-Year Plan discussions. Insight gathered through the process has been shared with system partners to support strategic planning and future service design. The engagement also helped build a richer understanding of how local people view emerging priorities, and highlighted the value of targeted, inclusive approaches to community involvement.

Research Ready Surrey

In 2024/25, NHS England awarded an additional £80,000 grant to support the continued development of the Research Ready Surrey (RRS) programme. The focus remained on increasing the diversity of participation in health and care research by strengthening engagement with underrepresented communities.

The programme was delivered in partnership with the Surrey VCSE Alliance, Surrey Community Action, The Good Company, Nottingham Trent University, and the NIHR Kent, Surrey and Sussex Clinical Research Network.

Research Ready Surrey

Winter Engagement Programme 2024/2025

The Winter Engagement Campaign 2024/25 was delivered as part of the Surrey Heartlands ICB and Surrey Health and Wellbeing Board’s joint winter communications and engagement plan. Designed to promote winter readiness, increase uptake of vaccinations, and support appropriate use of NHS services, the campaign reached over 1,200 people across the region.

How we worked with our communities for Winter health readiness

As part of our involvement and engagement work, it is equally important to engage our workforce, valuing them as an equal partner across key programmes and projects.

The following represent some examples of work we have undertaken with staff across the ICB and our wider workforce.

Surrey Heartlands: values and behaviours

To support the development of a shared culture across Surrey Heartlands Integrated Care System (ICS), qualitative research was commissioned to explore the values, behaviours, and experiences shaping cross-system collaboration.

This phase focused on understanding how the emerging organisational culture was perceived by staff, and how the updated Values and Behaviours Framework could be embedded more effectively at all levels of the ICS.

Feedback was gathered from Integrated Care Board (ICB) staff working across multiple directorates, including leadership, Place-based teams, secondary care, and pharmacy. Participants largely supported the core values of inclusivity, community focus, and relationship-building, noting that these principles were broadly aligned with NHS and ICS ambitions. However, several barriers to implementation were identified.

Staff described the language used in the framework as overly complex, with overlapping definitions and limited clarity on how values translated into day-to-day behaviours. The absence of tangible links between personal actions and organisational objectives contributed to a perception that the framework remained abstract. A tiered structure demonstrating how values could be reflected in practice across different roles was widely recommended.

Concerns were also raised about a perceived mismatch between leadership behaviours and the values promoted by the framework. This disconnect was seen to contribute to reduced trust and engagement. Greater visibility of leaders, more consistent modelling of expected behaviours, and a clearer articulation of the ICB’s identity were identified as priorities for improvement.

Participants emphasised the importance of fostering a no-blame culture, promoting psychological safety, and enabling innovation through learning. Equity and collaboration across the system were identified as essential to strengthening relationships and improving joint working.

Recommendations from the research focused on ensuring practical application of the framework, including integration into staff appraisals, learning and development programmes, and routine decision-making. A strong message emerged that meaningful cultural change required collective ownership and the active involvement of staff in shaping the way the organisation functions.

Staff Engagement: Surrey Heartlands appraisal review

In 2024/25, Surrey Heartlands introduced a revised appraisal process designed to strengthen staff development, align objectives with organisational values, and embed wellbeing into routine performance conversations. To understand staff experience of the updated process, a mixed-methods evaluation was undertaken involving 60 survey responses and 10 in-depth interviews with staff across the ICB.

The updated approach includes an annual appraisal, a mid-year review, and structured prompts on wellbeing, values, and personal development. Staff broadly welcomed the changes, noting improvements in structure, the quality of templates, and the focus on ongoing dialogue rather than one-off review.

Participants highlighted the benefits of clear objectives, supportive appraiser relationships, and regular opportunities for reflection. Where line management was effective, conversations were described as more meaningful and motivational. Mid-year reviews and one-to-one check-ins helped to reinforce progress and clarify expectations.

However, experience varied, with some describing the process as overly formal or repetitive particularly where objectives had not changed year on year. The Scope for Growth model and the values component were helpful for some but perceived by others as rigid or disconnected from day-to-day practice. Wellbeing prompts were valued in principle, though their impact depended heavily on the manager’s confidence and the level of trust between appraiser and appraisee.

Key areas for improvement included:

• Greater flexibility in the process and templates
• More consistent training and support for appraisers
• Clearer follow-up on agreed development actions
• Stronger integration of values into everyday practice

The review has provided valuable insight into how the appraisal process can be further refined to support a culture of continuous development, wellbeing, and alignment with organisational priorities. Feedback from this evaluation will inform adjustments ahead of the 2025–26 cycle.

Workforce Development: United Surrey Talent Strategy evaluation

The United Surrey Talent (UST) Strategy was launched in 2022 as a cross-sector initiative to unify and strengthen the health, social care, and VCSE workforce across Surrey.

To evaluate the progress and impact of the first phase, a qualitative study was undertaken involving 16 interviews, two focus groups with staff and a workshop with stakeholders from across the system. The evaluation explored the extent to which the strategy has supported collaboration, workforce integration, and innovation through the 32 pioneer projects.

Findings indicated that the strategy has made significant progress in fostering joined up working and inclusive development pathways. Notable successes included a reduction in agency spend, improved morale among teams, and the introduction of structured career progression routes.

The Health and Social Care Academy and Future Leaders Programme were consistently highlighted as high-impact components of the first phase.

Despite these achievements, several challenges were identified as a focus for the next stage of the UST programme. Complex governance processes, short-term funding arrangements, and limited workforce mobility across sectors were reported as ongoing barriers to integration.

Additionally, while pioneer projects delivered localised successes, the wider impact of the strategy proved difficult to quantify without more reliable and evidence focused outcome monitoring.

Key enablers of success included inclusive leadership, agile decision-making, and a commitment to co-production with frontline staff and system partners. Participants emphasised the importance of sustaining momentum of UST going forward through stronger communication, the sharing of learning across sites, and dedicated support for those leading innovation.

Looking ahead, priorities for the next phase of the programme include securing longer-term investment, simplifying governance processes, and embedding successful initiatives into mainstream workforce development plans. Insights from the evaluation will inform both strategic direction and operational delivery as the UST programme enters its second phase.

Over the past year, we have focused on deepening our relationships with local communities, strengthening our approach to personalised engagement, and supporting the infrastructure that enables meaningful patient and public involvement. 

This has included sustained work with community-led organisations and tailored support for Patient Participation Groups (PPGs).

A key part of our approach has been to empower community-led organisations to become equal partners and active participants in decision-making, service design, and delivery.

By working alongside trusted local groups, we are helping ensure that engagement is not only inclusive but also led by those who best understand the needs and strengths of their communities.

As we look ahead, our priority is to build on this work by continuing to develop practical, inclusive ways of listening to and involving our people and communities. 

This includes creating safe spaces for community-led conversations, acting on the insights we hear, and co-producing solutions in partnership with those closest to the issues.  We will want to ensure that our future work reflects

1. from treatment to prevention
2. from hospital to community
3. from analogue to digital.  

We will continue to embed this approach across our system, ensuring that the actions set out in our Clinical Strategy which outlines both our immediate priorities and our longer-term vision for health and care are shaped by lived experience.

Just as importantly, we will close the loop by sharing with our communities how their voices have informed decision-making and service development.

By recognising and building on the strengths, networks and knowledge within our local communities, we are committed to creating a system where partnership is the default and where involvement leads to visible, meaningful change.

Priorities for 2025/26

As we move forward, we intend to continue strengthening our commitment across the system to working with people and communities. Building on the foundations laid in previous years, we intend to focus on embedding inclusive, impactful engagement into everything we do, ensuring that people’s voices are at the heart of designing and delivering health and care services.  

As national NHS reform continues through 2025/26, alongside emerging changes in local government structures, we recognise the need to remain flexible and responsive.

While the full impact of these reforms is not yet clear, it is evident that the principles of meaningful involvement and community partnership must be central to how we adapt and move forward and indeed are referenced strongly in the Model ICB Blueprint (published in May 2025).

The engagement and co-production work undertaken to date provides a strong platform from which to build and must now be embedded further across the system and any newly agreed operating model.

As a system, our key priorities include:

• Strengthening system-wide approaches to working with people and communities by refining our processes, tools, and templates, supporting programmes, Place-based teams, and clinical workstreams to embed involvement more consistently and effectively.
• Upskilling and enabling staff across the system, including within provider organisations and commissioning functions, to engage confidently with people and communities as part of core business.
• Building on the learning from our Health Inequalities Programme, using insight from research, engagement and funded projects to deepen understanding of access barriers, improve equity of experience, and support targeted interventions that address the wider determinants of health.
• Aligning engagement approaches across the system, working in partnership with local authorities, the voluntary, community and faith sector, and NHS providers to share insight, coordinate activity, and amplify the impact of our collective work.

We will continue to build trusted relationships with communities, act on the feedback we receive, and work collaboratively to ensure that involvement is visible, valued and demonstrably shapes the future of health and care across Surrey Heartlands.