Partners involved in this vertical integration:
- Surrey Heartlands Health and Care Partnership
- Surrey County Council
- Epsom and St Helier University Hospitals NHS Trust
- GP Health Partners Limited
- Dorking Healthcare Limited
- Surrey Medical Network in the East Elmbridge area
- Central Surrey Health
- Surrey Medical Network Limited
- Princess Alice Hospice
Background
The Surrey Downs ICP is one of four place level partnerships within the Surrey Heartlands ICS and covers a population size of approximately 300,000. It brings together the acute trust, community providers, GP federations, the county council, districts and boroughs and the local voluntary sector to tackle health inequalities, empower the local population to lead healthy lives, and support their physical and mental wellbeing.
Setting up the partnership
The origins of Surrey Downs ICP stretch back to 2016 when providers started coming together to address shared challenges. The biggest concern across providers was that local hospitals were admitting an increasing number of older people who would have better outcomes receiving treatment closer to home.
Under the leadership of Daniel Elkeles, chief executive of Epsom and St Helier University Hospitals NHS Trust and Surrey Downs ICP leader, the '@ home' project was set up. The partnership started on this relatively small-scale project, with the dual aim of admitting fewer people into hospital and discharging those who had been admitted more swiftly into the care of partners in the community. The '@ home' service has been a great success and now provides joined up care to people at risk of admission, resulting in an 8% reduction in overnight stays at Epsom General Hospital for over 65s.
The partnership took another step forward in 2018 when it was awarded an integrated secondary, community and primary care contract. All three GP federations were included within the scope of the arrangement and Surrey Downs Health and Care was established soon afterwards as a joint venture to help deliver the contract. The scope of the partnership has expanded in recent years to include integrated stroke and acute frailty services.
Progress has been made rapidly since then, with the ICP board being established in 2019 with a shared vision and objectives agreed by all partners. This was closely followed by a delegated local commissioning model being developed with the CCG, alongside the first joint financial recovery plan.
Individual integrated services have developed rapidly too – a good example of that is Chirag Patel, general manager for 'Home First' (the service which supports patients' discharge home from hospital sooner by facilitating their on-going social and therapy assessments at home) and integrated stroke services across Sutton and Surrey Downs. When he joined the partnership four years ago he had six people in his team – now he has 400. This illustrates how the ICP is shifting resources away from hospitals into community settings to provide more proactive, preventative care.
Over the past year, the focus of the partnership has increasingly turned to population health, with radical service changes being introduced in response to the COVID-19 pandemic. The ICP has established a series of committees in common with local partners, which form the alliance at the ICP board.
The case for change
Thirza Sawtell, executive director of integrated care at Epsom and St Helier University Hospitals NHS Trust, identifies the partnership's focus on delivery and commitment to achieving change for patients and service users as its unique selling point. She says: "We're really proud of the fact that we have the person and their care at the centre of what we do. When people see us working, it is not possible to tell who works for what organisation in our teams: indeed it is irrelevant. What people see is a large group of professionals whose passion is delivering outstanding care to their patients. This ethos applies across our Home First services, our frailty units, our integrated stroke services and our PCNs."
Dr Robin Gupta, the PCN clinical director in Dorking, highlights the value of multi-disciplinary team (MDT) working, and closer collaboration between primary and community care. The community medical team has grown significantly in recent years, with GPs working alongside district nurses, community matrons, physiotherapists, and occupational therapists to support patients with complex needs in the community. He reflects on how this directly benefits patients and tells us, "The MDT is a fully integrated service across the community health teams, the council, volunteers, and the mental health team, so it’s a huge wraparound service that Surrey Downs Health and Care have been able to implement. It’s better for patients, better for primary care, and better for community care".
Russell Hills, GP and clinical chair of Surrey Downs ICP, agrees with this assessment and tells us: "We're trying to think about what’s it like to be a resident of Surrey, and what we can do to make sure they can access the best health and social care."
This steady shift of focus has changed the configuration of health services locally. Daniel Elkeles reflects on how this shift towards community care has impacted on his trust, "There's been this huge shift of pressure away from our acute hospitals – I'm really proud we have the fewest number of acute beds we've ever had, even with COVID-19, because these guys are looking after so many people in community hospital beds, and community settings."
Great effort has also been put into improving communication between organisations for the benefit of patients in Surrey Downs. Emma Alderman, operations manager at Surrey Downs Health and Care, notes that the roll out of SystmOne and EMIS Web to community services has been pivotal in this respect. Additional funding has also meant the ICP has been able to invest in laptops for local care homes, improving communication and supporting MDT working with GPs.
All this collaboration and partnership working has ensured that the ICP has seen a 6% reduction in emergency admissions into Epsom Hospital for over 80s for three years in a row.
The impact of COVID-19
"Throughout the last year our COVID-19 response has demonstrated at pace what you can do around the integration agenda," says Dr Hills. Weekly co-ordination meetings were put in place for community and GP partners to allow the teams to respond rapidly to COVID-19, with care homes being brought into the fold as the pressures on the sector became increasingly apparent. Staff worked incredibly flexibly, with school nurses working on wards, podiatrists working in district nursing teams – working outside the traditional boundaries of their roles to ensure patients were provided with the best service.
Susan Sharkey, senior manager of adult social care for Surrey County Council, also reflects on COVID-19 and the significant challenges this brought about for the ICP, "As soon as COVID-19 came in, the world kind of flipped on its axis and we had to match our teams to what was happening."
Susan notes that the "collegiate approach" of the teams working in the partnership was key in shaping the ICP’s approach and shares her pride that "they rallied around, rose to the challenges and just got on with it."
Simon Littlefield, director of nursing and quality for Sutton Health and Care and Surrey Health and Care, also praises the way colleagues came together during the pandemic, sharing an example of how teams across community services and hospices worked to support end of life care and to share information on infection prevention and control. He praises the willingness and commitment of all partners to share knowledge and to "really deliver the best care" for patients during an incredibly challenging time.
Nicki Shaw, chief executive of Princess Alice Hospice, reflects on how the demand for end of life care increased significantly at the start of the pandemic. She recalls receiving a call from Daniel Elkeles when he was looking into creating a Nightingale-type hospital in the local area. Nikki says the ICP was able to mobilise provision for end of life care relatively quickly because "the relationships are there, the trust is there, but also because we know where each other's strengths are, and so we know we can contribute that added value, which has been really important". Nicki's hospice also provided education and psycho-social support to care home staff.
Dr Hilary Floyd, the medical director for a GP federation of 20 practices across the Epsom locality, discusses the establishment of the NHS Seacole Centre which provided rehabilitation for COVID-19 patients after discharge from hospital. In just 35 days, with teams across the integrated care partnership and the local resilience forum working together, the centre was transformed from a disused and derelict military hospital (which had been empty for years) to a working rehabilitation centre. This meant that those recovering from COVID-19 and in need of rehabilitation could be moved out of local hospitals to give them more capacity for the sickest patients. Dr Floyd welcomes the collaborative spirit within the ICP saying "it's really nice to be part of a team, a team that supports each other".
For Dr Floyd the ICP's realisation that processes didn’t need to be perfect, was important. There was value in "learning and working together, delivering programmes of work quite quickly and constantly changing."
As the pandemic progressed, new challenges arose for the ICP, but these were also overcome by the ICP's willingness to put aside organisational and professional roles and work collaboratively.
Dr Gupta shares how cross team working across the ICP meant that they were able to roll out the vaccination programme to vulnerable housebound patients, "The rollout of the COVID-19 vaccination programme has worked really well because we decided as GP practices that we could deliver the vaccines for housebound patients more efficiently in Dorking because of the huge geography and this would enable our district nurses to keep working in the community medical team rather than taking out that capacity".
Challenges
The challenges facing the ICP have changed as the partnership has evolved. Thirza Sawtell tells us about the effort that went into building relationships locally. She says: "We started quite small, but small wasn’t easy, it involved all of the partners, including Surrey County Council, community services, primary care services, mental health services and acute services working together. Where we are as an ICP hasn't just come about because we put a structure in place. We have those good relationships and that's taken real leadership and disagreements, as well as agreements, about how things work…there wasn’t always agreement, but partners always came from the place of trying to get it right for patients."
Dr Hills agrees with this assessment and tells us, "Whilst we haven’t always necessarily agreed on everything, that’s usually just because we’re trying to work out a new way of doing something and we’re all coming at it from a different perspective."
As partnership working has matured, Thirza tells us about the ongoing challenges around developing the right governance within the ICP "that is safe, appropriate and works effectively, but also delivers what the right thing to do is". Thirza notes Daniel’s ‘mantra’ of “we need to make the right thing to do the easiest thing to do” and adding "it's impossible to understand how often the system prevents that happening, so our governance from the beginning has always been about shared decision making".
Next steps
Looking to the future, Daniel Elkeles sees a "huge opportunity in planned care. There's a massive opportunity to join up our pathways so that there are a lot fewer outpatient referrals, by sharing the expertise from within the hospital and into with the PCNs. And there is a lot of scope to deliver joined up care at an MDT level within the PCN. This is particularly successful across chronic conditions, with the MDT focused on looking after a whole person". Each PCN already has a lead GP, lead manager and lead nurse or therapist working as a leadership trio.
The ICP also plans to implement its health inequalities reduction plan this year, as well as pressing ahead with proposals to roll out its population health management approach to all localities. For Daniel, the focus is on "how you turn the NHS into a proactive care system." He reflects on the need to tackle health inequalities in each locality, a concern which Dr Hills also shares. He says, "The health inequalities space is really important and we’ve decided to think about population health in the context of place."
National policy to support provider collaboration
Daniel outlines the ICP's hope that a "bigger share of the health budget" will be "delegated from the ICS to our place" through contractual mechanisms. He acknowledges that this will bring new challenges such as "how we allocate resources between ourselves and our partners who are part of the ICP." Potential issues around fairness and transparency would have to be addressed.
Dr Hills agrees with this and discusses the preparations that have been put in place to ensure the ICP would be ready to manage a delegated budget. The ICP is actively working through the governance issues, Dr Hills says, but he is confident that the collaborative approach which underpins the partnership would mean that any issues could be worked through.