Surrey Downs Health and Care

This case study shares key learnings on: 

• Creating formal structures and governance.
• Aligning between neighbourhood teams.
• Engagement with patients and communities.

Background 

Surrey Downs Health and Care (SDHC) is a formal partnership between Epsom and St Helier University Hospitals NHS Trust (ESTH), Surrey County Council and the three GP federations operating in the patch. These partners come together to provide adult community health services in Surrey Downs, serving approximately 300,000 people in the geography.  

SDHC provides bedded care in two community hospitals and an integrated frailty unit; community nursing and therapies through local primary care networks (PCNs); specialist community services, for instance diabetes and neurorehabilitation; and urgent and episodic care through urgent community response services and virtual wards.  

An evolving approach to delivering integrated care  

In 2016, key partners started to work together as SDHC to deliver integrated services and improve health outcomes. This included delivering a hospital at home service through a multi-disciplinary team spanning primary, secondary and social care, and creating a partnership board. This yielded results, with the hospital at home service achieving a 6% reduction in emergency admissions in the first year, against a national increase 6%.  

Initially, this work was driven by shared challenges including an ageing population, workforce shortages, fragmented care delivery and an over-reliance on hospital-based care. 

Over recent years, the model has evolved considerably, with more formalised structures developing, and a significant focus on integrated working at neighbourhood level. In 2019, integrated neighbourhood teams (INTs) of staff from health, social care and the voluntary sector were developed around the six PCN footprints in the patch. 

INTs are described as the ‘engine’ of the Surrey Downs model of integrated care (see figure below). These teams focus on building partnerships at neighbourhood level to co-design services, delivering tailored proactive care, integrating pathways for planned care for long-term conditions, and providing rapid same day emergency care.  

There are two main parts of the Surrey Downs approach to neighbourhood working. The first is the delivery of joined-up health and care services through INTs. The purpose of the teams is to meet local needs effectively by coordinating services across health, social care and mental health to ensure local people receive holistic, joined-up care close to home.  This is complemented by neighbourhood boards operating in each of the seven neighbourhood footprints, which bring together local people, voluntary organisations and leaders from across the local health and care system. The boards were established to give people and communities an opportunity to shape the development of neighbourhood models of care.  

The enablers 

Since 2018, the SDHC partnership has been brought together through a contractual joint venture, with ESTH acting as the host. A legal agreement binds partners together and makes them jointly accountable to ESTH for the delivery of outcomes and services.  

This approach has paved the way for a formal structure to deliver integrated neighbourhood care. SDHC has an integrated neighbourhood vehicle, or partnership, in place, which is underpinned by the contractual joint venture. This arrangement enables partners to come together through formal governance structures, including the partnership board, to collectively design, deliver and oversee services across organisational boundaries.  

Likewise, there is a single leadership team - comprised of a clinical director, operations manager, GP lead and clinical lead - overseeing the neighbourhood workforce and holding collective accountability to the ICB for service delivery and outcomes. This formal structure is viewed as key to supporting effective decision-making.   

The team has also created a framework to support alignment between neighbourhood teams. The framework covers core elements of the approach, including the leadership structure for each team, and interface with same day emergency care. Alongside setting direction, the framework also leaves sufficient flexibility for local determination.  

This work was initially funded through an outcomes-based contract to reduce non-elective admissions and length of stay for over-65s. The model expanded from a focus on home first, and in 2018, the adult community health services contract was awarded to the SDHC partnership, enabling shared ownership and a more flexible use of funding. The contract, which is held by ESTH as host provider, has grown from £3m to over £40m, now covering services like acute frailty and virtual wards.  

Delivering benefits for local people  

An integrated neighbourhood approach has begun to have a positive  impact on patients’ outcomes and experiences. For instance, therapy services have been redesigned, and therapists embedded within INTs. This has led to improved coordination, reduced duplication and a reduction in average waiting times for therapy services from 18 to 3 weeks.  

Data collection and evaluation has been embedded from the outset. A counterfactual model has been created to evidence impact and track progress over time. The data shows that, since 2019, overnight hospital admissions have reduced year-on-year, with a sustained reduction of over 30% compared to pre-pandemic levels. This reduction in unplanned care reflects a shift towards community-based care delivered through neighbourhood working. 

For older residents supported through proactive interventions by the INTs, a six-month before-and-after intervention comparison showed 35% fewer A&E attendances, 31% fewer non-elective hospital admissions and 11% fewer GP contacts for those supported by the INT. These outcomes demonstrate the value of early intervention and joined-up local care in reducing avoidable escalation.  

Next steps for the partnership  

Going forward, the team is looking to drive forward further work to address inequalities in access to neighbourhood care and reach into communities to ensure hard-to-reach groups also benefit from this approach.  

There is also scope for the 10-Year Health Plan to codify elements of neighbourhood working to support local leaders to scale up this type of work. However, changing organisational culture remains an important part of the puzzle, and this must be driven forward at a local level.