1/14 Brilliant visit to @SurreyDownsHC, part of @SurreyHeartland ICS today. Very impressed with the excellent progress they have made in actually integrating services on the ground, delivering better care and improving outcomes. Thread below with what particularly impressed me.
2/14 Impressed with the way that the @SurreyDownsHC’s vision for integration starts with concrete action to improve services. Of course governance, finances and structures are important. But they start with a data driven understanding of the needs of their population…
3/14 …And they then put the relevant professionals together to work out how they can improve the relevant service or pathway. Strong emphasis on enabling right collaborative relationships between different people from different disciplines and organisation to drive improvement.
4/14 Key elements of pathway improvement include having the right people in room; strong emphasis on co-design including patient and carer input; data driven approach to “is it improving outcomes” and then using PDSA methodology to assess if adequate progress is being made.
5/14 Impressed with the way that @SurreyDownsHC has primary care & GPs at the heart of their leadership approach. Lots of people talk this talk but this really feels like genuine equality. Strong view that investing in primary care leadership training has been a key driver here.
6/14 Very impressive innovative approach to community service delivery @SurreyDownsHC. Joint venture with primary care, trusts and social care as joint and equal partners. Then delegate budget and responsibility to Primary Care Network Hubs who are empowered and accountable…
7/14 ….With hubs led by a quadrumvirate of a Clinical Director, GP lead, community nurse lead and operations manager. Great way to join up community services & primary care and empower hub to shape service to meet local need. But also clear where accountability lies - with hub.
8/14 Impressed with how “put right people in room to co-design an improved pathway” @SurreyDownsHC has led to new integrated post covid recovery service created at real pace. Brings together GPs, community services, consultants (eg respiratory & chronic fatigue), mental health…
9/14 …into a highly effective single service. Strong emphasis on the different elements of care required being joined up and treated holistically and the patient having their care co-ordinated for them. Very positive early outcomes but big demand - 100 to 120 referrals a week.
10/14 Great to see genuine and full partnership in @SurreyDownsHC between the NHS and @SurreyCouncil in their whole system frailty model. Not just enabling effective rapid hospital discharge and post discharge care provision from a single, joined up, co-located, hub but….
11/14 …a proactive service in which any patient with a raised frailty score can be referred in for a multi disciplinary team review of need, driven by the question “what matters most to this patient and what do they need?” Data driven whole population health in action.
12/14 Striking how busy it currently is across the ICS. A&E attendances up by 20% vs normal. GP demand up by 20% vs normal with number of face to face appointments same as pre-covid. Ambulance service under very significant pressure. Vaccination campaigns at full pelt…
13/14 …Worries about current high rate of staff leaving with strong competition from hospitality and retail. Concerning anecdote about strong social care provider ready and keen to expand pre-covid now having to hand back domiciliary care contracts due to lack of staff.
14/x Thanks to the wonderful @clairefuller17, new ICS Chair Designate Ian Smith and the whole @SurreyDownsHC team for a great visit. It’s good to talk, see and be really inspired!
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