Comment

The scale of Surrey Heartland's ambition

Director of transformation Sarah Parker and executive director of public health Helen Atkinson discuss the challenges Surrey Heartlands has faced as a partnership, and their role in supporting the whole system in its successful journey towards devolved health and social care.

Our experiences of reviewing, developing, and commissioning services ensured we had some understanding of whole-system change and the key ingredients of building relationships, developing trust, and clarifying the end-state vision. However, I’m not sure we could ever have been truly prepared for the opportunity, complexities, and sheer scale of creating a devolved integrated health and care system.

We are both humbled and energised by being part of a team supporting this move towards devolution. Surrey Heartlands Health and Care Partnership is on a journey to change our culture. Much of that will focus on tackling the reasons for variation in care and outcomes that can be avoided, as well as working as a whole system to plan priorities and remove barriers that are inadvertently getting in the way. These include historical ways of managing money by area or organisation rather than as a whole system. We work with and across the 11 organisations in our partnership on this, with a focus on 14 specific transformation workstreams that will improve health and care outcomes.

Our jobs include both nudging and active leadership approaches to continually support and challenge the partnership membership. This is no easy task: we have overcome mountainous challenges as a partnership to achieve such success so far, and this is just the start. We realise and advocate the vast potential of this strategy with every step forward.

Initial hurdles

The 2012 Heath and Care Act started a shift in focus towards collaboration, but the significant accelerator to this journey was from the NHS Planning Guidance in 2015. It told NHS organisations and local authorities in England to work together and develop ‘place-based plans’ for the future of health and care services in their area. This led to 44 sustainability and transformation partnerships forming, some of which are today developing into integrated care systems – including ours in Surrey, which is also supported by a devolution deal. This was only possible in Surrey because of the active support from our local authority and the determination of all the health organisations to face the challenges and opportunities square-on. We had strong relationships, but the cultures of competition and protective organisational silo working meant this has been – and still is – a complex journey.

Despite the close relationships between organisations in the new partnership, there were still hurdles to overcome together. Diplomacy was the name of the game in the early stages. Healthcare and local government organisations did not have the same ways of thinking, the same culture, the same priorities, or the same relationship with their public.

Funding to create a new culture

Funding was a particular area of sensitivity, with questions surrounding where the money would come from and who was best placed to spend it. The experience of shifting money through the Better Care Fund had not gone well in Surrey, and had in fact fostered resentment and distrust. This time, we wanted to start thinking differently.

Challenges like this gave way to some very difficult conversations and some tough discussions. The first thing we all focused on – and it’s something that we still focus on today – was understanding each other better, truly signing up to a shared vision, and adopting a set of values and principles that change the culture of how we work. The second thing was how to spend the transformation funding we received through our devolution deal money, looking at opportunities across the system. Members of the partnership remain accountable to their individual organisations, but also work together as a system in the best interests of our citizens.

It has sometimes been difficult to get organisations to ‘buy in’ to the partnership, to give more than lip service. We had discussions and even lock-in sessions to help everyone understand the values they would need to demonstrate to benefit citizens. This all led to a Memorandum of Understanding. Now, we call each other out on our behaviours. We work as a partnership, which is vital to making a devolved care system a success.

This approach has been of great benefit to everybody involved. The NHS has been able to share the effect of policy on patients, while local government has broadened the agenda beyond purely clinical health pathways to a focus on the wider determinants that impact on health outcomes. All of this was a response to huge financial constraints. It could have been damaging, but it has strengthened us instead.

Devolution for evolution

So why did we choose to aim for a fully devolved system? Why was the old method not working for us? In short, it was a disconnect between different parts of the system at large. We were working in silos; there was no joint effort. Patients could often leave acute care and ‘slip’ through the net, or be stuck in hospital unnecessarily.

What we aim to do now is to bring the vision together. We need to finalise the agreement to leave some of our old organisational allegiances behind – again, it’s the need to function with a single culture. Decisions that used to be made solely by one organisation now need to be made collaboratively. For example, we think about how we could plan together and cross-subsidise where needed in the development and accessibility of electronic shared care records and digital innovation.

Together means together

We have set up a joint commissioning committee, a partnership board, and have a single system operating narrative. We are looking at aligned and pooled budgets and joint intelligence systems. We are developing integrated care partnerships to deliver care at place and are considering how we integrate for things we want to do at scale. Our aim is truly to function as a fully integrated system.

Encouraging awareness of each other is one of the most beneficial things the organisations are focusing on right now. A recent Royal College of Physicians report has said that one in 10 journeys in England are healthcare-related. Of course, these journeys have an impact on traffic congestion and poor air quality, which exacerbates poor health in people with asthma and other respiratory conditions. We are starting to recognise the links between policy and citizen health.

Thanks to the information shared about this issue, innovative solutions like Skype appointments are being explored. This is where technology comes in to play as a major area of focus for us. Without ambitious steps in introducing technology, progress like this would not be possible.

So, where do we go from here? We’re excited to see where a devolved health and care system will take Surrey Heartlands. Having seen the positive changes we’ve introduced so far, we are keen to take this collaborative effort further, continuing our hard work to improve citizens’ lives.

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