Integration of health and social care

NHS Surrey Heath CCG is starting a wide-ranging and ambitious programme of integrating health and Adult Social Care after the plans were approved by the CCG's Governing Body and the Cabinet of Surrey County Council.The aim is to create a one place, one budget, one team model with the CCG as the lead organisation.

These integration plans follow 18-months of change in the CCG area including:

  • 8 to 8 working for General Practice
  • Three GP hubs created with integrated care teams encompassing Mental Health, Community Nursing and Social Care ( 7 staff now appointed and dedicated to the Integrated Care Team )
  • Co location of rapid response and reablement staff
  • The CCG was nominated as a finalist in the Health Service Journal Awards 2015
  • A single point of access to the above services - see video below:

The ultimate aim is the creation of a single budget and management structure for the commissioning of care for older people and adults with long term conditions and/or complex needs including mental health.

The aim is to start the programme of integration in late 2015, with the first phase ‘going-live’ in April 2016 but given the complexity it is possible that shadow arrangements may be put in place for 2016/17 with full delegation from April 2017.

The CCG's Governing Body approved this direction of travel at its meeting on 3 November 2015.

This approach should benefit people who use health and care services with improved quality and improved efficiencies.

Case study: Proactive care to for people living with frailty

Here in Surrey Heath we want to ensure people are supported to live healthy and independent lives, in their own homes, for as long as possible. To achieve this we are working with adults who are at risk of loss of independence and increased vulnerability – this can be described more generally as living with frailty. Our proactive approach to frailty management has helped maximise and maintain independence for people living with frailty, prevent unnecessary hospital admissions and support positive experiences of care.

One such person our work has helped is Marelyn, who lives at home with her husband Norman. Marelyn was referred to the Surrey Heath Integrated Care Team because her long term conditions require the support from different health and social care professionals. Through this referral, Marelyn was identified as someone who would benefit from further assessment to identify any potential issues and support her remain as healthy, independent and safe.

Professionals from different organisations worked together to develop an understanding of Marelyn’s priorities and agreed a plan to help support her which took into account what matters to her the most.  

As a result, Marelyn has received care and support from a range of professionals including the community matron, community rehabilitation team of physiotherapy and occupational therapy, speech and language therapist, carer support team and community dentist. The team provided equipment in Marelyn’s home to support her independence as much as possible and to help with safe care. Her family have also been supported to help them look after Marelyn.

Marelyn said: “You are all so good and marvellous for what you do for me – not just me but also for Norman. If it wasn’t for you we wouldn’t have all the support we have – you find out what we really need.”

Marelyn and her family are now seen every two weeks to check that they are coping and that any issues that are starting to cause concern are dealt with as soon as possible.

The benefit of integrated care meant that the Community Matron could easily visit Marelyn and her husband with other services that could support them. Carer support from the council’s Adult Social Care visited with the Community Matron to assess Marelyn and they now provide visits twice a day to help support her husband Norman.

Marelyn’s daughter said: “Having the community matron has helped support me and my father too - she has given us the support to carry on. Without her there Mum would have ended up in hospital a lot more times. The whole family, as well as Mum, are really happy and feel very lucky to have such a great team involved, we definitely noticed it has stopped Mum from going into hospital.”

Marelyn is now doing well and is happy in her own home. Marelyn and her family continue to be supported by the Integrated Care Team. She feels she has been well supported by the team and her husband and daughter feel they have someone to turn to when they need to find solutions to problems that unfold when caring for someone with a long term condition.