There is an increasing national drive for health and social care to work in partnership – across organisational boundaries and in multi-disciplinary teams – and we know this more joined up ‘integrated’ approach brings real benefits for patients. 

We are on a journey to create a much more integrated system across Surrey Heartlands, working as a multi-organisational partnership both in terms of planning and commissioning services across our population, and in developing more integrated services on the ground.

We already have some great local examples such as the Bedser frailty hub in Woking which provides a ‘one-stop shop’ service for older, more frail patients, with health, social care and others working together to make sure patients get the care they need without being passed from organisation to organisation.

At the Epsom Health and Care @Home Service, which runs from Epsom Hospital, a multi-disciplinary team (including doctors, nurses, social care workers, therapists, community matrons) work together to keep patients out of hospital or to get them home as quickly as possible, sharing information and making decisions as one team without any of the complexities of having to make referrals between organisations.

Following a recent visit, Michael Macdonnell, director of system transformation at NHS England commented: “These single teams that combine multiple organisations and professionals are where integrated care happens”.


Part of the issue to date is that health and care services have developed in rather a piecemeal way, focused on treating specific illnesses or conditions rather than what are often complex underlying issues such as financial trouble, social isolation, loneliness and health behaviours.  We know that people who use the system don’t wear a single badge. They don’t just have diabetes, anxiety, or trouble dressing, or a difficult housing situation. They are complex individuals, surrounded by varying cultures and influences. Yet the current system can be confusing to access and navigate, and isn’t necessarily focused on people’s complete needs. 

“When people work together there is either a boundary or a wall, and we need to work at getting rid of those boundaries.” Adult Social Care Manager.

“It’s the system that isn’t right, not the people.” Resident with long term condition.

As we move towards this more ‘integrated’ way of working – and we are one of just 14 Integrated Care Systems in the country – we have been thinking about which services we should be planning across larger areas (the Surrey Heartlands geography, across the county or beyond), and those that are better delivered at a more local level, through our Integrated Care Partnerships (ICPs). 

The ICPs are local groups of health and care organisations *, importantly including borough councils and voluntary/community sector members, working across our existing Clinical Commissioning Group boundaries (Guildford & Waverley, North West Surrey and Surrey Downs).

Each ICP is continuing to develop their own priorities and models of care, reflecting the different needs of each local population, and thinking about how they will work differently in the future.  Common themes are emerging, with more emphasis on wellbeing and prevention and on breaking down the barriers between organisations.

Across each of these local partnerships we are starting to think about new and different ways of designing services so we can look after people’s whole needs as we have started to do in the examples above.

From April next year we want to start working in a new way and whilst it’s unlikely that patients and the public will see any big or immediate changes, we know that in the long run there will be significant benefits for local people.

*Integrated Care Partnerships include;  acute hospitals, mental health, social care, community services, commissioners (CCGs), GPs and GP federations, district and borough councils, community and voluntary sector partners.