Surrey Heartlands ICS lays out new care strategy and ambitions

Surrey Heartlands Health and Care Partnership has released its newest strategy, which aims to improve patient care outcomes through a more joined up, integrated approach.

The strategy is built on population insights and data gathered from multiple sources of communication with Surrey residents, such as the Joint Strategic Needs Assessment, Surrey’s Health and Wellbeing Strategy and traditional face-to-face interactions with the local communities.

The strategy highlights three main ambitions for the ICS: prevention, delivering care differently and what needs to be in place to deliver these ambitions.

Ambition One: prevention

Surrey’s Health and Wellbeing Strategy focuses on the most disadvantaged areas of the population – particularly those suffering from the poorest health outcomes.

One of the key ways the strategy will deliver preventative action is through “supporting people to lead healthy lives by preventing physical ill health and promoting physical well being.” This involves:

  • Ensuring people are eating healthily and keeping active
  • Addressing lifestyle factors such as addiction, homelessness and domestic abuse which negatively impact health and wellbeing
  • Providing easy access to diagnostics and immunisations to prevent diseases
  • Maximising support to allow people to live independently for as long as possible

Supporting people’s mental health and emotional wellbeing is another priority, along with preventing poor mental health in the long term which will help to facilitate better health outcomes. This priority is also focused on creating communities and social environments “that tackle isolation and build good mental health and emotional wellbeing.”

The final prevention priority involves providing residents with the support they need to reach their full potential and addressing the wider determinants of health. The desired outcomes include:

  • Ensuring people’s basic needs are met i.e. food security, poverty and housing
  • Foster a sustainable economy in which people have access to wider training and employment opportunities
  • Creating healthy environments through transport and land use planning
  • Ensuring that community safety is well established through domestic abuse and safeguarding services

Ambition Two: delivering care differently

The ICS is committed to creating a model of care which is responsive to the needs of the communities it serves, whilst empowering people to make informed decisions about their own healthcare.

Surrey will develop integrated Neighbourhood Teams comprised of GPs, district nurses, social care providers and voluntary sector representatives to respond reactively to residents needs and give them the tools they need to take a proactive approach to their own healthcare.

Same day urgent care – alongside the neighbourhood teams, same day urgent care services will serve as a first point of contact for people with routine health concerns. Community diagnostic hubs, urgent community response and integrated frailty models of care will be accessible for residents, ensuring they have the right care at the right time.

Provider collaboratives – The Surrey Heartlands provider collaborative combines three acute hospital trusts and mental health providers working together to improve health outcomes for the population. They will use the collective learning from children and family services collaborative to ensure wait times are reduced and address health inequalities on a broad scale.

Social care – the strategy defines social care as “unlike healthcare” as it is “means tested and this creates an additional layer of complexity.” The strategy has a vision to bring together the component parts of care provision through a skilled, integrated workforce. The Surrey Carers Partnership Board launched in May 2022 which developed a framework for co-production and collaboration for the voice of all carers. The Surrey Care Assocation’s role within the ICP will also enable care providers to offer more immediate support to the discharge process and ensure people are able to access social care support to maintain their wellbeing.

Mental health – the strategy recognises that “mental health exists on a spectrum, and a person’s place on that spectrum at any given moment is affected by a variety of physical, social, economic and cultural factors.” The ICS will work with partners on a Mental Health Improvement Plan focusing on a number of projects designed to improve mental health outcomes, prevention and early intervention. They will facilitate specific support for people with autism and learning difficulties, offering support for both children and their families.

Children and families – through improved coordination, the ICS will identify gaps in services to ensure no one is left behind. The strategy aims to provide families with clear and high quality information on the services and support accessible to them, such as Children and Family Health Surrey and Mindworks. Neonatal and maternity services are to be improved through multi-professional delivery models at a neighbourhood level, as well as a re-designed mental health support approach to support all children across the region.

The success of the aforementioned ambitions is attributed to three key metrics: access, continuity and reducing inequality.

Ambition three: what needs to be in place to deliver these ambitions

Working with communities is a major goal within the strategy to achieve its broader ambitions; the need to “nurture new and different relationship between residents and the NHS, local government, voluntary community etc” taking precedence in this aspect of the plan.

Surrey has adopted ‘the four Cs’ principles in order to deliver these ambitions:

  • Community capacity building: building trust and relationships
  • Co-designing: decided together
  • Co-producing: delivering together
  • Community-led action: communities leading, with support when they need it

The aim is to move away from programmatic service-based interventions to community capacity. The ICS has already set up warm hubs and food banks to support people to stay healthy and well. Horley and Growing Health Together is one example of the collaborative work at primary care network level involving a range of healthcare providers and organisations in the community to create connections and improve health and wellbeing amongst the people they serve.

Surrey Heartlands has also set up an online citizens panels to conduct regular surveys and research amongst communities – allowing a demographically representative panel to offer their opinions and experiences to better inform healthcare services in the future.

From this point, the document moves on to address wider areas of importance in the strategy.


Surrey’s United Workforce strategy “describes an approach across all partners to develop the right culture, behaviour, values, skills, training and leadership across our workforce.”

The six key workforce programmes will involve building expertise, with the ICS aiming to become a leading expert in workforce management and development; building new capabilities, with a Health and Care Academy to be established; developing fulfilling careers, integrating to develop better opportunities; and establishing a Surrey offer, to create innovative incentives and retention programmes. In edition, the strategy highlights the plan to enable the United Surrey team, creating a single governance vehicle and enabling connection across partners and systems; and the need to modernise and integrate recruitment, increasing effectiveness through talent sharing, market analysis and diverse recruitment channels.

Leadership and development

Through the involvement of diverse multi-professional health and care leaders, the Health and Care Professional Leadership (HCPLF) framework will aim to adopt an integrated systems leadership support offer, designed to develop system working, behaviour and skills. This is currently being trialled by the East Surrey Leadership Programme.

Leadership academy programmes and educational opportunities will be made available along with the development of neighbourhood teams. The aligning of profession specific leadership opportunities will allow the system to leverage skills of the wider partnership and provide a renewed approach to these professions.

The United Surrey Talent strategy will monitor the metrics of these programmes to ensure that the objectives are being met.


The strategy notes that “estates can be a catalyst for integration” and as such, the ICS will look to establish the conditions for communities to improve their wellbeing “on their own terms, in non-clinical ways.”

The strategy lays out a long-term vision up to 2030 which includes:

  • Developing a clear understanding of health and wider public estate opportunities
  • Working closely with communities and social care services to identify and support the delivery of priority schemes to reduce health inequalities
  • Identifying new models for health delivery pathways e.g. ‘health on the high street’
  • Establishing a flexible integrated health and care estate that provides the appropriate services and empowers communities to support each other


The strategy makes it clear that “digital and data offers a huge opportunity for delivering care in innovative ways that help citizens live healthier lives at home.”

Surrey’s workforce strategy is committed to developing a digitally skilled workforce to successfully deliver initiatives such as the children’s eRedbook, virtual wards, the collaborative bank, population health management, digital social care record and falls prevention technology.

Meanwhile, the ICS’s data strategy will develop a system-wide integrated data and digital platform focussed on a population health based approach to health care.

A system intelligence function (also known as the data operating model) will be created to enable analytical communities to be better connected; ensuring they can provide integrated insight required for the system.

A population health hub will be established to enable sustainable and successful interventions and innovations across the wider system.


The strategy states that “section 75 of the NHS Act 2006 allows partners, i.e. the NHS bodies and local councils, to contribute to a common fund which can be used to commission health or social care related services.”

As such, Surrey ICS is able to integrate services across the partnership and jointly commission services. The Better Care Fund programme allows the ICS to pool funds and distribute them strategically.

Innovation and research

Surrey has a long-term ambition to become a dynamic health and care ecosystem; through their innovation strategy, they will look to address unmet system needs and inequalities.

The strategy’s four key objectives for 2022-2025 are:

  • Manage, create and deliver an effective innovation pipelines tailored to the needs of the local population.
  • Invent ways of working that will deliver maximum benefits to the health and care system.
  • Develop a strategy to attract industry investment that support the development of solutions.
  • Create a strategy that supports research to be scaled across the system and embedded into care.

The strategy concludes with an encouraging message for the future:

“When individuals need additional support, we aim to deliver care that is responsive to their needs and puts them at the centre of decision making. We will do this by working with out communities, with a digitally enabled, highly skilled workforce that has the tools and resources to undertake their role to the best of their ability.”

For more information about Surrey’s ICS strategy, please click here.