Claire Fuller: How integrated care systems can work within the existing legal framework

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  • Posted:Wednesday 21 March 2018

Speaking at our breakfast event on Integrated care on 21 March 2018, Dr Claire Fuller, Senior Responsible Officer at Surrey Heartland, presents Surrey's version of integration in health care.


  • CF: Claire Fuller
  • CH: Chris Ham

CF:    I’m here to talk about the Surrey Heartlands.  So, we are not an ACO and we have no aspiration to become an ACO, and I’m going to talk a little bit about how we have managed to deliver integration and change within the confines of the current legislation.

    Within the Surrey Heartlands we’re a wave one ACS, we’ve got a population of 850,000, budget of £1.3billion spread across ten organisations.  And for any of you that know Surrey of old, you will have seen any different configurations of possible boundaries to try and make Surrey work.  Surrey doesn’t work.  We have leaky borders, we have patients that flow into South West London, into North West London, into Sussex, into Hampshire and into Frimley.  Wherever you draw the line around us, there will always be patients whose natural flows leave and go beyond it.  And in fact, we’ve even got one of our acute trusts, actually the one site sits within the Surrey Heartlands, one site sits within South West London.

    The CCG is regulated by NHS South and the acute trust is regulated by NHS London.  The trust deficit sits in NHS London’s control total, whereas the CCG deficit sits within the Surrey Heartlands total.  So, when you come to have conversations about how do you do planning, I have got regulators that have never really had conversations before that I’m then trying to engage and encourage to have a conversation, but how we work together as a system.  So, this stuff is not easy.

    Distinctive features about the Surrey Heartlands, we find a devolution agreement with NHSE, NHSI, Surrey County Council and the three CCGs back in June and behind our devolution agreement has very much been a vision about joining up the fragmented health spend. So, very much bringing together the NHS England Direct Commissioning spend, looking at how we can work differently with dental, with the ophthalmologists, with specialised commissioning, but also we’ve signed MOUs with Health Education England and with the HSN and we’re looking to explore how we can work differently with Public Health England, so that we can join up what is a fragmented budged so that we can work together with the broader public sector and make sure that we bring influence across the whole field to improve our populations’ health outcomes, rather than just focussing on that 20% that health can do on its own.

    So, no matter how good we make healthcare and how accessible we make healthcare, we will only ever improve the populations’ health outcome by 20%.

    Most people will think of Surrey as being full of very crowded trains that are travelling between half past six and half past eight into London, but actually we have a very high number of elderly people and a very high carer population, as well as a big learning disability population and a big Gypsy Roman Traveller population.  And as such, one of our principles and one of our underlying commitments is to make generational change rather than continue with the crisis management.

And we’re doing this through a commitment to the first thousand days which will include improving the readiness of our children as they enter school, so making sure our children enter school with a narrow as possible gap in health inequalities, because we know that if you hit school with health inequality, that gap will only get bigger.
And also, by focusing on the mental health of our young people in Surrey, because the mental health of a young person, as a girl aged 14, is the best predictor of health inequality of a child aged 4, which is still my favourite fact of the year because it’s just astounding.

How are we doing this?

Our plan is that our ICPs which are integrated care partnerships, not organisations, will take on responsibility for capitated budgets for identified population segments by 2019.  We’re going to do this by having an integrated strategic commissioner at the Surrey Heartlands level and then have the place-based delivery models around each one of our acute trust flows.

Over the last year I find myself increasingly talking about governance and strategy, which I have to say when I started becoming involved in the managerial role of the very early days of a CCG, so having come from being a jobbing salary GP into the early days of CCGs I can remember us all going strategy, governance, what are they?  I now realise what they are and how important they are.  So, you’ll be very relieved to hear that.

I was really interested in the point about democratic accountability because actually that’s been one of our real drivers in how we have organised our system.  So, we have four structures, all of which are voluntary and not legislated, but take advantage of what is the Health and Social Care Act.  So, we have a transformation board which is made up of all our ten organisational CEOs plus medical directors or clinical leads, chaired by David McNulty who is an independent chair but was previously the Chief Exec at Surrey County Council, and it has been David’s leadership right from the early days of even back when we were a STP rather than an ICS, that I think has led to our devolution agreement and also very much to our different ways of working.

So, we’ve the transformation board.  We have a joint commissioning committee which is made of our CCG governing body members, so including lay members and clinical leads, but still sticking to the principle of a clinical majority for decision making.  But sitting alongside them are elected cabinet members from Surrey County Council.  We also, on the joint commissioning committee, have NHSE and NHSI representation and Matthew Tate, who is our joint accountable officer, actually holds a joint contract with NHSE, so he has what they’re calling synthetic devolution where by virtue of his contract with NHS England he is then able to act some of NHS England at place for us.

So, we then move on and we have our place-based ICPs which really is everybody at place sitting around a table.  So, commissioners with providers, with social care, with voluntary, with mental health and with primary care at scale.

And then our fourth voluntary place is our academy, which is a virtual clinical advisory group really, who have the remit to set the outcomes to make sure our care is standardised across the integrated care system to bring innovation and to spread best practice.

So, when we talk about an ICS, we talk about a combination of a strategic commissioner plus the broader transformation board partnership, so it is the two together.  And the role of the transformation board is driving the strategic change, shaping culture and creating an environment in which change happens.
And you can only do that if you’ve got a commitment from senior leadership, so we meet monthly as a transformation board.  We’ve just had a two-day, again, developmental residential and the Chief Execs meeting fortnightly in between to make sure we drive change forward.

Joint committee is our governance vehicle for the integrated strategic commissioner and they agree the outcomes that have been advised by the academy, they set the budget for the ICPs and they have a performance management and an assurance role and will also hold digital commissioning at scale.  So, the things that you only want to do once across a big footprint; your estates, your digital, your comms, all the things that make sense.

When you start looking at what happens at our ICP level that’s about delivery and one of our earliest and most advanced ICPs is really in the Epsom area.  So, Epsom Health and Care which has been around for a couple of years and has been a joint contract, so the money flows from CCG to lead provider, so down through the acute trust which is Epsom, St Helier, in that instance, and then Epsom, St Helier have an alliance contract across all partners; the GP federation, adult social care, mental health and the community provider, and each one of those partners has an equal vote in all decision making, and there is a right of veto.  So, unless all partners agree, nothing happens.  So, the GPs feel safe in that environment because actually you can go don’t like it and the change doesn’t happen.

Staff that work in Epsom Health and Care remain employed by the host organisation, but we had the lanyard moment where everybody actually chose a colour and chose a name and actually started wearing a single lanyard. So, if I’ve got a patient that is under the care of Epsom Health and Care somebody will come out wearing an orange lanyard and I won’t know and Mrs Holden, who was seen yesterday, won’t know whether they’ve come from the acute trust, primary care or community.

By working together, they’ve driven down length of stay, so in the acute trust they’ve knocked a day off the length of stay.  They’ve reduced non-elective admissions by 5% and they’ve reduced A&E attendances in that age group, which is the over 65s as well.  So, you can see of course it’s the integrated working that is making the change happen, but you don’t necessarily need a single organisation to deliver it.  There are other ways of doing it.

We have an integrated care system which is built on voluntary partnership with aligned priorities.  Systems, and particularly our system in Surrey, is very much a dynamic moving beast.  To create that into a single organisation I think would be nigh on impossible because, as we’ve found in the past, if you try and draw line around it, it may work in other bits of the country but for us it just doesn’t work because of the patient flows.

So, really what we’re working on is a pragmatic delivery within the confines of what is a current legislative position and have decided to just crack on and do what we can rather than stop and sit and wait what happens with the law.

CH:    Where does the private sector fit into Surrey Heartlands partnerships and plans?

CF:    Until March 31st we’ve had Virgin as one of our community providers, and actually we’ve gone through a series of re-procurements of the three CCGs community contracts, so Virgin previously ran a community contract for the majority of Surrey and first the North West Surrey CCG went through and the contract was won by CHS Surrey, which are a social enterprise and they’ve evolved now across the top end of our patch.

    The Guildford and Waverley contract is the one that ends on March 31st and that’s now been win by an integrated bid from the acute trust plus the GP federation, and in the Epsom area there CHS Surrey contract came up and actually instead of bidding on their own, they have bid collectively with the three GP federations from Surrey Heartlands plus the acute trust and themselves again as an alliance to bid for the community contracts.

    So, we’ve always had a large number of AQPs in Surrey, traditionally set up by GPs.  They continue to operate, they continue to offer elective services.  But in terms of our community services, we have fewer than we did.

CH:    So, you’re bringing some of those services back inhouse having gone through a period when they’ve been contracted to Virgin.