The Frimley Health integrated care system (ICS) covers a relatively affluent area across parts of Surrey, Hampshire and Berkshire. Life expectancy is generally higher than the national average, with the exception of several pockets of deprivation. A growing population and ageing demographic mean that demand for health and care services is rising.
The ICS is based around the footprint of one acute trust – Frimley Health NHS Foundation Trust. Two large community and mental health providers – Surrey and Borders Partnership NHS Foundation Trust and Berkshire Healthcare NHS Foundation Trust – deliver services across the Frimley Health footprint and surrounding areas. The ICS covers three CCGs (following a recent merger of three CCGs in East Berkshire) and two share a single accountable officer. There are no major financial or performance issues in the system.
While the ICS is relatively straightforward in terms of the geography of local acute NHS services, it is far more complex in relation to community and mental health services and local authority boundaries; it spans five local authority areas and covers only a small proportion of some of these.
The ICS builds on a strong history of local collaboration. Examples include the development of new care models and integrated working in the North East Hampshire and Surrey Heath CCG areas, and improved performance at Heatherwood and Wexham Park Hospitals NHS Foundation Trust after it was acquired by Frimley Health NHS Foundation Trust in 2014.
ICS structure and governance
Frimley ICS is relatively advanced in its system working. It has been operating a ‘shadow’ financial control total in 2017/18 and has agreed a system-wide operational plan for 2018/19.
In the early stages of development, work to build collaborative relationships between organisations was prioritised over work on governance and structure. Governance arrangements to underpin the partnership working are now being established and these are expected to transition through several stages before reaching their final form.
Working arrangements include a system-wide decision-making board where representatives from NHS and local authority partners have delegated authority to make some decisions on behalf of their organisations. There is also a programme delivery board and several system-wide working groups to provide assurance and deliver on agreed national priorities and local transformation initiatives. A single health and wellbeing alliance board and five local health and wellbeing boards provide a link to local communities and support communication and engagement, and a broader system-wide engagement group has been developed to advise on the overall objectives. Financial transparency and collective resource management is supported through a finance group comprising the chief financial officers and financial directors from NHS and local authority organisations. Other groups – for example, a mental health reference group and a group comprising chairs, non-executive directors and lay members – have been developed to provide expert input to the ICS, and over time these may be brought more formally into the governance structure.
These developments have been underpinned by a set of system-wide commitments agreed by all partners – for example, that there will be financial transparency, that risks and benefits will be shared, that the ICS will be representative of all stakeholders and geographies, and that it will be driven by data, evidence and strong clinical leadership.
ICS priorities
The ICS focuses on eight key areas:
supporting people to take responsibility for their own health and care
developing integrated community hubs
developing general practice at scale
developing an appropriate support workforce for the system
strengthening the social care and support market
reducing unwarranted clinical variation
implementing a shared care record accessible to professionals across the system
delivering improvements in mental health.
These initiatives are at different stages of development, and many build on work that predates the ICS. North East Hampshire and Farnham CCG developed new models of care as part of the national vanguards programme (see box), and Surrey Heath CCG has also established integrated community working. Early evidence of impact is promising, and the ICS plans to spread these models more systematically across the entire footprint.
Examples of progress: expanding services in the community
As one of the primary and acute care system (PACS) vanguards, North East Hampshire and Farnham introduced a range of measures to join up services and enhance community support, including the following.
Five integrated care teams to support individuals with complex care needs in their own homes. These teams include community nurses, occupational therapists, physiotherapists, social workers, paramedics, pharmacists, mental health practitioners, geriatricians, GPs and voluntary sector workers.
Schemes to prevent ill health and support self-care, including: support for carers; training for pharmacists and other professionals to give self-care and wellbeing advice; and a social prescribing scheme to link people to local services and support.
Improved access to primary care through extended opening hours and an online tool that allows patients to consult with a GP without having to visit the surgery.
A wider variety of health care professionals in primary care, with direct access to physiotherapists and clinical pharmacists, and a paramedic home visiting service.
A range of initiatives to improve the connections between hospital and out-of-hospital services – for example, GPs working in A&E and on hospital wards to facilitate discharge.
Better mental health crisis support through the introduction of Safe Havens, as well as expansion of the Recovery College to improve the health and wellbeing of people living with, or recovering from, chronic mental or physical health conditions.
The local system has reported positive evidence on the impact of these models, including:
year-on-year reductions of 2 per cent for emergency hospital admissions and 10 per cent for avoidable admissions, as well as a 4 per cent reduction in GP referrals
a plateau in A&E attendances compared to increases for demographically similar CCGs
reductions in mental-health-related hospital attendances and admissions since the introduction of the Safe Havens.
Stakeholder engagement
A number of engagement events have been held to communicate the changes taking place, including targeted events for carers and workshops on mental health and prevention. Engagement has been much stronger at a local level than at the ICS level – for example, elements of the new care models in Surrey Heath and North East Hampshire and Farnham were co-designed with patients and service users.
Most interviewees did not feel that sufficient engagement had taken place, and this was identified as a priority for further work. The introduction of a single health and wellbeing alliance board across the system is intended to act as a link to local communities and to advise and support the ICS in its communication and engagement work.
Key enablers
Features of the local system that have supported progress include:
a history of collaborative working and strong relationships between many of the local organisations
advanced examples of service redesign and integrated working in parts of the ICS
longstanding leaders with a high degree of influence and credibility
no significant financial or operational pressures among the local organisations, creating a relatively stable and low-risk context for collaboration
capital and transformation funding to support the development of new models of care.
Next steps
The Frimley ICS is expected to take further steps towards operating as a single system rather than as a collection of organisations. These include further developing the emerging governance arrangements, formal operation of a single system control total, and a more aligned approach to regulation and performance management across the system. Some interviewees described ambitions to further streamline local commissioning arrangements, and others identified a potential to consolidate support functions such as communications and human resources.
As the focus of the ICS moves from planning to implementation, a key priority is to deliver on planned service changes. There is promising evidence on the impact of changes in parts of the patch, and the challenge now is to spread and scale these across the system.
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