Our achievements

Welcome

Our Guildford and Waverley population will start well, stay well and live well.

Welcome to our Guildford and Waverley Delivery Plan Insight Report – a guide to the local system achievements for 2023 to 2024 and a look forward to 2024/25. 

Place is a partnership and an ethos. It enables health and care partners to work closer together and differently with and within our communities. Place brings together health, local government, and wider partners to utilise their collective resources and expertise for the ultimate benefit of local people. 

We are proud of what we have achieved to date – providing efficient, effective services and improving outcomes for our local communities through collaboration and integration.  

Looking ahead we are working within challenging economic environments which require us to consider how we drive forward our shared ambition. Through a joint delivery plan, we can work together to achieve the required impact our local people. 

Our ultimate ambition is to improve health and care outcomes for all – transforming services to meet need.

We can achieve this by working together. 

Jo Cogswell

Executive Lead for Guildford and Waverley
Executive Director of Strategy and Joint Transformation

Our local population

Our population, and its needs, is changing.

The population of Surrey that we serve is rapidly changing.  We need to re-think our model of care, otherwise the demand for our services will quickly become more than we can cope with.

Growing

The population of Guildford and Waverley is growing.  By 2034 we expect to see a 1% increase in our population overall.

Ageing

By 2034, we expect to see a 20% increase in people aged over 65 years and an increase of 15% in the population aged 15-29. The proportion of elderly patients with over four diseases will more than double.

Life expectancy

Life expectancy across Guildford and Waverley is up to 8 years lower in the most deprived areas and people are living up to 19 years of their lives in ill health.

Diversity and priority populations

Our populations are changing with increases in ethnic minorities (3% increase). There has been an increase in migrant settlers and those seeking support.

We have a higher proportion of care home residents and unpaid carers in Guildford. There is also a higher proportion (3.5%) of 16+ year olds identifying as LGB+ than England (3.2%), the second highest across Surrey.

26% of our population have a long-term condition such as Diabetes, Asthma and High Blood Pressure.

4% of our population utilise 20% of general practice appointments.

12% of patients admitted to hospital on a planned basis are more complex than before the Covid pandemic.

Accident and Emergency attendances have been growing at a rate of 10% every five years.

Surrey Heartlands

Clinicians, managers, staff and carers all work hard to support residents and look after people, but too often they are constrained by the way the system is organised and the boundaries and fragmentation created.

To deliver the scale of change and improvement required we are going to have to fundamentally change the way our system is organised. Our system architecture needs to be simpler, and we need to focus more resources on delivering the right quality of service for local people.

Services will be organised around three key footprints:

• Neighbourhoods – including towns and villages
• Places
• Integrated Care Systems (ICS)

Neighbourhoods

Neighbourhoods are made up of towns and rural communities where people live, work and build community connections.  Neighbourhoods typically comprise around 30-50,000 people and are the core building blocks, around which, as many services as possible will be delivered through our Integrated Neighbourhood Teams.

Neighbourhoods focus on providing holistic care and working closely with local people to improve health outcomes and address the wider determinants of health.

In Guildford and Waverley, we have four neighbourhoods that align to the existing Primary Care Network (PCN) footprints:

1. Central and North Guildford
2. East Guildford
3. West of Waverley
4. East Waverley

Places

Surrey Heartlands has four distinct Place footprints that have brought local partners together to deliver services:

1. East Surrey
2. Guildford and Waverley
3. North West Surrey
4. Surrey Downs

Places oversee the development and delivery of our Integrated Neighbourhood Teams, the delivery of our improved hospital arrangements and a wide range of key service pathways in the community.

Places work with their local hospitals to deliver more specialist services closer to home, reinforcing neighbourhood teams.  Place footprints typically serve 250,000-300,000 people.

The national context for healthcare is changing, presenting us with new challenges and opportunities. We need to respond to some of the most demanding times the NHS has ever seen and fundamentally change the way in which we deliver care, treatment and support to people across Surrey.

Integrated Care Systems

Integrated Care Systems comprise two decisions making and legal entities:

• Integrated Care Boards (ICBs) – statutory entities responsible for the strategic planning and funding of the majority of local NHS services.
• Integrated Care Partnerships (ICPs) – statutory committees across the NHS, local government, communities and the voluntary sector responsible for developing the health and care strategy for an area.

Collectively ICBs and ICPs have four central aims:

1. Improving outcomes in population health and health care.
2. Tackling inequalities in outcomes, experience and access.
3. Enhancing productivity and value for money.
4. Helping the NHS to support broader social and economic development.

Overall, our Integrated Care System in Surrey Heartlands is setting out a plan to organise the system and our local services to reduce inequality, improve outcomes and deliver for local people.

We are setting out a comprehensive plan to achieve:

• Delivery of improved services for the people of Surrey Heartlands
• Achieve a break-even financial position, looking after public funds

We are leading the way in implementing and improving the structures created to meet the requests made by legislation.

We are progressing how we plan within an integrated approach and streamlining governance, aiming to bring the ICB, ICP and pre-existing Health and Wellbeing Board into one integrated board structure, reducing cost and simplifying planning.

Improving services for the people of Surrey Heartlands

We know services need to improve. We need better systems to proactively identify people in need; we need to organise care with greater simplicity so residents can navigate services with ease; and we need to modernise care to deliver improved access and outcomes.

The Critical Five ambitions set out by Surrey Heartlands also underpin a lot of the work we do in Guildford and Waverley.  These are the key interventions over the next five years that will drive improvements to the care we provide and the experience of local people.

Keeping people well and redesigning urgent care pathways

Helping people stay well at home, increase self-care and strengthen urgent community care to provide viable alternatives to Accident and Emergency.

High risk care management

‘Wrap’ care around vulnerable citizens so that their care plans and pathways are tailored and coordinated.

Safe and effective discharge

Improve discharge processes, integrate and improve all community-based care.

Effective hospital management

Manage resources and patients effectively to deliver high quality care and ensure safe and efficient hospital ‘flow’.

Surrey Heartlands efficiencies

Efficiencies that will deliver greater benefits through being organised and delivered at scale across our system.

The Critical Five are fundamentally changing the health, care and support offer for the better, impacting every area of service.

Guildford and Waverley Place

Who we are

We are health and care partners in Guildford and Waverley who are committed to improving the health and wellbeing of local people through the development of a Place Based model.

Our partners include:

• Royal Surrey NHS Foundation Trust
• Procare Health
• Surrey and Borders Partnership NHS Foundation Trust
• Surrey Children’s Partnership
• Surrey County Council
• South East Coast Ambulance NHS Foundation Trust
• Guildford Borough Council
• Waverley Borough Council
• Phyllis Tuckwell Hospice
• Voluntary Sector Organisations

What we do

We seek to tackle some of the most significant health and care challenges facing people in Guildford and Waverley.

We believe we can achieve more by working together. We want to go further in joining up health and care services and considering all of a person’s health, wellbeing and social care needs. This means investing in our collective resources with a focus on prevention, the wider determinants of health outcomes and reducing health inequalities.

Vital to our success is harnessing the skills, assets, and goodwill of local communities to develop a culture of healthy living and supportive neighbourhoods.

We work to a single, shared set of goals to deliver excellent outcomes for local people, with a delegated budget and decision making to reduce duplication of effort and resources.

Our vibrant team brings a wealth of expertise with a shared vision to bring people the best holistic care through innovative solutions and a responsive and supportive culture for our staff.

By bringing together local health and care organisations we’re using all our experience and know-how to improve the way we spend public money and making sure we take big decisions together for the benefit of local people.

Focus of our work

Our Local Delivery Plan for 2023/24 focused on four key areas to create the right environment for growth and sustainability.

The plan focused on creating the local response to the wider system plans and national requirements with all our partners.

Working together to support thriving communities

At a neighbourhood level with District Borough Councils, voluntary and community groups, faith sector and local businesses to implement an integrated approach to providing the right support for individuals and communities.

Advancing community services and integration

Making it easier for people to access the care that they need when they need it and creating the space and time for our workforce to provide the continuity of care that is so important to our populations.

Tackling inequalities in outcome, experience and access

Engaging with residents to understand root causes and their impact.

My Care, My Way

Personalised care for those with long-term multiple conditions and identifying what can be put in place to anticipate and respond to their needs

Showcasing our local achievements

This year has seen a wide showcase of local achievements, and we have had an opportunity to reflect on our success and impact.

Winter Demand and Capacity Schemes

Last winter we were able to put heath and care schemes in place to support urgent care and help manage operational pressures. This additional funding also helped to provide extra workforce where it was most needed. 

The demand and capacity schemes focused on a priority cohort within each Primary Care Network area:

• Central and North Guildford: all age respiratory hub
• East Guildford: Paediatric and respiratory minor ailment hub
• West Waverley: Paramedic led urgent home visiting service for housebound and frail
• East Waverley: Senior clinician frailty admission avoidance service, focused on providing additional capacity and continuity of care for the most complex frail requiring urgent review.

As a result, over 7,000 additional appointment slots were filled, with over 90 Accident and Emergency (A&E) attendances and ambulance conveyances avoided and 1,100+ GP appointments saved.

The schemes demonstrated the value in mobilising urgent care schemes in primary care.

Night-time Economy project

A successful partnership initiative offering medical assistance as well as a safe space during nights where high volumes of activity were expected was established last Autumn.

The partnership included Ambulance services (St Johns and South East Coast Ambulance (SECAmb), Surrey Police, night-time support staff, volunteers, public health and University of Surrey welfare colleagues.

A pop-up treatment centre located in Guildford centre was set-up to coincide with University of Surrey Freshers Week in September 2023. This provided a safe environment for young people and helped to manage patients on site without the need to visit A&E between the hours of 10pm to 4am.

Data shows patients can be effectively managed outside of a hospital environment, reducing the pressure on hospital, ambulance service and other partners.

The project managed a 90% discharge rate across the two nights and the crew were able to transfer to hospital continuing advanced emergency care if required.

Modernising General Practice – The GP Development Toolkit

Over the course of the last two quarters of 23/24, all practices within Guildford and Waverley participated in the Surrey Heartlands Development Toolkit.

This programme has encouraged practices to review their access models and encourage a wider consistent offer to patients, as well as discussing ways to engage with local patients and communities about the changes taking place in general practice.

As part of the follow up from the programme, Guildford and Waverley practices have shared a variety of achievements such as:

• Moving to new triage models to modernise access.
• Outsourcing of telephone systems to improve consistency in communication.
• Creating a Child’s Immunisation Ambassador to increase immunisation uptake.
• Running NHS App awareness sessions in partnership with the local Patient Participation Group.
• Introducing robotic process automation (RPA) in processing of bloods and registrations for time saving.
• Developing multi-condition clinics for patients with one or more long term conditions to promote holistic care and to reduce multiple trips to the practice.

Virtual Wards

Virtual wards (also known as hospital at home) allow patients to get the care they need at home safely and conveniently, rather than being in hospital. 

They are specifically effective in managing the health and care needs of patients with long-term conditions through the use of personalised care plans and remote monitoring digital technology in a patients’ own home.

The Royal Surrey’s ‘Hospital at Home’ service plays a crucial role in effectively supporting people in their own homes. During 2023/24 we have increased our number of virtual ward beds from 16 to 44.

Guildford and Waverley Health and Care Alliance participated in the NHS Surrey Heartlands ICB procurement process to secure a supplier for a remote monitoring digital platform to support the further development of virtual healthcare across services.

Our integrated virtual ward model will allow expansion to manage several different cohorts of patients including, frailty, oncology and respiratory.

Multi-Agency Discharge Event

A Multi-Agency Discharge Event (MADE) fortnight took place at the end of March 2024. The aim of the event was to improve performance at the front door of our Acute Trust and patient flow.

In addition, we wanted to reduce our non-criteria to reside patients, make improvements to ward discharge processes, increase same day emergency care alternatives to A&E and improve the discharge processes on palliative, end of life and Care Home pathways. 

Processes were put in place to support MADE such as increasing opportunities for teams to feedback though huddles and escalation calls. The hard work resulted in the system achieving a 76% performance for urgent and emergency care for the month.

This initiative has seen a positive impact with learning to take forward. It has also helped to improve relationships between partners across the system.

Integrating Respiratory Care

A review of patient cohorts in the Central and North Guildford area showed that there are significant numbers of residents with variety of conditions and high numbers with co-morbidities.

Chronic Obstructive Pulmonary Disease (COPD) was highlighted as an area of concern with 66% of people with COPD also registered with long term conditions.

Data suggested that there is increased GP activity for children and young people with Asthma and an 84% likelihood of this group attending A&E.

We developed a holistic and multi-disciplinary team (MDT) approach to respiratory services that is sustainable, enabling early and accurate diagnosis, improving medicines management and providing clear personalised management plans to optimise lung health and keep people well.

Women’s Hubs

Following the launch of the national women’s health strategy and operational planning guidance, every ICB in England has been required to have a women’s health hub to support enhanced access to women’s health services within our local population.

In response to this requirement, Guildford and Waverley established an integrated community gynaecology service to support intermediate care for women. The GP-led service aims to improve access to specialist gynaecological care. In addition, a women’s healthcare network has been established to support the education of women’s health in primary care, enhancing knowledge on women’s health at the first point of access. 

There has been a positive impact with 30-40% of all Guildford and Waverley gynaecology referrals being seen by the service.  We know it provides timely, local access to care, receives frequent positive patient feedback, and is a previous winner of the Women’s Health Initiative award. The hub also provides women’s health education across a network of GPs supporting enhanced women’s health knowledge at the first point of access.

Cranleigh Place Shaping

For some time Cranleigh residents had been raising concerns around the impact of poor local infrastructure on accessibility to local community services and support. Cranleigh had also been identified on the next phase of the roll-out of the Surrey County Council Towns Programme.

Initially, the Alliance worked alongside the community link officer, local partners and the community to define programme of work, scoping and mapping the existing community, health and care services across Cranleigh, spotting opportunities to connect, align, identify gaps and new initiatives.

As part of this work, conversations and engagement were carried out with wider Cranleigh stakeholders around alternative estate infrastructure delivery options, making the most of the estates on offer.

Connections were also made with the Knowle Park Trust to explore Green Social Prescribing options such as community gardening projects, conservation volunteering and children and young people outreach to support people to engage in nature-based interventions and activities to improve their mental and physical health.

This is a good example of communities being meaningfully engaged and involved in the future development of their local area.

Integrated Dementia Support Model

In December 2023, Guildford and Waverley launched an integrated community support offer for people living with dementia and their carers/families. The model was developed in line with the Fuller Stocktake ambition of creating neighbourhood teams who wrap around care for their local population.

The local dementia support offer was developed with colleagues from Surrey and Borders, Admiral Nurse Service, Care Co-ordinators and Voluntary Action South West Surrey and provides an integrated approach to diagnosing well, living well and supporting well.

Integrated Frailty approach

During 2023/24, the Integrated Frailty Delivery Group met monthly with the aim of working collaboratively to improve pathways and the integration of services for our local population living with frailty. The group, with membership from across our partner organisations and professions, developed:

• an integrated falls pathway
• an integrated frailty guide, and a clinical support for care homes guide.

Through an integrated approach we have shifted referrals to ‘Hospital at Home’ from the acute, providing discharge support, to avoiding hospital admission.

In April 2023, only 24% of referrals to ‘Hospital at Home’ came from community and this has increased to 78% in February 2024.

There has been an impact on the number of patients in Royal Surrey with a high length of stay (LOS). Over 75s and people with frailty markers have seen their LOS significantly reduced. Other improvements include:

• improved service information
• better communication between Ambulance Service, urgent care and ‘Hospital at Home’
• increased patient follow-ups between community and urgent care
• development of the Community Co-ordination Centre (CCC) into a single point of access/triage into frailty services.

Better Care Fund

The Better Care Fund (BCF) is a national programme which aims to incentivise the NHS and local government to work more closely together around people ensuring wellbeing is front and centre of health and care services.

A variety of schemes have been funded locally via the BCF all of which support the main objectives to:

• enable people to stay well, safe and independent at home for longer.
• provide people with the right care, at the right place at the right time.

These schemes include a supported employment programme for local people with mental health issues, additional investment in end-of-life services, funding for both My Care My Way Matrons, Care Home Matrons and the Community Nursing Discharge Team, the production of health and wellbeing packs and support for local Discharge to Assess (D2A) delivery among others.

Delivery Plan for 2024/25

We want all our population to achieve these five outcomes.

1.      Live a healthy, active and fulfilling lives and makes good choices about wellbeing

2.      Get the health and social care support and information they need at the right time and place

3.      Be safe and feel safe and confident

4.      Benefit from education, skills and opportunities that help them succeed in life

5.      Live in communities that are welcoming, supportive and allow people to contribute

Guildford and Waverley Partnership is united by a vision to ensure our local population start well, stay and live well, age well and die well.

Each of our partners has a responsibility within the wider community from traditional health and care services through to local councils, charities and housing associations.

We bring our individual strengths, knowledge and resources together to deliver better outcomes for the Guildford and Waverley community.

The local community is our most important partner, and we work with the community to understand their knowledge and experience and how we can create communities where everyone lives healthy, active and fulfilling lives and makes good choices about wellbeing.

Our local plan builds on our Partnership success and focuses on three key areas.

1.           Working alongside local people and communities

2.           Working in partnership to use our collective resources

3.           Developing our Neighbourhood Partnership Teams

The Partnership have worked together on this delivery plan to focus on local impact whilst ensuring we have a shared view and ambition. The key areas have an ambitious range of projects and programs that will ensure we are supporting our local people.

We will have a common purpose, a shared delivery approach, a Partnership and a model of transformation and innovation.

The local community is our most important partner.

Working alongside local communities

Local people and communities are the key partner in Guildford and Waverley, we want to connect people to support each other, create opportunities for social inclusion and grow accessible community based support.

Our focus will be to:

• invest into mental health projects across children and young people and adults
• create a new community hub in Ockford Ridge, Godalming
• support wellbeing and build community resilience.

Working in partnership to use our collective resources

As a Partnership we want to ensure our local communities are well connected with effective infrastructure that grows sustainability. How we use our public buildings and work with residents to embrace our environmental responsibilities will ensure we maximise our one public estate.

Our focus will be to:

• Develop our estates including primary care and new leisure facilities in Cranleigh.
• Gain insight to our local population needs through a shared population health data and smart analytic methodology.
• Ensure our citizens voice is heard and respected across all decision making processes.

Developing our neighbourhood teams

We are working to ensure our local population has health and care support and information at the right time and place. We want to ensure people feel supported and community-based care is joined up and accessible.

Our focus will be to:

• create a new integrated care hub that brings together services and coordinates care
• build our local neighbourhood partnership teams to bring together the provision of health, care and voluntary support to enable people to remain well in their own homes.

In summary

Our vision is to work collectively to improve the health and wellbeing of people who live in Guildford and Waverley, ensuring they have access to the most appropriate services available to them when and where they need them. By doing this we will move forward in tackling health inequalities and supporting people to live their best lives.

Our initiatives and programmes all set out to provide good care for all, with a focus on prevention and personalised care and where possible with increased support. We continue to have a better understanding of our population health and wellbeing and by working in partnerships we can increase our connectivity to communities.

With a growing and ageing population, it is more important than ever that we look at ways to thrive; to be healthier and feel supported.

We are committed to making our ambition a reality and we hope that this document sets out what we have done so far and what we plan to do to make it happen.

My thanks to the wealth of individuals across Guildford and Waverley that have contributed to the neighbourhood projects and local initiatives that are key to building healthier communities in Guildford and Waverley.

The shared commitment to the integration of health and social care services, public and voluntary sectors remain strong.  Whilst it is encouraging to see the solid progress in proactively identifying people in need and making it easier to navigate services and support, it is not job done.

We will continue to listen and respond to the evolving needs of the amazing communities that shape our towns, villages and neighbourhoods, so that everyone can start well, stay well, live well, regardless of their circumstances.

Sara Hurley

Chair, Guildford and Waverley Health and Care Alliance Board
Non-Executive Director, NHS Surrey Heartlands ICB

With a growing and ageing population, it is more important than ever that we look at ways to thrive; to be healthier and feel supported.