The changes being made

Surrey Heartlands is doing three key things which it believes will make a big difference:

  • Devolution – gaining greater control of budgets and accountability for the decisions made locally
  • Developing a clinical academy – so that all local people have access to the best and most innovative care; ensuring plans are clinically led and supporting clinical innovation, spread of good practice and elimination of unwarranted variation.
  • Citizen engagement – engaging and involving local people on a scale not done before.

Clinical academy

The clinical academy is a virtual network supported by the Kent, Surrey, Sussex Academic Health Science Network. It has been set up to:

  • Facilitate clinical ownership of the challenge of tackling variation
  • Empower citizens to be better informed to make decisions about their care and take personal responsibility for their health
  • Enable pockets of innovation to grow and make a positive impact
  • Spread best practice, test and evaluate current and new innovations and support system leadership
  • Help create and establish an environment for generating ideas and making them happen
  • Support clinical work streams in designing financially sustainable pathways of care.


A statistically representative online panel of around 1,300 residents (building to 3,000 in the first half of 2018) has been developed for regular surveys. The outcomes of research using the panel will provide statistically robust insight into the attitudes and expectations of the general population and are invaluable in ensuring the findings from a previous qualitative research programme resonate with the wider population. The partnership has also recruited seven citizen ambassadors to ensure the voices of local people are heard.

Improving diabetes services

In December 2016 the partners were awarded £1.8 million over two years to invest in diabetes services. The programme contains three main projects:

  • Improving patient outcomes against the NICE-recommended treatment targets, by supporting GPs to ensure patients receive annual diabetes checks, developing a diabetes education programme for health care professionals and working with Diabetes UK to promote self-management.
  • Increasing the number of people who attend education in diabetes and learn how to self-manage the condition, by increasing the places available at different locations and at different times, offering online education and ensuring everyone understands the difference education can make.
  • Recruiting diabetes specialist nurses to work in hospitals and GP practices to improve patient outcomes and experience by optimising diabetes control, providing specialist diabetes support for patients and carers when in hospital and improving communication on discharge, and providing diabetes education across the hospital.

Transforming services and outcomes for cancer patients

The Surrey & Sussex Cancer Alliance sits across three sustainability and transformation partnerships (Surrey Heartlands, Frimley Health and Sussex & East Surrey). It includes two cancer centres and six cancer units.

Its aim is to improve and transform services and outcomes for cancer patients by focusing on earlier diagnosis, and by offering more help to patients after their diagnosis of cancer, to ‘live with and beyond’ the disease.

The work streams of prevention, early diagnosis, treatment and care, and living with and beyond cancer will link to other existing Surrey Heartlands programmes and will lead many of the partners’ efforts around topics such as cancer screening, rapid diagnostics, surgery, radiotherapy and wellbeing for cancer patients.

Other work that has already taken place:

  • A 24/7 advice line and a single shared care record for pregnant women have been introduced across Surrey Heartlands, both aimed at supporting the focus on the first 1,000 days and reducing still birth and perinatal death rates.
  • GP referrals to outpatients across Guildford & Waverley have been reduced by seven per cent through the introduction of an ‘advice and guidance’ telephone service for GPs.
  • Non-elective admissions and length of stay in the over 65s have been reduced thanks to the new ‘at home’ integrated health and social care team in the Epsom area.
  • The ‘Handi-App’ for help and advice for parents/families on the right care for babies and children has been introduced across North West Surrey with early satisfaction rates of 93 per cent. This will be rolled out across Surrey Heartlands to help reduce A&E attendances not requiring treatment or interventions.
  • Non-elective admissions of patients from care homes have been reduced following the roll-out of catheter care training.
  • Partnership working with adult social care has reduced delayed transfers of care from hospital, with Surrey rising in the rankings from 94th to 58th in the country.
  • Hospital discharges have been improved through collaborative working with adult social care and community services for example, Home First at Royal Surrey County Hospital and the Integrated Care Bureau at Ashford and St Peter’s Hospitals, and positive re-ablement for patients in their own home.
  • The partners have retained a position as a global exemplar on digital machine learning and artificial intelligence.