Suffolk & North East Essex Shadow Integrated Care System

In an integrated care system, NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve. Local services can provide better and more joined up care for patients and service users when different organisations work together in this way. For staff, improved collaboration can help to make it easier to work with colleagues from other organisations. And systems can better understand data about local people’s health, allowing them to provide care that is tailored to individual needs. By working alongside councils, and drawing on the expertise of others such as local charities and community groups, the NHS can help people to live healthier lives for longer, and to stay out of hospital when they do not need to be there. In return, integrated care system leaders gain greater freedoms to manage the operational and financial performance of services in their area. Following feedback received during engagement activities conducted across Suffolk and North East Essex since 2017, our shadow Integrated Care System is considering developing the following areas as Higher Ambitions:

  • Mental health – zero suicides and better support for children’s mental health and well-being;
  • Care closer to home – reduction in the number of unplanned admissions to hospital;
  • Reducing the health gap – more comparable health outcomes for those living in our most and least deprived communities;
  • Improved end of life care – less people dying in hospital and more people enabled to die either at home or the place of their choice;
  • Positive about obesity – fewer children and adults developing obesity and more people with obesity able to access treatment and support including bariatric surgery;
  • Less loneliness – ‘living alone’ no longer being a factor in admission to hospital.
  • We are also looking with partners at how becoming an integrated care system could support the above aims.

The success of our higher ambition also relies on our relationship with our patients, people who use our services, our staff and clinicians. We will take an engaging and co-production approach to our system by getting patients, people who use our services, our staff and clinicians to lead change. Taking decisions together we will ensure that collective action can make a positive difference to the health and care of people across Suffolk and North East Essex and financial performance of services in their area.


Addressing health inequalities through population health management


What is population health management?

Population health management is a term commonly referred to within our system.  It is about helping people to stay healthy for as long as possible.  If they do need care, our system will work in a joined up way that makes it easy for them to access services, and if they do need to stay in hospital, we will support them to return to their home as quickly as possible.

Suffolk and North East Essex is developing a plan to help this become a reality.  A key part of this will be to address health inequalities.  Health inequalities are differences in health between people or groups of people that may be considered unfair. There is a social gradient in lifespan; people living in the most deprived areas in England have on average the lowest life expectancy and conversely, life expectancy is higher on average for those living in areas with lower deprivation.

A key part of our work will be to really understand these groups and what they are likely to need from health and care professionals.  Doing so will mean that provider organisations can deliver services in the most appropriate way for our communities across Suffolk and North East Essex and in the most convenient locations for people.  However this cannot be achieved by a single organisation, service or programme working in isolation.  It will need effective partnership from across the health and care system. 

By working together, we want to ensure that every one of the one million people in Suffolk and North East Essex:

·       is able to live as healthy a life as possible;

·       has a good start in life;

·       has a good experience of ageing;

·       has a good experience at the end of their life;

·       has access to the help and treatment that they need in the right time and the right place;

·       has good outcomes and experience of the care that they receive.

Our system employs analysts who give system leaders insight into population needs, system performance, health outcomes, resource utilisation and costs – and how they change over time.  Any decisions and actions we take will be based on what people have been telling us, best practice as well as these data. 


Suffolk and North East Essex Population Health Management Group

A group has been established whose remit is to develop and implement a strategy for population health management.  The role of the group is to ensure:

·   local Population Health Management data are fully accessible and easily understood by our partners to enable effective targeting of care and support;

·   data are presented in an easy to understand way for our citizens and communities so that they understand how we reach our decisions;

·   research into local need and what matters in health and wellbeing to our population is carried out; 

·   local services and the quality of care they provide is assessed at regular intervals;

·   We are able to predict the future demand on services arising from anticipated demographic change, and in particular the growth in population that will result from significant new housing developments in our footprint

·   population health data is shared with all relevant partners;

·   progress is monitored, using population health data to inform future planning and service delivery.


National Documents relating to Population Health Management

–        A vision for population health: Towards a healthier future

–        Embracing population health management

–        Population Health Management: an opportunity to break the cycles of poor health

–        ICS Community of Practice + other documents from NHS Collaboration Platform