Suffolk & North East Essex Shadow Integrated Care System


We are committed to implementing Achieving World Class Cancer Outcomes (2016) working with the new East of England Cancer Alliance. This alliance aims to share and implement learning and best practice, link to new models of care and radical transformation, integrate care pathways across health and social care, focus on prevention and access to services, improve the patient experience, monitor performance and support improvements, and fully involve patients, carers and families.

Our system will work to save lives and improve patient outcomes and experience for those with cancer across Suffolk and North East Essex by driving changes in delivery of cancer care across a whole health and care system that will save lives, reduce variation and improve quality of care.

Our cancer strategy is underpinned by seven themes where we intend to address:

  1. Fewer people getting cancer;
  2. More people surviving cancer through earlier diagnosis;
  3. More people being diagnosed swiftly with a more individualised treatment plan;
  4. More people having a good quality of survival;
  5. More people being supported to live as well as possible both during and after treatment has finished;
  6. Those with suspected recurrent disease are able to re-access specialist care without delay;
  7. Patients afforded the same quality of care irrespective of factors such as age.

Diabetes is a major public health problem with diabetes diagnosis in the UK having risen from 1.4 million to 3.5 million since 1996. It is estimated there are over 4 million people (including those which have been undiagnosed) living with diabetes in the UK and this is estimated to rise to 5 million by 2025. Diabetes costs the NHS over £1.5m an hour (or 10% of the NHS budget for England and Wales), and an estimated £14billion a year treating it and its complications. The two main funded diabetes programmes in Suffolk and North East Essex include the NHS Diabetes Prevention Programme and the Diabetes Treatment and Care Programme but there are a large number of other services offered in primary and secondary care such as podiatry, retinal screening, dietary advice and specialist support.

Mental Health

The Five Year Forward View for Mental Health, published in February 2016, sets out a clear and unarguable agenda for the reform of mental health care. The strategy is built around the evidence and opinion of the thousands of people who contributed to its development, to increase significantly the availability and quality of care and treatment for people with mental health problems – to improve their outcomes and wellbeing but also to tackle the wider costs of mental ill health to the health service and society as a whole. (Mental Health Five Year Forward View One Year On).

We are committed to the National Mental Health Investment Standard which promoted parity between mental health and physical health, together with investment in early intervention in psychosis and psychiatric liaison services. The ‘Next Steps on the Five Year Forward View’ sets a number of targets for mental health. These include:

  • A significant increase in psychological (talking) therapies.
  • Better mental health care for new and expectant mothers, with an increase in the numbers treated.
  • Improved care for children and young people, with an increase in the numbers treated.
  • Extra physical health for people with and SMI (Servere Mental Illness)checks
  • Increase in treatments for common mental health conditions, and faster access to digital therapies
  • Extra crisis home treatment services to reduce out of area placements.
  • Early Diagnosis of Dementia and better pathways of care Post Diagnosis.
  • Increase access to Individual Placement and Support (IPS)

Our priorities are to:

  • Provide co-designed excellent, cost effective and transformational mental health services.
  • Promote health, independence, resilience and wellbeing with a stronger focus on improved awareness and identification of people with mental health problems.
  • Deliver holistic and integrated mental and physical health responses and support so that needs are considered and treated together.
  • Develop a skilled workforce focused on resilience and recovery approaches.
  • Reduce reliance on inpatient provision, increasing home treatment options, treating people in least restrictive setting including delivering our learning disability Transforming Care Plans.
  • Development of outcome focused services

Our approach is to:

  • Deliver early identification and early intervention via locality based integrated approaches.
  • Establish a joined up, family focused response to children and young people.
  • Deliver care and treatment in the least restrictive environments with emphasis on community approaches and recovery.

Through a number of engagement exercises including the Big Care Debate, Urgent Care Review and market engagement activities in Suffolk, our system has been finding out from local people what is important to them. They have told us that they want to take responsibility to stay well and independent as long as possible in their own communities, using technology and apps to help them with this.

We will develop plans that will help people adopt healthy lifestyles – for example by stopping smoking, drinking less alcohol, eating more healthily and being more physically active – and will look at how social, economic, environmental and cultural factors affect the health of our communities. Our prevention agenda will focus on early intervention. A key aim of this work will be to focus on the individual as well as enhancing organised support from local health, care and other community services.

We will also seek to combat loneliness, close the gap in access to mental health services and improve the outcomes for people with mental health problems. In particular, we will focus on the emotional health and wellbeing of children and young people. Finally, we will tackle accident prevention to reduce the number of falls and fractures that occur in our communities.

We are developing an STP prevention strategy, which will focus on several areas:

  • Managing clinical risks, for example working with GPs to help people understand and manage long term conditions such as high blood pressure
  • Prevention at scale on lifestyles, addressing the top six risk factors for early death and reduced quality of life: smoking, high blood pressure, being overweight or obese, lack of physical activity, poor diet, and excessive alcohol consumption.
  • Healthy hospitals, through helping both staff and patients to be as healthy as possible.
  • Personal and community resilience, supporting communities to help themselves to stay healthy.
  • We will deliver our prevention strategies in a coordinated way and will include a range of communication and engagement activities aimed at behavioural change. Prevention work is often a long term investment, so we recognise the need to support people now to make lifestyle choices that will benefit them and the system in future years. We will better utilise ‘place’ based prevention as a means of supporting healthy lifestyle choices and provide an environment that enables and sustains good health and wellbeing.
  • Prevention is a key priority for all STP members, with each organisation doing its part to deliver our prevention vision.
Primary Care

We aim to provide all services in primary care unless safety determines otherwise. This programme will address some of the variation that exists within primary care, particularly around prescribing. It will support better working between practices as well as integration with community, acute and social care partners. We are designing new models of care that will shift care away from hospitals and into community locations. This will include the creation of neighbourhood or locality hubs that are fully integrated with community and social care.

Our priorities include the following:

  • Integration between primary care community services and social care.
  • Primary care at scale/super practices/a single partnership and allied collaborations.
  • Improved use of technology in general practice and within the neighbourhood / locality hubs.
  • Innovation estates solutions to ensure the primary care estate and infrastructure is fit for purpose.

Our system considers primary care to be the foundation of all health services and very important to patients and the system as a whole. It is at the heart of all our plans recognising the key play primary care plays in achieving our aims.

Urgent and Emergency Care

The ICS has in place an Urgent and Emergency Care (UEC) Programme that focuses on transforming the way urgent and emergency care services are provided to all ages, improving hospital services as well as out-of-hospital services. This is so professionals are able to deliver more care closer to home and reduce unnecessary hospital attendances and admissions in a system that is safe, sustainable and that provides high quality care consistently, where appropriate. There is a considerable evidence and experience base to inform ‘what works well’ in urgent and emergency care systems, and the damage caused by poor patient flow.

The Urgent and Emergency Care programme is working to achieving the following aspirations:

  • people with urgent care needs, including mental health crisis, receive a highly responsive service that delivers care close to home, minimising disruption and inconvenience for patients and their families.
  • those with more serious or life-threatening emergency care needs, receive treatment in centres with the best expertise and facilities to maximise the chances of survival and good recovery.
  • people who are admitted to hospital in an emergency should receive the same high quality care 7 days a week.

Our system believes most of these ambitions will be achieved at local level which will result in the following:

  • More responsive services provided in hospitals;
  • Provision of urgent care services outside of hospital, ensuring care close to home;
  • More calls to ambulance resolved without conveyance to emergency departments;
  • Greater electronic access to records, including advance care plans through an enhanced summary care record & ‘special’ patient notes;
  • Increased use of frailty units and ambulatory care units, reducing hospital emergency admission rates and length of stay for urgent conditions and frail and/or older people;
  • Stronger partnerships with care homes, homecare and housing providers reducing avoidable admissions and delayed transfers of care;
  • A single point of access for clinical advice with a 24/7 integrated urgent care service implemented, including a clinical hub that supports 111, 999 and out-of-hours calls from the public and all healthcare professionals;
  • Services marketed so patients understand what is available to them;
  • Consistent pathways defined for UEC with equitable access, including designation of acute services and community urgent care facilities.