Suffolk & North East Essex Integrated Care System

How we work in neighbourhoods

Neighbourhoods provide a focus for smaller, identifiable populations based on particular characteristics or needs, agreed within the Alliances. Without the need to meet the requirements of a fixed size or model, different areas can find different solutions for different problems. Alliances will play a key role in oversight and support of effective neighbourhood arrangements that deliver for local populations. These neighbourhoods might be based around GP catchment areas or local government ward boundaries, with local partners working together in networks, responding to the characteristics and needs of the local population. Equally neighbourhoods may act in a three-dimensional way being defined by a school community or a virtual community meeting needs through the use of social media. At neigbourhood level the role of district and borough councils and the voluntary and community sector will also be key.

In Suffolk, there is a focus on the Integrated Neighbourhood Teams identifying local issues that relate to their specific populations, and developing a joint plan as to how they, as a system, can begin to address these, with support of the Clinical Commissioning Groups (CCGs).

The Integrated Neighbourhood Teams work with wider partners in their locality, making sure that wider issues of health and wellbeing can be addressed. To support this work, named leaders have been identified for each area, and some functions picked up alliance wide where this makes sense, for example data analysis and training development.

We now have the opportunity to closer align these teams with the Primary Care Networks.

There are four main objectives:
  • Fewer people need unplanned care and support (reduction in crisis situations).
  • Greater numbers of people have access to and are supported by activity outside of statutory services.
  • Resources in the delivery of community-based health and care support are used more efficiently.
  • The ongoing costs of supporting people are reduced as people’s independence is increased.
Integrated Neighbourhood Teams

Integrated Neighbourhood Teams bring together physical, mental health and social care practitioners that work with General Practices within a locality to provide a single coordinated care response for people, underpinned by prevention, self- care, early intervention, reablement and rehabilitation, (including people living in nursing and care homes).

Primary Care Networks (PCNs)

See below how our Primary Care Networks are developing across the ICS.

The West Alliance Steering Group identified that Community Pharmacy had the potential to support the system with a lot of its key priorities, but there was no mechanism for harnessing this potential to make sure that all Healthcare Professionals within the West Alliance area were focussed on the same outcomes.

Through Alliance working, a framework was developed which would ensure that the community pharmacies within the West Suffolk and Ipswich & East Suffolk Alliances were supported to develop towards delivering services that were really needed in their communities. Funding from the ICS Primary Care Realising Ambition Fund allowed us to support both the delivery and evaluation of the initiative. With support from the County Council to develop their commissioned services to deliver the best possible patient outcomes and the provision of population data to ensure the right services are being offered, community pharmacies could be engaged.

There are now 40 pharmacies across Ipswich & East and West Suffolk supporting training of staff members to be Health Coaches on the High Street, to train around 150 patient-facing staff members in the early diagnosis of cancer and to ensure all pharmacy team members recognise the signs of deteriorating mental health. These pharmacies are poised to work with the developing Primary Care Networks, are engaging with other local providers to deliver clear health messaging.

Our plan for 2019/20 to 2023/24 is enable Primary Care Networks to mature and thrive; meeting local need and national expectations. Our Roadmap to achieve this has 12 key steps, many of which are built on firm foundations of collaborative working and which will now be accelerated by national PCN policy and investment:

  • Leadership and ‘organisational’ development – we will continue our investment in Clinical Directors and wider management teams across each Alliance and within localities; building capability, capacity and confidence to deliver our plans. Each Alliance and locality is completing its ‘maturity matrix’ and a local progression plan
  • Using Local Needs and Assets Assessments – we now have local needs assessments and emerging asset maps for each of our localities. These will be continuously refreshed and actively used to inform PCN and locality plans to meet local needs and tackle local inequalities. In due course these will be supplemented and potentially superseded by Population Health Management tools
  • Reviewing and expanding public and stakeholder engagement to help shape primary care and locality based plans; this will build on the strong foundations of our partnerships with Patient Participation Groups and community based working, led by our local authority, voluntary and community partners
  • Developing local incentive and quality improvement schemes at PCN and locality levels supported by our Alliance based approach to commissioning – this will build on the Alliances’ established Transformation Funding
  • Supporting the integration of mental health services into PCNs alongside increasing well established social care and community team working with General Practice – this a key element of the Suffolk Mental Health and Emotional Wellbeing Strategy
  • Progressing our shared commitment to supporting people most in need with complex, multiple health needs and experiencing health inequalities through risk stratification and multi- disciplinary based planning and support for individuals
  • Working within localities and with ICS-wide partner bodies to ensure pharmacists, opticians and dentists are involved with PCNs and wider locality teams; we will build on our current Healthy Living Pharmacy and community based eye care programmes to achieve this
  • Supporting existing and new Social Prescribing schemes in each locality; ensuring shared learning, robust evaluation and continuous improvement
  • Building on our established models of multi- disciplinary support to care homes including with the Care Home Enhanced Service
  • Reviewing and approving local estates programmes to enable joined up working and the highest standards of care
  • Planning and delivering workforce programmes which inspire and enable retention and recruitment of primary care and integrated locality based teams
  • Delivering digital solutions in line with national requirements and local aspirations for joined up care

Primary Care Networks (PCNs) are crucial to the implementation of the NHS Long Term Plan, both through more resilient delivery of primary care in local neighbourhoods, and the integration of health and care services to better respond to the characteristics and needs of the local population. PCNs are key to addressing the wider ICS ambitions to improve population health and wellbeing, and to building lasting relationships between our partners.

We have 102 GP practices in our ICS footprint and as of 1st July 2019, 24 PCNs. These cover the full geography and provide 100% coverage of the ICS area. All PCNs have been established with Clinical Directors identified.

  • West Suffolk PCNs
  • 1 Blackbourne Rural
  • 2 Bury St Edmunds
  • 3 Sudbury GP Network
  • 4 WGGL
  • 5 Haverhill
  • 6 Forest Heath
  • Ipswich and East Suffolk PCNs
  • 7 Barrack Lane and Ivry Street
  • 8 DHG South
  • 9 East Ipswich
  • 10 Felixstowe
  • 11 Mid Suffolk
  • 12 North East Coastal
  • 13 North East Ipswich
  • 14 North West Ipswich
  • 15 North West Suffolk
  • 16 Orwell
  • 17 South Rural
  • North East Essex PCNs
  • 18 Tendring
  • 19 Creffield Medical Group, Turner Road Surgery and Tollgate Medical Practice
  • 20 COLTE Partnership
  • 21 Colchester Medical Practice
  • 22 Clacton Alliance
  • 23 East Hill & Abbeyfields
  • 24 Bluebell, Highwoods, Lawford, Mill Road, Winstree

Last Updated on December 10, 2020

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