Continuing Healthcare


This page tells you about Continuing Healthcare.  You may also find information you need on the Personal Health Budgets page.


NHS Continuing Healthcare Team                0300 561 1444            This email address is being protected from spambots. You need JavaScript enabled to view it.
Cedar Court
Guildford Road
KT22 9AE


Surrey Heartlands CCG hosts NHS Continuing Healthcare and NHS Funded Nursing Care (FNC) services across Surrey on behalf of our own residents and for residents of Farnham and Surrey Heath, who come under Frimley CCG.


What is NHS Continuing Healthcare?

NHS Continuing Healthcare funding is a package of ongoing care that is arranged and paid for by the NHS. This is for individuals who have been assessed and found to have a ‘primary health need’ as set out in the National Framework. Such funding is provided to an individual aged 18 or over, to meet health and associated social care needs that have arisen as a result of disability, accident or illness.

NHS Continuing Healthcare is free (with no financial assessment) unlike support provided by local authorities, for which a financial charge may be made depending on your income and savings.

You can receive NHS Continuing Healthcare funding in a variety of settings, including your own home, or in a care home with nursing. If you choose to receive your care in your own home, the NHS already provides for healthcare, e.g. services from a community/district nurse or specialist therapist. They will fund associated social care needs (e.g. personal care and domestic tasks, help with bathing and dressing). If you choose to receive your care in a care home with nursing, the NHS will also pay for your care home fees, including board and accommodation.

If you are eligible, the Continuing Healthcare Team will be responsible for identifying and funding a package of care that has been discussed and agreed with you and your family or representative. Funding is subject to regular review and if your healthcare needs change the funding arrangements may also change.

A public information film from NHS England provides a guide for individuals and their families to NHS Continuing Healthcare and what to expect throughout the complex assessment process. There is also an easy-read guide ‘What is NHS Continuing Healthcare’ for people with learning disabilities.

The revised 2018 National Framework sets out the principles and processes of NHS Continuing Healthcare and NHS-funded Nursing Care. This guidance, which replaces the previous version of the National Framework published in November 2012, was implemented on 1st October 2018.

NHS England recognises that information and support are vital to all individuals involved in the CHC process and has therefore funded an independent information and advice service through a social enterprise called Beacon. This service is supported by a consortium of leading voluntary sector organisations including Age UK, Parkinson’s UK and the Spinal Injuries Association.

Beacon provide information and advice on their website and individuals are also able to access up to 90 minutes of free advice with a trained NHS continuing healthcare adviser.

The Continuing Healthcare Team support the use of advocacy for any individual to represent their views or speak on their behalf. This could be a family member, friend or peer, a local advocacy service or someone independent who is willing to undertake an advocacy role.


How is eligibility for NHS Continuing Healthcare assessed?

Eligibility is not dependent on a particular diagnosis or disease or determined by where your care is provided. Where a person’s “primary need” is a health need, they are eligible for NHS Continuing Healthcare. Deciding whether this is the case involves looking at all the relevant needs from the assessment process. Where an individual has a primary health need, the NHS is responsible for providing all of their health and social, including accommodation, if that is part of their need.

Consideration of primary health need includes taking into account what those needs are and their impact on the care required to manage them. In particular, to determine whether the quantity or quality of care goes beyond the limits of Local Authority.

Consideration is given to the following areas:

  • Nature and type of need: This describes the particular characteristics of an individual’s needs (which can include physical, mental health or psychological needs) and the type of those needs. This also describes the overall effect of those needs on the individual, including the type (‘quality’) of interventions required to manage them.
  • Intensity of need: This relates both to the extent (‘quantity’) and severity (‘degree’) of the needs and to the support required to meet them, including the need for sustained/ongoing care (‘continuity’).
  • Complexity of need: This is concerned with how the needs present and interact to increase the skill required to monitor the symptoms, treat the condition(s) and/or manage the care. This may arise with a single condition, or it could include the presence of multiple conditions or the interaction between two or more conditions. It may also include situations where an individual’s response to their own condition has an impact on their overall needs, such as where a physical health need results in the individual developing a mental health need.
  • Unpredictability of need: This describes the degree to which needs fluctuate and thereby create challenges in managing them. It also relates to the level of risk to the person’s health if adequate and timely care is not provided. An individual with an unpredictable healthcare need is likely to have either a fluctuating, unstable or rapidly deteriorating condition.


To support consistent decision making, the NHS Continuing Healthcare Decision Support Tool (DST) has been developed for use by practitioners. This enables them to obtain a full picture of needs and to inform the decision regarding the level of need that could constitute a primary health need.

The DST, combined with the practitioners own experiences and professional judgement, will enable them to apply the primary health needs test in practice in a way which is consistent with the limits on what can be legally provided by a Local Authority.

Eligibility for NHS Continuing Healthcare is based on an assessment of an individual’s presenting care needs. An NHS Continuing Healthcare Checklist may be completed initially to decide if a full assessment, known as a DST should be undertaken.

The DST provides the basis for decisions on eligibility for NHS Continuing Healthcare funding. This must be completed by the multi-disciplinary team, which will include as a minimum, two professionals from different health professions or one professional from a healthcare profession and one who is responsible for undertaking community care assessment (a social care professional). Specialist staff and mental health staff could also be involved dependent on the individual’s needs.


What is NHS-funded Nursing Care?

NHS-funded Nursing Care (FNC) is the funding provided by the NHS directly to care homes with nursing to support the provision of nursing care by a registered nurse. Where the individual is living in their own home or a care home without nursing, then the NHS will provide such care via community services, such as district nurses.


How is eligibility for NHS-funded Nursing Care assessed?

In all cases individuals will be considered for eligibility for NHS Continuing Healthcare (CHC) before a decision is reached about the need for NHS-funded Nursing Care.

If a checklist indicates that no referral is necessary for a full assessment, but registered nursing needs are identified, then FNC can be awarded without the need for a further assessment.

If the Decision Support Tool identifies that the patient is not eligible for CHC then it will go on to consider whether they are eligible for FNC.

The registered nursing needs are services provided by a registered nurse and involving either the provision of care or the planning, supervision or delegation of the provision of care, other than any services which, having regard to their nature and the circumstances in which they are provided, do not need to be provided by a registered nurse.


How do I apply for NHS Continuing Healthcare or NHS-funded Nursing Care?

A nurse, doctor or other qualified healthcare professional or social care practitioner can apply the Checklist to refer individuals for a full consideration of eligibility from within the community or hospital setting.

A referral can also be made in the form of a telephone call, email or letter from a patient or their representative. This will usually result in the completion of a Checklist by the CHC Team.


What is a Fast Track

The Fast Track application is there to ensure that individuals who have a “rapidly deteriorating condition and may be entering a terminal phase” have access to NHS Continuing Healthcare funding with minimum delay and without the need to complete a DST.

A completed Fast Track Pathway Tool, which clearly evidences that an individual is both rapidly deteriorating and may be entering terminal phase, is sufficient to establish eligibility.

The Fast Track Tool will be completed by an ‘appropriate clinician’ described in the National Framework as a person who is:

  • Responsible for the diagnosis, treatment or care of the individual under the National Health Service Act 2006 in respect of whom a Fast Track Pathway Tool is being completed;
  • A registered nurse or a registered medical practitioner.


The ‘appropriate clinician’ will be knowledgeable about the individual’s health needs, diagnosis, treatment or care and be able to provide an assessment of why the individual meets the Fast Track criteria.

If you are involved in supporting those with end of life needs, (including those in wider voluntary and independent sector organisations) you should contact the appropriate clinician who is responsible for the diagnosis, care or treatment of the individual and ask for consideration to be given to completion of the Fast Track Pathway Tool.


How do I appeal an eligibility decision?

Where an individual has been found not eligible for NHS Continuing Healthcare or NHS- funded Nursing Care following completion of a DST, they or their representative can appeal the decision within 6 months of the date of the outcome letter.

Appeals in the first instance should be sent to:

  • NHS Continuing Healthcare Team
    Cedar Court
    Guildford Road
    KT22 9AE

  • Tel: 0300 561 1444
  • Email: This email address is being protected from spambots. You need JavaScript enabled to view it. 


When an appeal is received it will be acknowledged by way of a telephone call from a clinician, which also allows the opportunity to establish any process issues that the appellant may have in addition to the outcome of the DST. A letter will then be sent to the appellant together with a questionnaire to complete and a request for documentation in relation to their authority to act.

Once this has been returned, evidence will be obtained from all parties involved in the patients care for a period of six weeks either side of the date of completion of the DST being appealed. This evidence will be reviewed by a clinical assessor who was not previously involved in the completion of the DST. The appellant will then be advised in writing of their decision.

If the appeal is not resolved at this point, then the next stage of the local appeal process is the offer of a Local Resolution Meeting (LRM). The individual and/or their representatives will be invited to attend the LRM and to participate in the discussion. The meeting will be chaired by a member of the clinical team who will be accompanied by a Clinical Assessor. 

This meeting will review the original DST decision and the outcome of the first appeal. Notes will be made of the meeting discussion and these together with the Clinicians’ decision will be sent to the appellant. We aim to offer a date for the LRM as soon as the request is received and these meetings are currently taking place within two months.

Where it is identified at the Appeal stage that the DST was not conducted as an MDT the team will make every effort to hold the LRM as an MDT. Although Local Authority are not required under the terms of the National Framework to attend the LRM, an invitation is always sent to them, ahead of the meeting affording the opportunity to attend if they wish to do so. Where the DST was not completed as an MDT, and the Local Authority choose not to attend, the LRM will be held using clinicians from different backgrounds wherever possible.

If, following the LRM, the individual or their representative remain unhappy with the CCG’s decision, they can approach NHS England to request an Independent Review Panel (IRP) by writing to:

  • NHS England South
    South West House
    Blackbrook Park Avenue
    TA1 2PX
    FAO: Continuing Healthcare Administrator


All appropriate steps will have been taken by the CHC Team to resolve the case locally before an IRP is convened.

 The IRP can be asked to review either or both of the following:                              

  1. The procedure followed by a CCG in reaching a decision as to that person’s eligibility for NHS Continuing Healthcare


  2. The primary health need decision made by a CCG


The IRP meeting, arranged and hosted by NHS England in accordance with the National Framework, will make a recommendation to the CHC Team in the light of its findings on the above matters.

Following an IRP, if the original decision is upheld, but there is still a challenge, the individual has the right to make a complaint to the Parliamentary and Health Service Ombudsman (PHSO).

The complaint needs to be made in writing, within 12 months of the date of the IRP outcome letter to the PHSO at the following address:

  • Parliamentary and Health Service Ombudsman
    Millbank Tower
    SW1P 4QP



Can I make a retrospective claim for care already received?

The CHC Team will only consider requests for retrospective reviews where it is satisfied that one or more of the following grounds for the review exist:

  • The CHC Team failed to carry out an assessment of the patient’s eligibility for NHS Continuing Healthcare funding when requested to do so.
  • The request for a retrospective review is for periods of unassessed care.
  • The period to be considered is after 01.04.2013 as the opportunity to claim for periods before that date has now passed.


Requests for a retrospective review, which should detail the period you want to be considered, should be sent to:

  • NHS Continuing Healthcare Team
    Cedar Court
    Guildford Road
    KT22 9AE

  • Email: This email address is being protected from spambots. You need JavaScript enabled to view it. 


If the CHC Team agree to undertake a retrospective review the applicant will be asked to complete a questionnaire and provide documentation in relation to their authority to act.
Once this has been returned, evidence will be obtained from all parties involved in the patients care for the duration of the claim period.

The evidence will be reviewed by a clinical assessor who will complete a Portrayal of Needs (PON) document detailing the individual’s health needs throughout the period of the review. Once completed the PON will be shared with the applicant who will be requested to confirm the details presented and provide any further comments they may have.

The clinical assessor will use the PON, together with any comments made, to produce the retrospective Decision Support Tool(s). The DST(s) will contain a recommendation on the individual’s eligibility for NHS CHC or NHS-funded Nursing Care (FNC) for the period of the review. That recommendation will be submitted to a multi-disciplinary team (MDT) panel, as the Local Authority do not participate in the retrospective process.

Wherever possible, the MDT will comprise two healthcare professionals from different backgrounds from within the CHC Team. The MDT panel will consider the clinical assessor’s recommendation and make the final decision on eligibility.

A letter detailing the outcome of the retrospective review will be sent to the applicant. The outcome will be either:

  1. The individual was eligible for Continuing Healthcare Funding/NHS-funded Nursing Care throughout the period of the Retrospective Review


  2. The individual was eligible for Continuing Healthcare Funding/NHS-funded Nursing Care for part of the period of the Retrospective Review


  3. The individual was not eligible for Continuing Healthcare Funding/NHS-funded Nursing Care for any part of the period of the Retrospective Review


If the CHC Team decide that the individual was eligible for all or part of the period under consideration, arrangements for a reimbursement will be made.

If the applicant is unhappy with the outcome of the Retrospective Review they can notify the Appeals Team within six months of the date of the outcome letter that they wish to appeal the decision further. Any appeal of a retrospective review will follow the appeals process. 


This page tells you about Continuing Healthcare.  You may also find information you need on the Personal Health Budgets page.



Model Publication Scheme Class: Not part of the MPS



One in two people born after 1960 will be diagnosed with some form of cancer in their lifetime (Cancer Research UK). This risk increases with age, but thankfully today many people will be cured, or go on to live a long time with treatment controlling the condition.


Almost half of cancers are diagnosed at a late stage in England (Cancer Research UK, 2014). This means that the cancer is far along in its growth and may have spread to other areas of the body.

The following information aims to help you to:

  • reduce your chance of developing cancer;
  • recognise signs of cancer to make sure you get treatment as early as possible
  • signpost to further support, if you are diagnosed with cancer. 

On this page you will find information on:

What is cancer?

Cancer is a condition where cells in an area of the body grow and reproduce uncontrollably. The cancerous cells can invade and destroy surrounding healthy tissue. This Cancer Research UK webpage provides further information.


Can I reduce my risk of cancer? 




In the UK, around 360,000 people are diagnosed with cancer every year. We know there are over 200 different types of cancer, but do we do not know all the causes.

However, experts estimate that more than 4 in 10 cancer cases could be prevented and by making simple changes to your lifestyle you can significantly reduce your risk of developing cancer.

For example:


As well as the above links, the Healthy Surrey website and Change4Life website has lots of useful tips on being active and eating well for you and your family.


What cancer screening is available?

Screening is a way of identifying apparently healthy people who may have an increased risk of a particular condition and who will most likely benefit from it.

The NHS offers three types of screening for adults in England to help identify cancer at an early stage. These are:

  • Breast - is offered to women aged 50 to 70 to detect early signs of breast cancer. Women over 70 can self-refer via the NHS website
  • Bowel - a home testing kit is offered to men and women aged 60 to 74. If you’ve’ misplaced your kit or you are 75 or over, you can ask for a kit every two years by phoning the free bowel cancer screening helpline on 0800 707 60 60
  • Cervical - is offered to women aged 25 to 64 to check the health of cells in the cervix. It is offered every three years for those aged 25 to 49, and every five years from the ages of 50 to 64.

Further details can be found on the NHS screening website.

Screening tests are for people without symptoms. If you have symptoms, but have had a normal screening test result, you should still see your GP.


What cancer vaccination is available?

All 12- and 13-year-olds in school Year 8 are offered on the NHS the human papillomavirus (HPV) vaccine – boys and girls. The vaccine, helps protect against cancers caused by HPV, including:

  • cervical cancer
  • some mouth and throat (head and neck) cancers
  • some cancers of the anal and genital areas
  • protecting against genital warts.


It is important that girls who receive the HPV vaccine also have regular cervical screening once they reach the age of 25.

Find out more about the HPV vaccine.


How do I spot the signs of cancer?

Spotting cancer early means treatment is more likely to be successful. You can find out more about the common signs and symptoms of cancer on the NHS website and Macmillan Cancer Support 

You know yourself best. If you notice anything that isn’t normal for your body, go and see your GP. Encourage your loved ones to do the same.


What will happen if my GP suspects I have cancer?

Your GP should refer you urgently to a hospital specialist if he/she suspects that you may have cancer. You should then be contacted within two weeks of this referral being received by the hospital. 

For further information on what an urgent referral means and to prepare for your appointment look here.


What cancer treatment will I have?

In cases where cancer has been confirmed, you should start treatment within 31 days from when the hospital specialist has decided that you require treatment.

Surgery is a common treatment for most types of cancer, as solid tumours can often be surgically removed.

Other commonly used treatments include chemotherapy (cancer killing medication) and radiotherapy (the controlled use of high energy X-rays).


How can I get help to live as well as possible after a cancer diagnosis?

Improvements in the diagnosis and treatment of cancer mean that more people are living longer after a cancer diagnosis, but not everyone is living well.

Macmillan’s I've Finished Treatment webpage provides lots of advice on coping with life after cancer, and getting support. Speak to you key worker about health and wellbeing events being run locally or visit the Cancer Care Map website.


What is Surrey Heartlands Clinical Commissioning Group (CCG) doing to improve outcomes and survival rates for cancer patients?

By 2024, we want people in Surrey Heartlands to live healthy and fulfilling lives to reduce their risk of cancer. Should they be diagnosed with cancer we want people to be diagnosed as early as possible, to have prompt, high quality treatment and to feel fully supported throughout their journey to ensure the best chance of survival and recovery, whilst maintaining a good quality of life.

Across Surrey Heartlands, we have some positive cancer patient outcomes with 75.6% (2016) of patients surviving one year. We aim to improve one year survival rates to 80% by 2024.

Surrey Heartlands also has high reported patient experience through the National Cancer Patient Experience Survey (2018) with an average patient rating of care of 8.9 out of 10. However, there remain areas that need to be improved to ensure equity of outcomes for all patients. 

To improve outcomes, Surrey Heartlands CCG is working with system partners on a range of projects to transform pathways to diagnosis, improve patient experience and implement the 28 day to diagnosis pathways.

We are also working with partners to improve the personalised care offer to cancer patients and their families.

If you would like to get involved in Surrey Heartlands cancer work stream, please contact Becky Clack, Cancer Transformation Programme Manager on 07917 722703 or This email address is being protected from spambots. You need JavaScript enabled to view it.


Useful links and services



Model Publication Scheme Class: Not part of the MPS



Community Pharmacy

Community pharmacists like GPs, nurses, dentists and other healthcare professionals, are part of the NHS family. Every day about 1.6 million people visit a pharmacy in England.

Community pharmacies range from large chain stores, often on the high street or in supermarkets to smaller independently owned pharmacies often serving smaller or more rural communities. Many Pharmacies are open long hours offering healthcare advice, without the need for an appointment, when other health care professionals are unavailable.

The traditional role of the community pharmacist as the healthcare professional who dispenses prescriptions written by doctors has changed. In recent years community pharmacists have been developing clinical services in addition to the traditional dispensing role to allow better integration and team working with the rest of the NHS.


Out of Hours Medicines and Prescriptions

If you run out of medicine or your prescription outside of your GP surgery's normal opening hours and need some urgently even if you're away from home go to the Out of Hours Medicines page of the website.


Why should you seek the help of a Pharmacist?

As qualified healthcare professionals, Pharmacists can offer clinical advice and over-the-counter medicines for a range of minor illnesses, such as coughs, colds, sore throats, tummy trouble, earache, cystitis, skin rashes, baby teething, red eye and aches and pains. They are also trained to provide health and wellbeing advice.

Pharmacists undertake a four year Masters in Pharmacy degree course followed by a one year placement working in a pharmacy under the supervision of an experienced pharmacist. At the end of this year they take a professional examination and those who successfully complete the examination are able to register as a pharmacist.

Pharmacists have the right training to make sure you get the help you need if your symptoms suggest something more serious, for example, they will tell you if you need to see a GP, nurse or other healthcare professional.

Most pharmacies have a private consultation room where you can discuss issues with pharmacy staff without being overheard.


What help and services do Pharmacies provide?

Community Pharmacies provide a range of services and help ranging from:

  • A Repeat Dispensing Service. This service allows you to collect your regular repeat prescription medicines direct from your local pharmacy for an agreed period of time, without having to go back to your GP. You will need to give your permission to your GP for him/her to share information with your chosen pharmacist. When you need your prescription, instead of requesting it from your GP, you will be able to get your medicines directly from your local pharmacy.
  • Medicines Use Reviews* (MURs). An MUR is a consultation between the pharmacist and a patient that lasts approximately 10-20 minutes. It provides an opportunity for the patient to discuss how they use their medicines and to find out more about them; and the service is designed to supplement (and not replace) the more in depth clinical reviews that are conducted at GP practices. * This service is being replaced Apr 21 with the roll out of the Community Pharmacist Consultation Service
  • New Medicine Service (NMS). The service is for people who have received their first prescription for a medicine to treat any of the following conditions:
    • asthma
    • lung conditions such as chronic bronchitis and emphysema
    • type 2 diabetes
    • high blood pressure
    • conditions where you take a medicine to control the way your blood clots.
  • Disposal of Unwanted Medicines. If you have any medicines that you no longer use, you can take them to your local pharmacy for safe disposal.
  • Other services. that may be available at your local pharmacy:
    • you may be referred to a pharmacy for advice after calling NHS 111
    • emergency contraception
    • asthma inhaler use and advice
    • chlamydia screening and treatment
    • stop smoking service
    • blood pressure, cholesterol and blood sugar testing
    • substance misuse service, including needle and syringe exchange schemes
    • weight management service
    • flu vaccination


Useful links



Review Date: 2021-02-26
Review Due: 2022-02-26
Model Publication Scheme Class: Class 9: Services Commissioned

Learning Disabilities

What is a learning disability?

People with learning disabilities are among the most vulnerable and socially excluded in our society. It is estimated that there are approximately 20/1,000 people with mild learning disabilities and 3-4/1,000 with severe and profound learning disabilities in the UK.

Over the past three decades, almost all the long-stays in hospital for people with learning disabilities have closed and virtually all people with learning disabilities are now living in the community and depend on general practice for their primary care needs.

There is often much confusion between what is a learning disability or a learning difficulty.

Here is an explanation:

A learning disability is a reduced intellectual ability and difficulty with everyday activities – for example household tasks, socialising or managing money – which affects someone for their whole life

Someone must meet all 3 of these criteria for a learning disability diagnosis

  • Significant impairments in intellectual functioning (IQ below 70)
  • Significant impairment of social or adaptive reasoning. The person requires support to achieve their survival needs i.e. eating, drinking, planning, appropriate clothing for weather etc. and with social problem solving and reasoning
  • Impairment of onset before 14 years old.

What is not a learning disability?

  • It is not a mental illness
  • It is not Autism or ADHD in isolation. Autism is sometimes mistaken as a learning disability. Autism affects a person with their social interaction, communication, interests and behavior. Someone with Autism can have a learning disability but not always.
  • A person can have a learning difficulties on a scale might have a mild learning difficulty or a severe learning difficulty.
  • A person with an IQ score that falls slightly above 70 would be deemed to have a learning difficulty
  • The person may have a specific difficulty processing certain types of information i.e. numbers (dyscalculia), reading and writing (dyslexia), dyspraxia. These conditions are specific learning difficulties.
  • Blindness or deafness in isolation is not a learning disability. Although people with a learning disability can have, in addition to their learning disability diagnosis, have loss of hearing and/or sight)

Better working to support people with learning disabilities

Across Surrey we are working towards greater integration of health and social care for people with learning disabilities, in order to improve the service they receive.

This will mean creating a single team across Surrey County Council and the NHS, with staff receiving information and training on supporting people with a learning disability and/or autism and it will be a contractual requirement that services are able to accommodate their needs.

One of the key aims of our work is to ensure that more people can live in the community, with the right support, and closer to home.

To help achieve this, we have our county-wide Learning Disability Partnership Board, a county-wide Autism Partnership Board and the Learning Disability and Autism Programme Delivery Board.

We are also committed to service user and carer engagement and this is done through our local Valuing People groups.


Transforming Care

Surrey Heartlands CCG is working hard to make sure that fewer people with learning disabilities and/or autism will need to go into hospital for their care by improving services in the community.

We have plans in place for the discharge from all CCG beds for adults with learning disabilities and/or autism and, where people do need to stay in hospital, we will work to ensure their care is the best it can be so they can be discharged as soon as possible.

We have a small local Forensic community team (FIND) for people who have forensic support needs with a learning disability and/or autism and we are currently in discussion with our local providers with regards to providing settled accommodation and support for people with these needs.

We are also working in partnership with health, social care and our provider partners to:

  • Develop discharge pathways and community alternatives to hospital stays.
  • Carry out Care (Education) and Treatment Reviews (CTRS and CETRS) to ensure that all those involved in a person’s care and treatment are acting to ensure that the person can be discharged from hospital as soon as they are well enough to leave.
  • Conduct eight week visits for all adults and six week visits for all children and young people in out-of-area inpatient settings to ensure they benefit from increased focus on their care.
  • Maintain the quality of our learning disability and autism inpatient facilities. We will be working with Experts by Experience service users and carers to check the quality of our local services.

There is further information available on the following links:


Acute liaison and reasonable adjustments

When people are ill and need to go into hospital they may find it difficult to explain their symptoms. They may not be comfortable with the hospital environment and as a result may not receive the care they need.

Surrey Heartlands CCG is working in partnership with all our local hospital trusts in order to develop services which provide reasonable adjustments to help people with learning disabilities receive high-quality care.

Examples include making sure that every acute hospital has both adult and paediatric learning disability liaison nurses.

Please check with your local trust to see what services we have put in place to help you and your family receive the best care.

Royal Surrey County Hospital 

Frimley Park NHS Foundation Trust

East Surrey Hospital             

Ashford St Peters

Epsom St Helier                      

Surrey and Borders NHS Foundation Trust


Annual Health Checks

People with a learning disability often have poorer physical and mental health than other people. An annual health check can improve people’s health by spotting problems earlier.

All people with a learning disability are entitled to be registered on the GP learning disability register. From age 14 + they will be offered an enhanced annual health check.

Our new Primary Care Networks will be working hard to:

  • Increase the numbers of people with learning Disabilities having an annual flu vaccination.
  • Increase the numbers of people having the enhanced health check.
  • Reduce the use of unnecessary medication ( STOMP)



Surrey Heartlands CCG is part of the national Learning Disability Mortality Review (LeDeR) Programme. The LeDeR programme is commissioned by the Healthcare Quality Improvement Partnership (HQIP) and funded by NHS England. 

The aim of the programme is to support local areas to review the deaths of people with learning disabilities (aged four years and above), identify learning from those deaths, and ensure services are developed in order to address any learning from the review. The University of Bristol is contracted to establish and develop the review process and evaluate the findings. 

For more information on the programme please click HERE.  

Anyone can report the death of a person with a learning disability to the LeDeR programme.  All deaths of people with learning disabilities who are aged four years and above should be reported.  Deaths can be reported via:

Eileen Clark, Deputy Director for Quality and Nursing and Kathryn Fisher, Head of Integrated Learning Disability Commissioning are the Local Area Contacts (LACs) for the Surrey Heartlands CCG programme.

They can be contacted at This email address is being protected from spambots. You need JavaScript enabled to view it. and This email address is being protected from spambots. You need JavaScript enabled to view it..


You can read the latest LeDeR Annual Report to get an overview of the LeDeR programme and how this has been implemented in our local area. It provides an overview of the number of deaths that have been reported to LeDeR for these areas and summaries the learning that has come from the completed reviews.


Carer support

Providing care for someone with a learning disability can be very demanding and it is important to ensure that you make time to look after your own health and well-being, not least because in many cases carers support their loved one for the rest of their life. Across Surrey, support is available to help the person you care for reach their full potential, and to support you and your family.

Speaking to people who are facing similar challenges to you can help you make sense of things. Having a network of people who you can turn to for advice and support can be very helpful. Key to all this is understanding the rights you have as a carer enshrined in the Care Act 2014 and the Children & Families Act 2014. There are many things you will want to consider including planning for the future.

Please click here for more advice on services and support available to you.


Model Publication Scheme Class: Not part of the MPS



Medicines Optimisation


On this page

  • Role of Medicines Optimisation
  • Ask your Pharmacist
  • Branded verses Generic prescribing of medicines
  • Help with health costs
  • Surrey Heartlands CG Medicines Optimisation Team
  • Antibiotic Resistance


Role of Medicines Optimisation

The use of medicines is the most common therapeutic intervention. It is estimated that that 15-20% of a CCG’s money is spent on medicines. Medicines Optimisation is simply looking at all aspects of the safe supply, use and disposal of medicines.

Effective Medicines Optimisation will help contribute towards:

  • Improving health
  • Improving patient care and satisfaction
  • Reducing medication wastage

Prescribing is a key component of Medicines Optimisation. Doctors or other healthcare staff accredited as prescribers can prescribe medicines for patients under their care using a written order or prescription. Whilst prescribers can decide on whatever medication they think is appropriate for the patient, they are expected to take into account the evidence for the clinical and cost effectiveness of the medicines they prescribe.


Ask Your Pharmacist

  • Pharmacists across provide a range of services.
  • 96% of people can get to a pharmacy within 20 minutes by walking or using public transport.
  • Community pharmacists provide rapid access, without appointment, to a healthcare professional and now offer a range of clinical and public health services.
  • Ask Your Pharmacist, it may save you making an unnecessary trip to your GP or A&E.


Help with Health Costs

You can find more information on prescription charges, prescription exemptions and health costs by clicking here. Please discuss the prepayment certificate with your pharmacist if you pay for your prescriptions and have to have regular prescriptions since you may be able to save money.

  • Help with Health Costs - site with information on help with health costs including prescription prepayment certificates.


Surrey Heartlands CCG Medicines Optimisation Team

Your Medicines Optimisation team is a dedicated group of pharmacists and pharmacy technicians working towards the common goal of improving the use of medicines across Surrey Heartlands. Within Surrey Heartlands there are four teams located within each Integrated Care Partnership (ICP). Our aim is to ensure that patients within Surrey Heartlands get the medicines they need to achieve the greatest health outcomes for both the individual and the local community within the resources available.

We use our experience and knowledge of medicines to ensure medicines use is as safe as possible. We constantly review new evidence and guidelines so that everyone can obtain the best outcomes from the medicines that they take.

By working closely with all members of local GP practices, our aims are to:

  • promote effective prescribing to prevent, as well as treat, disease to keep our local population healthy in future years.
  • help patients with long-term conditions, such as diabetes and heart disease, to use their medicines effectively to reduce disease progression and keep them healthier and independent for longer.
  • review new drugs that come on to the market and ensure that drugs that have been appraised by NICE are made available to those who will benefit most from them.
  • tackle the issue of wasted medicines which has been estimated to cost the NHS £300 million each year, of which £150 million is avoidable.

We also work closely with other local organisations including community pharmacies, Acute Trusts, borough councils and community health services to proactively deliver a quality service and help patients make the best use of their medicines. Read more about how we are collaborating together through Integrating Pharmacy and Medicines Optimisation (IPMO) across Surrey Heartlands.


Did you know?

  • If you have any unused medicines at home, you should take them to your local community pharmacy for disposal
  • If you have any queries or difficulties with your medicines you should first talk to your community pharmacist
  • Local prescribing decisions are available to view on the Prescribing Advisory Database.


Antibiotic resistance

Antibiotic resistance is one of the biggest threats facing us today.

  • Why it is relevant to you
    Without effective antibiotics many routine treatments will become increasingly dangerous. Setting broken bones, basic operations, even chemotherapy and animal health all rely on access to antibiotics that work.
  • What we want you to do
    To slow resistance we need to cut the unnecessary use of antibiotics. We invite the public, students and educators, farmers, the veterinary and medical communities and professional organisations, to become Antibiotic Guardians.
    Choose one simple pledge about how you’ll make better use of antibiotics and help save these vital medicines from becoming obsolete.
  • Visit to make your pledge.


You can help to keep antibiotics effective.



Review Date: 2021-02-26
Review Due: 2022-02-26
Model Publication Scheme Class: Class 9: Services Commissioned
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