More health and care services will be provided closer to people’s homes and we will help people stay at home when they’re unwell.
We aim to coordinate care better so that it meets the needs of the individual. We aim to pay close attention to the health and care services necessary to keep people living at home successfully, because we know this is the best way to keep people healthy and to maintain their independence. When people become unwell, we will take every opportunity to spot warning signs and focus local support to help people live with long term health conditions. We would like to see more joint working between local health and social care, with GPs playing a central role, supported by hospital clinical teams. As much care as possible must be led by primary care (GPs). We are supporting our GPs to share best practice, work together, access advice from hospital consultants and to provide the enhanced primary and community care that our local people need.
Time to care
Testbeds to support GPs.
Our ‘Time to care’ programme aims to support our 105 GP practices to manage increasing patient demand, help them to become more efficient, and to provide better quality of care to their patients. It also aims to improve the way in
which GP practices work with local hospital, community, social care, and voluntary sector providers to provide proactive
care close to the patients’ home.
Integrated Neighbourhoods
Multi-disciplinary teams, led by GPs targeting those at risk (such as those with long term
conditions, frail, elderly).
We aim to build on our teams which are staffed by district nurses, matrons, social workers, therapists, and pharmacists to provide integrated, proactive care for those with long term conditions, such as the dying, care home residents, and mental health service users.
Community experts
Specialist clinicians will support Primary Care Networks.
To support the Primary Care Networks we need an integrated team of community-based experts to care for the more complex patients and provide advice and education. However, more needs to be done to ensure that access to the
teams is fair, that the teams can access advice, and clinicians are able to review complex patients together to agree a
management plan.
Sharing knowledge
This is a central role of the patient care plan, and electronic access to patient information across
the system.
Proactive and person-centred care relies on there being one single care plan, owned by the patient and their family; one electronic care record accessible by all; one set of best practice protocols all can adopt; and one route through
which expert opinion can be accessed day or night.
Embedded mental health
Ensure community mental health is within Primary Care Networks, and that there are links
to liaison psychiatry and recovery.
Our Integrated Neighbourhoods already provide joined up community mental health services. We want to join up our
community and mental health teams further to make sure the psychological needs of people with long term conditions
and the physical health needs of patients with severe mental illness are met consistently.
Learning disabilities
Implementing ‘transforming lives’.
We have been working closely with the councils to implement ‘transforming lives’ for people with learning disabilities.
The Collaboration for Leadership in Applied Health Research and Care (CLAHRC) is evaluating the use of integrated
personal health and care budgets for people with learning disabilities
Your own bed, not a hospital bed
For end of life and intermediate care.
We aim to provide more rehabilitation closer to, or at, home to retain a patient’s independence, and provide more end
of life care at home, rather than in hospital.
