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At the heart of general practice since 1960

Meet the vanguards: NHS England's new pilot projects

See what bids to become NHS England ‘new models of care’ have been successful in your area

Tower Hamlets Integrated Provider Partnership

Patient population: 270,000

It is made up of a collaboration of partners that include Tower Hamlets GP Care Group Community Interest Company (representing primary care); Barts Health NHS Trust (the local acute and community health services trust); East London NHS Foundation Trust (local mental health trust) and London Borough of Tower Hamlets (local council and social care).

A patient in Tower Hamlets will benefit from having straightforward easy to access health and social care services and a positive patient experience.

This new model of community care will now ensure a single shared assessment and plan for patients. It will enable social care, primary, community and acute health services to truly co-ordinate their services around the patient, rather than the patient and their carers having to navigate themselves through numerous health and social care services.

A key part of the Tower Hamlets proposal is to have a greater focus on a positive patient experience and, as such, patients can expect an improved experience of care across all health and social care services in the local community.

The current collaboration of four organisations will be broadened to include both local voluntary and community sector organisations, as well as patient and service user groups, to share experiences and skills in the best interests of patients.

 

NHS Sutton CCG

Patient population: 180,000

Sutton CCG covers a registered GP population of 180,000 and 27 GP practices. The Vanguard application has been made in partnership with London Borough of Sutton, AgeUK Sutton, the Alzheimer’s Society, Epsom & St. Helier Hospitals NHS Trust, South West London & St. George’s Mental Health Trust and Sutton and Merton Community Services (the Community division of the Royal Marsden).

The Vanguard site will develop a care home provider network to support training across local care homes, and a new model of health and social care locally, which will include tele-health and expanded in-reach services, providing the right care at the right time where patients need it.

This means a patient who has three in-patient hospital stays in a month, will now get the care they need from hospital specialists at home, enabling them to stay close to their family and friends. 

 

Yeovil District Hospital NHS FT

Patient population: 1,500

This Vanguard is a partnership of Yeovil District Hospital NHS Foundation Trust, Somerset CCG, South Somerset Healthcare GP Federation and Somerset County Council that will be working to deliver an Integrated Primary and Acute Care System. 

The Hospital Trust and GP Federation are joining together to establish a joint venture which will hold a single budget for the population and target resources to parts of the system where they can make the most difference to patients.

This will initially focus on approximately 1,500 South Somerset residents who have multiple long term conditions, providing integrated care in three hubs that bring together primary, secondary and other sorts of care in one place. 

The hubs will provide care co-ordination, senior medical input and a single personalised care plan that helps people to look after themselves. 

Other GPs will increasingly provide ‘enhanced primary care’, offering support such as health coaching to patients with less complex conditions, and ultimately the PACS model will benefit the whole community by improving surgical processes and networking better with neighbouring trusts.

Under the new joint venture scheme a patient who suffers, for example, from diabetes, hypertension and depression will see improvements in the way people work together to meet their needs.   Their treatment will be guided by a care plan that they will design with their care co-ordinator, setting out what they want from their care. 

When the patient visits the hub, their team of different professionals will work together to deliver the plan.

In between visits, the patient will be supported by remote monitoring of their condition, and will use the ‘Patients Know Best’ web platform to view their plan and keep in contact with the hub team.  

Under the new joint working patients will see improvements in the way people come together to meet their needs, with less duplication, fewer delays and more proactive health and care services.

GPs, hospital consultants, community staff, and social workers will work as a single team to share information about patient care needs, and deliver a more integrated set of services which meet their individual circumstances and prevent unnecessary admissions to hospital.

Working together, health and care staff will also be able to respond to patients’ wider care needs so they can enjoy an independent, and healthy lifestyle. 

 

NHS Hampshire and Farnham CCG

Patient population: 220,000

The Vanguard is made up of providers and commissioners of health and social care for a population of 220,000 in North East Hampshire and Farnham.

It will focus on the development of an integrated health, social care and wellbeing system which will put the person at the centre of their care.

NHS and social care services will share resources and skills to support people to stay healthy and well at home.

Care will be provided by local multi-disciplinary teams working together, across physical and mental health services and in partnership with the voluntary sector to provide a personalised service. 

The Vanguard will support people with respiratory and cardiac problems and people who have fallen.  For example, a patient with a long term respiratory condition, waiting for many long assessments to be completed by different parts of the health and care system will, in the future, have a single assessment, together with their family and carers, to help them stay healthy and well. 

 

Isle of Wight

Patient population: 140,000

The Isle of Wight covers a registered GP population of 140,000 and 17 GP practices. The Vanguard application team known as ‘My Full Life’ is a partnership consisting of Isle of Wight CCG, Isle of Wight NHS Trust, Isle of Wight Council and the GP collaborative One Wight Health.

The Vanguard will develop person-centred, coordinated health and social care services for the island. This will support better outcomes for people, working with local communities to build capacity and resilience of people, families and carers.

This will be achieved through a greater use of digital technology coordinated through a single point of access. It will include patient-led monitoring and will be supported by primary care led integrated locally based services, delivering care out of hospital right across the Island. 

This will mean a patient with multiple long term conditions, such as diabetes, will be supported to manage their condition so it enables them to live the life they want to lead. This will include monitoring their condition and working with their GP practice to ensure they receive out of hospital care and are able to remain at work.

 

Whitstable Medical Practice

Patient population: 53,382

The Vanguard for Whitstable in Kent is made up of the Whitstable Medical Practice (Dr John Ribchester is pictured), Northgate Medical Practice and the Saddleton Road & Seasalter Surgeries.

They will be working in partnership with local health, care and support organisations including Canterbury & Coastal CCG, Kent County Council, East Kent Hospital University Foundation Trust, Kent Community Health Trust, Kent Partnership Trust and AgeUK.

Whitstable’s Multispecialty Community Provider will cover a population of 53,382 local people currently registered to GP practices in the area.

Patients, such as an elderly person with dementia living in residential care, for example,  will see the benefits of the new model of care through better trained care workers looking after them each day.

These care workers will have learnt in a new setting, alongside colleagues from other disciplines and with access to new technology. This will result in a team looking after the patient that has better insight into dementia and from specialist input from a geriatrician with expert knowledge of the condition.

The patient and their family will feel fully involved in all decisions about their care plan, and will be able to set goals and outcomes for their care and support that are important to them personally.

 

Southern Hampshire

Patient population: 220,000

Southern Health NHS Foundation Trust is working in partnership with 16 local NHS, local government and voluntary sector organisations to develop their Vanguard Multispecialty Community Provider across Southern Hampshire. 

 The Multispecialty Community Provider aims to improve the health, well-being and independence of people living in Southern Hampshire by delivering higher quality, more accessible and more sustainable out-of-hospital care.

It will serve a population of nearly one million, with the initial focus on launching three rapid implementer local sites covering South West New Forest, Gosport and East Hampshire. 

These sites will include 27 GP practices with a combined population of 220,000 and cover a rural area with an aging demographic (South West New Forest), an urban population with high levels of deprivation and significant pressure on local GPs (Gosport) and an aging population in a semi-rural area with difficult transport links (East Hampshire).

The Multispecialty Community Provider will support people to take a more active role in self-managing their care and offer access to improved care when needed. 

For example, an older patient leaving hospital after an episode of pneumonia would be supported to stay at home.  Their GP practice would work with them to co-develop a care plan that will help them to maintain their independence and stay at home as they continue to manage their existing health conditions such as diabetes. 

They will have regular check-up appointments at their local practice or hospital but also be able to access urgent appointments at their practice when they need them.  Their integrated care record will mean that they will not have to remember and repeat their medical history and that staff will understand their needs wherever they go for help.   

 

NHS East and North Hertfordshire CCG

The Vanguard is made up of Hertfordshire County Council, East and North Hertfordshire Clinical Commissioning Group and Hertfordshire Care Providers Association. 

All of the care provider organisations in the East and North of Hertfordshire are committed to supporting and continuing to improve the care for its most vulnerable elderly residents. 

The Vanguard will focus on enhancing the skills and confidence of care home staff through a package of education and training. 

The programme will create dedicated multi-disciplinary teams for Care Homes which will include GPs, community psychiatric nurses, district nurses and geriatricians. They will work with homes to support residents proactively as well as if a resident’s condition deteriorates.  They will develop a rapid response service so that care homes have access to services in two localities with a combination of community nurses, matrons, therapists and home carers who can be deployed within 90 minutes if required.

This means care home patients will be supported in the home by staff that are accredited because they have undertaken a package of education and training.  In addition patients will know that should their condition deteriorate, a team of experts is ready to respond to their needs before making an assessment as to whether they need to go to hospital.

 

NHS Mansfield and Ashfield and Newark and Sherwood CCGs

The Better Together Programme Board partners are: Mid Nottinghamshire Clinical Commissioning Groups (Mansfield and Ashfield and Newark and Sherwood CCGs); Aspirant Accountable Provider Alliance (Sherwood Forest Hospitals NHS Foundation Trust, Nottingham University NHS Trust, United Lincolnshire Hospitals NHS Trust, East Midlands Ambulance Service, Nottinghamshire Healthcare NHS Trust, Central Nottinghamshire Clinical Services, Circle); Voluntary Sector Special Purpose Vehicle (three District Council CVSs); General Practice Provider Clinical Cabinet (facilitated by the Local Medical Committee); Nottinghamshire County Council.

This PACs will deliver integration between health and social care services within a single outcomes-based contract.

This will be made possible by moving to a model of home-based proactive care. 

Specific services within this model will include a single point of access and health and social care triage with A&E, integrated teams as well as community based crisis response teams. This will all be supported by improved data sharing between Primary and Secondary care providers, and data sharing between A&E and the out of hours GP services.

Following implementation of the new care model, a person who is discharged from hospital after a bout of pneumonia, for example, will be given a wrap-around care package which includes both integrated care team support, and support from community based crisis response teams. This means that they have the opportunity to stay at home rather than be admitted to a care home. 

 

Derbyshire Community Health Services NHS Foundation Trust

 Patient population: 97,000

Derbyshire Community Health Services NHS Foundation Trust providers cover a registered GP population of 97,000 and provide 12 GP practices. 

Derbyshire Community Health Services NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust, Erewash GP Provider Company, Derbyshire Health United (Out of Hours Service & 111) and NHS Erewash Clinical Commissioning Group made a joint application to become a Vanguard site. 

The Vanguard will develop a prevention team made up of health and care professionals including GPs, advanced nurse practitioners, mental health nurses, extended care support and therapy support. 

It will deliver services to people who do not require hospital services and can be treated for their conditions in a community setting.  This will include care planning for people with long term conditions including diabetes, chronic vascular disease and chronic lung conditions.

There will also be focus on extending access to GP services. 

‘RightCare’ records detailing treatment plans for the most vulnerable people will be made accessible on A&E and Out of Hours computer systems.  This will help A&E and out of hours staff to talk frail and vulnerable people through their concerns and support them to remain in their homes when they do not require specific hospital treatment.

 

Vitality (Birmingham)

Patient population: 70,000

The vanguard is made up of a single, local GP partnership called Vitality Partnership which operates from 15 practice sites across Birmingham and Sandwell and serves a registered population of 70,000 patients.

The vision for the vanguard is to develop a health and social care system accessible through GP practices, with a care-coordinator to support patients on their journey.  

This will be achieved by delivering medical services from a number of primary care centres across Birmingham and Sandwell. 

The larger centres will expand the range of social, mental, community and enhanced secondary care services on offer to patients by delivering community outpatient and diagnostic services.

This will mean that, for example, a person who has diabetes and suffers from high blood pressure will benefit from being treated in a familiar environment that is close to home and will be supported by a care co-ordinator to help manage their care plan. 

 

Wirral University Teaching Hospital NHS Foundation Trust

Wirral Health Partners is made up of: Wirral University Hospital NHS Foundation Trust; Cheshire and Wirral Partnership NHS Foundation Trust, Wirral Community NHS Trust; Wirral Clinical Commissioning Group; GPs on the Wirral; Wirral Metropolitan Borough Council; Cerner UK Ltd, Advocate Physician Partners ACO (USA based); and the King’s Fund.

Wirral Health Partners will accelerate a new model of integrated care across primary and secondary care providers, supported by a technology enabled population health model.

Integrated care teams will be expanded to reduce readmissions and support people to remain at home through primary/secondary care collaboration. Following implementation, the new model will work by identifying older people, such as Jane, 86, who are at potential risk of serious fracture following minor falls that result in emergency admission.

With approval of the patient, care plans will be developed, home assessments carried out and aids added to reduce the probability of falls happening. With this support, patients such as Jane are able to stay in her home and potentially avoid a serious fracture.

 

Northumbria Healthcare NHS Trust

The Northumberland Integration Board is made up of Northumbria Healthcare NHS Foundation Trust (Lead Partner); Northumberland Clinical Commissioning Group;  Healthwatch Northumberland; Northumberland County Council; Northumberland Primary Care Practices; Northumberland Tyne and Wear NHS Foundation Trust and North East Ambulance Service.

This vanguard will help communities to live long and healthy lives at home. This will be supported through the opening of the Northumbria Specialist Emergency Care Hospital, an extension of primary care to create ‘hubs’ of primary care provision across the county seven days a week. This redesign of community and acute services will ensure patient care is delivered increasingly in community settings, and bring together commissioning responsibility across the whole health economy.

Following implementation of the new model, patients will be able to access their GP over the weekend, preventing the need to go to the Emergency Department when symptoms worsen.  The model cuts across organisational boundaries and includes enhanced access to community nursing services, fully coordinated discharge and shared IT that will support better care in a number of health settings and in the home.

 

Salford Royal NHS Foundation Trust

Patient population: 230,000

The Vanguard is made up of the following organisations; NHS Salford Clinical Commissioning Group, Salford City Council, Salford Royal NHS Foundation Trust and Greater Manchester West Mental Health NHS Foundation Trust, which together form the Salford Together Partnership.  In addition, there is active support and engagement from Salix Health, the local GP provider consortium. 

Salford intends to create an Integrated Care Organisation. It believes that by pooling its expertise into one organisation, residents will receive more coordinated care as it will be provided by health and social care professionals working within the same organisation.

The integrated care organisation will be established giving Salford Royal lead responsibility for meeting the health and social care needs of the population through both direct provision and contracts with other local providers.

During 2015, Salford will commence work to combine health and care services for the entire adult population, including preparation to transfer Adult Social Care services to Salford Royal and to establish  arrangements for adult and older peoples’ mental health services.

At the same time, Salford will also be rolling out a new model of care. This has three parts; first, the establishment of multidisciplinary groups to identify people who are at most risk of becoming more unwell and to coordinate services around their needs. Second, working with the voluntary sector it will build supportive networks for individuals who are at risk of becoming socially isolated. Third, it will create a single centre for people to contact to guide them to the right support or services, as well as providing health coaching for people with long term conditions. 

 

Lancashire North

Population: 365,000

The partners of this Vanguard are all members of the Better Care Together Programme, working on behalf of the population of Morecambe Bay which has 365,000 residents. 

They include five NHS Trusts:  University Hospitals Morecambe Bay NHS Foundation Trust; Cumbria Partnership NHS Foundation Trust; Blackpool Teaching Hospitals NHS Foundation Trust; Lancashire Care NHS Foundation Trust.

The Vanguard also includes North West Ambulance Service NHS Trust (NWAS) and two NHS Clinical Commissioning Groups: NHS Lancashire North Clinical Commissioning Group and NHS Cumbria Clinical Commissioning Group.

Two Local Authorities, Lancashire County Council and Cumbria County Council are also in the Vanguard, together with two GP Provider Federations, the North Lancashire Medical Group and the South Cumbria Primary Care Collaborative.

The Vanguard will create a system that will take responsibility for the whole health and social care needs of the population within a single budget.

This will mean a smaller, more productive hospital service working hand-in-hand with integrated out of hospital services. 

It will focus on keeping individuals, families and communities healthy, developing capacity in general practice and community services, and focusing the hospital on the services only it can deliver.

This means that patients who work full time, for example, should have greater access to services at times that suit them, as the Better Care Together programme will develop more services and capacity in a setting closer to patients’homes.

 

NHS Harrogate and Rural District CCG

The Vanguard is made up of the following organisations; Harrogate District Foundation Trust, Harrogate and Rural District CCG, North Yorkshire County Council, Tees Esk and Wear Valley Foundation Trust, Harrogate Borough Council, Yorkshire Health Network. 

The vanguard will deliver access to advice and information for individuals in crisis 24/7 without defaulting to A&E as the first point of contact.  The aim will be to provide support to remain independent, safe and well at home with care provided by a team that the person knows they can trust and encompassed in a universal care plan.  This service will be provided by community hubs and an integrated team which includes GPs, community nursing, adult social care, occupational therapy, physiotherapy, mental health and the voluntary sector.

This means that people like Amit, who has multiple long term conditions and lives alone, will have an agreed care plan going forward that people involved in his care share and understand.  He will be able to access advice and information in times of crisis 24/7 which will support him to stay in his own home whenever possible.

 

Fylde Coast Local Health Economy

The Vanguard is made up of:  Fylde and Wyre Clinical Commissioning Group (CCG), Blackpool CCG, Blackpool Teaching Hospital NHS Foundation Trust, Lancashire County Council, Lancashire Care NHS Foundation Trust and Blackpool Council.  It also encompasses services provided by the voluntary sector.

The vision for the Vanguard is to create new models of care, wrapped around local people, spanning across all health and social care services.  It will mean that integrated teams of community nurses, allied health professionals, social care, mental health and third sector will be fully implemented by April 2016.  

By this point, one thousand people will be cared for within newly designed Extensive Care Teams for the frail and elderly population. This means that individuals such as Stanley, an 86 year old gentleman who has diabetes, angina and suffers from high blood pressure will have his condition managed by a co-ordinated and integrated health and social care team.  The team will have access to one care record to support the Stanley in his treatment.

 

Calderdale Health and Social Care Economy

The Vanguard is made up of:  Calderdale Pennine GP Alliance (represents 23 out of 26 Calderdale practices), Calderdale and Huddersfield Foundation Trust, Calderdale Clinical Commissioning Group, Calderdale Metropolitan Borough Council, South West Yorkshire Partnership Foundation Trust, Locala Community Partnerships (NHS), Voluntary Action Calderdale (represents 128 health-related 3rd sector organisations).

The Vanguard will be focused on two localities, one urban and one rural, representing 50% of the population and it will initially work to deliver integration across all services delivering care outside of a hospital setting through a single point of access.   The current providers will work in joint community based multi-disciplinary teams in all parts of Calderdale made up of an expanded team of community, social care, primary care, mental health and pharmacy services.

This means that patients like Janice, who currently needs support from a district nurse, social worker and her local pharmacist will be able to access this range of support in one place through a co-ordinated approach to ensure her needs are met.

 

West Wakefield Health and Wellbeing Ltd

Patient population: 63,000

The vanguard is made up of the 6 practices of West Wakefield Health and Wellbeing Ltd, covering a population of 63,000 people: Church Street Surgery, Orchard Croft Medical Centre, Chapelthorpe Medical Centre, Prospect Surgery, Lupset Surgery and Middlestown Medical Centre, NHS Wakefield CCG , Wakefield Council, Wakefield District Housing and is supported by South West Yorkshire Partnership NHS Foundation Trust, Wakefield Healthwatch, Mid Yorkshire Hospitals NHS Trust, Nova(VCS representative body), Yorkshire Ambulance Service and Local Care Direct.

The vision for the vanguard is to realise a fully integrated, expanded and digitally mature primary health and wellbeing system that includes delivering an improved 7 day service for their population, improving integration of community workers with community pharmacy and creating a team of care navigators who will have access to innovative digital technology that will help to ensure that the patient can access the right services that they require.

This would mean, for example, that a patient suffering from musculoskeletal problems will be able see a physiotherapist promptly without having to see a GP, and get professional assessment, advice and signposting. They would also benefit from having access to an allocated care navigator to assist them in finding the right care for their needs.

 

NHS Sunderland CCG and Sunderland City Council

Patient population: 284,000

The NHS Sunderland CCG and Sunderland City Council vanguard site covers a population of 284,000 people, and is made in partnership with: GP Federations – Sunderland GP Alliance and Washington Community Health Care, South Tyneside Foundation Trust ( provider of Sunderland community services), City Hospitals Sunderland Foundation Trust (acute trust), Northumberland Tyne and Wear  Foundation Trust (provider of mental health services in the city), Sunderland Care and Support Services (provide much of the previous Local Authority direct provision for adults), Sunderland Health Watch, Sunderland Local Medical Committee, Cumbria and North East Area Team, Voluntary and Community Action Sunderland.

The vision for Better Health for Sunderland will transform out of hospital and in hospital care, and help to enable self-care and sustainability. Staff will work as part of a multi-disciplinary team, focussing on more proactive, patient-centred care and prevention.

This would mean, for example, that elderly patients will be encouraged to recover in their own homes, or be placed in supported accommodation including care homes if that better suits their needs. Instead of ending up in hospital, patients will now have person-centred, co-ordinated care, and will have more input into the care that they receive.

 

Stockport Together

Patient population: 300,000

The Stockport together vanguard is an active partnership including: Stockport Metropolitan Borough Council, NHS Stockport Foundation Trust, NHS Pennine Care Foundation Trust and NHS Stockport CCG.

The vision for the new model of care builds on the GP registered list and will be integrated around the GP practice at neighbourhood level (20-30,000 population), at locality level (80,000 population) and at borough level (300,000 population). Hospital urgent care will be redesigned, with a single point of access that is integrated with community teams. People with complex conditions or at the end of life will have an integrated team working with them to support them and help them make the best decisions about their plan of care.

This would mean, for example, that a patient with a serious long term condition will have an integrated team working with them to help them realise the best possible quality of life, and supporting them to make the best decisions about their end of life care.

 

Primary Care Cheshire

Patient population: 330,000

A new Multispecialty Community Provider will now be developed in West Cheshire, an area in North West England with a population of 330,000. The lead partners for developing this model locally are NHS West Cheshire CCG and Primary Care Cheshire (a single entity). They are being joined by a further three participating partners: Cheshire & Wirral NHS Partnership Foundation Trust, Countess of Chester NHS Foundation Trust and Cheshire West and Chester Local Authority.

Under the plans put forward, patients can expect better and more integrated support from different local health and care services, with a particular focus on young children, managing long-term conditions and supporting elderly patients.

To this end, the new partnership will be launching 3 new programmes as part of their model: ‘Starting Well’ will focus on ensuring the best start in life for babies, children and young people in the local area; ‘Being Well’ will enable greater collaboration between local services and the several clusters of GP practices, supported by integrated teams, to help people manage long-term conditions, and; ‘Ageing Well’ will focus on excellent care for the frail/complex wherever they are living (including those in care homes).

 

Airedale NHS FT

Patient population: 506,000

The Airedale Partner’s Vanguard  objective is to enhance the quality of life, and end of life experience of  thousands of nursing and care home residents living in Bradford, Airedale, Wharfedale, Craven and East Lancashire.

The Vanguard application was made in partnership with a number of organisations including CCGs and their member practices, NHS providers, care home providers, social services and the third sector, technology partners and academic partners including the University of Bradford have also supported the bid.

The partners have a track record of innovative enhanced care delivery for this group of vulnerable, frail elderly people, many with multiple long term conditions including dementia and often approaching end of life. By using enabling technologies, such as telemedicine, the Gold Line and Intermediate Care Hub, nursing and care home residents and their carers are already benefitting from being able to access expert advice and support remotely 24/7.

Through the Vanguard programme, partners intend to go further and develop a more proactive health and social care enabling model focusing on optimising residents individual capabilities and building new clinical models of care. This model will be enabled through technology and an extended use of telemedicine providing a single point of access to all aspects of specialist health and care advice.

This would mean, for example, that a patient with Parkinson’s disease living in a residential home will be able to access clinical advice and support through secure video conferencing at any time of the day or night, so in the event of a fall, an experienced nurse in the tele-health hub would be able to assess the patient using the video link and after consultation with an A&E consultant will be able to arrange for them to be cared for in their familiar surroundings, rather than transferring them to A&E.

In addition, the enhanced care model provides links to social care to complete a falls prevention assessment of the layout of the patient’s room, and a multidisciplinary team including carers, nurses, therapists, social care and the voluntary sector work in partnership to deliver care and support, promoting independence and improving quality of life.

 

NHS Wakefield CCG

Patient population: 260,000

The partners participating in the proposed model to enhance integration with care homes and social care are Age UK, Wakefield District Housing, General Practitioners, Nova (support agency for voluntary and community groups), Wakefield Council, Yorkshire Ambulance Services, South West Yorkshire Partnership NHS FT and The Mid Yorkshire Hospital NHs Trust. Practices within NHS Wakefield CCG has a registered population of 260,000 people.

The model of care is designed to break the mould for older people in care homes, tackling social isolation and shifting from fragmented to connected care. They will develop a comprehensive approach to proactive assessment and care planning based around the wider determinants of health ‘somewhere to live; somewhere to love; something to do’ to optimise residents’ health and life experience. 

This would mean, for example, that an elderly patient in extra care housing could be supported to resume their hobby of walking following a hip replacement, helping to improve both physical health and quality of life.

 

Newcastle Gateshead Alliance

Patient population: 78,000

The partners proposing to work together to enhance health within care homes are Gateshead CCG and Gateshead Local Authority.  Gateshead has a population of circa 78,000 (2001).

A new organisation will be created called the Provider Alliance Network (PAN), which is to deliver the Gateshead Integrated Community Bed and home-based care service.  PAN will provide holistic care and seamless support across the traditional health and social care boundaries.  PAN will also oversee and connect healthcare for a population who are cared for and supported in long and short term stay community beds as well as helping those individuals in their family home undertaking re-ablement, rehabilitation and recovery services at home. 

This would mean, for example, that an elderly patient who has been in and out of hospitals will be visited by a multi-disciplinary team, who will work together with the patient to help them achieve their goals, including putting in place a Care Plan which will reduce the need for hospital admissions.

 

NHS Mansfield and Ashfield and Newark and Sherwood CCGs

The Better Together Programme Board partners are: Mid Nottinghamshire Clinical Commissioning Groups (Mansfield and Ashfield and Newark and Sherwood CCGs); Aspirant Accountable Provider Alliance (Sherwood Forest Hospitals NHS Foundation Trust, Nottingham University NHS Trust, United Lincolnshire Hospitals NHS Trust, East Midlands Ambulance Service, Nottinghamshire Healthcare NHS Trust, Central Nottinghamshire Clinical Services, Circle); Voluntary Sector Special Purpose Vehicle (three District Council CVSs); General Practice Provider Clinical Cabinet (facilitated by the Local Medical Committee); Nottinghamshire County Council.

This PACs will deliver a whole system integration of hospital, community, social and primary care within a single outcomes-based capitation contract. This will be enabled through moving from predominately reactive hospital-based system of urgent care, to one of home-based proactive care. Specific service interventions include a single front door and integrated triage at ED, locality based integrated care teams, specialist intermediate care teams, community based crisis response teams, referral GP review and speciality triage for referrals. This will all be underpinned by improved data sharing between Primary and Secondary care providers, and integrated data sharing between ED and out of hours GP services.

Following implementation of the new care model, Derek, a frail 85 year old gentleman who lives alone, was discharged from hospital after a bout of pneumonia. He was given a wrap-around care package which included both integrated care team support, and support from community based crisis response teams. This meant he could stay at home, in his preferred location, rather than being admitted to a care home. 

 

NHS Dudley CCG

Patient population: 318,000

The team behind the Vanguard application from Dudley is led by Dudley Clinical Commissioning Group and includes  Dudley Metropolitan Borough Council, Black Country Partnership NHS Foundation Trust, Dudley Group NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust, Dudley Council for Voluntary Services and Future Proof health Ltd.

The Multispecialty Community Provider model proposed by the partnership in Dudley aims to develop a network of integrated, GP-led providers across health and social care, each working at a level of 60,000 people, reaching a total population of around 318,000 across Dudley. This system will see the frontline of care working as “teams without walls” for the benefit of patients, taking shared mutual responsibility for delivering shared outcomes.  

Under the new provider system Ella,  a lady with frailty & long-term conditions & registered with a GP in Dudley, will have her care overseen by a multi-disciplinary team in the community including specialist nurses, social workers, mental health services and voluntary sector link workers. This will ensure holistic care that better meets all of Ella’s medical & social needs at one time in one place, but allows her to access advice and support for the isolation she can feel at living alone far from her family, and combatting her episodes of anxiety. When Ella  needs help urgently there is a 24 hour rapid response and urgent care centre which provide a single coordinated point of access for her so she doesn’t need to call 999.

As a result of the health and care system working better together in this way, people like Ella are not only receiving the coordinated support necessary for their health needs but they are also linking to  the wider network of care and social interaction in their community to help them to live more independently for longer.

 

Lakeside Surgeries

Patient population: 100,000 – plans to expand to 300,000

Lakeside Healthcare in Northamptonshire is one of the largest GP ‘super-practices’ in the country.  By merging four practices (Lakeside, Corby; Rothwell & Desborough; Albany House, Wellingborough; and Headlands, Kettering), 100,000 patients are brought together in a single list.  Through further planned mergers, both within and outside Northamptonshire, the intention is to expand the reach of the ‘super-practice’ to 300,000 patients, creating the largest GP-led primary care practice in the NHS.

By working in close partnership and collaboration with several local NHS providers (including: Kettering General Hospital; Peterborough & Stamford Hospital; University Hospitals Leicester; Northampton General Hospital and Northamptonshire Healthcare Trust), and also with key elected authorities (Northamptonshire County Council and Corby Town Council), and with Celesio (Lloyds Pharmacy), local social service providers and the voluntary and community sector, Lakeside Healthcare  plans to deliver a Multispecialty Community Provider (‘MCP’) service that will offer to patients a number of new services including: (i) a nationally acclaimed and respected Urgent Care Model (the ‘CorbyCare’ model - delivered both in community and front-of-hospital locations); (ii) an Ambulatory Care service, particularly designed to relieve pressure at the ‘front door’ of hospitals; (iii) a bespoke and effective long-term condition management service for the frail elderly and other vulnerable patient groups which might include admission to short-stay community beds managed by Lakeside; (iv) a highly focused GP-led complex-care management service; and (v) a number of hospital outpatient and planned care services, including dermatology, ophthalmology, MSK, geriatric medicine and mother & baby services.

Lakeside Healthcare aims to provide ‘extended primary care services’ to most patients, working in multidisciplinary teams that provide convenient care every day of the week.  The most vulnerable 7% of patients, who are intensive users of services, will be provided with ‘extensivist primary care services’ through which they will have access to longer, in-depth consultations with enhanced continuity of care.  The Lakeside team will work alongside hospital consultants to provide better and more integrated access to specialist care, and Lakeside will also employ its own consultants in key specialties.

Gordon is a frail 78 year old and lives alone in Corby.  Previously of good health, he now has high blood pressure and is prone to falling.  Gordon will benefit from registering with Lakeside because through the Lakeside ‘extensivist’ service he will be provided with a far greater degree of support than previously available. The practice will link up other services that can also help Gordon not only manage his hypertension better, but will also provide more rounded support to help him to stay safe at home.

However, if Gordon does fall, the Lakeside run Corby Urgent Care Centre will be available to deal with all Gordon’s minor injuries, providing x-rays and other tests that are usually only accessible in hospitals. If required, Gordon can be also admitted to a Lakeside observation bed for several hours so that staff can monitor his progress or be treated in an ambulatory care unit run by clinicians from Lakeside, providing enhanced continuity of care and avoiding unnecessary admissions.  This is a far better package of care for Gordon, in a setting that will be more familiar to him and provided by a team of doctors, nurses and other healthcare professionals that will see Gordon treated appropriately and then conveyed back to his home where the joined-up support will continue.

 

Principia Partners in health

Patient population: 126,000

Principia is constituted as a Community Interest Company and has three stakeholders classes: Rushcliffe GP practices; Rushcliffe community services providers; and the 126 000 registered population of Rushcliffe. GP practices in Rushcliffe have come together and are establishing a new and unique primary care partnership and organisation, which will lead on and indeed own the transformation of general practice and develop the progressive model which will be the base component and platform of the MCP.  Principia and Partners Health will also be joined by health and social care partners who have committed their enthusiastic support as part of our local South Nottinghamshire transformation work.  NHS Rushcliffe CCG is the sponsor, and the programme has the support of the patient and voluntary sector groups, which represent the local population. 

The proposal is to establish an MCP defined by a culture of mutual accountability, commitment and pride.  This will accept contractual responsibility for the health, and the quality and costs of care for the local population within the capitated resource allocated. This will be achieved through a new model of integrated care which is focussed on early intervention, living well at home and avoiding unnecessary use of the hospital. The impact will be a reduction in fragmentation, delays, duplication and inefficiencies experienced by patients and carers.  Care will be delivered closer to patients’ homes resulting in an enhanced experience and improved clinical outcomes, and better use of available resources. 

The MCP will move to have a capitated outcomes based contract which will cover health and social care. 

So Robert and Elsie, married both in their late 70’s live in a small rural village outside of West Bridgford and have done so since they retired 15 years ago where they lived and worked in Nottingham.  When the new accountable care organisation is in place Robert and Elsie (who both have multiple long term conditions) can expect to have a proactive care plan in place which is discussed with their local health & care team on a regular basis.  This conversation will build confidence and capability for the married couple to make good decisions about what they do to keep themselves fit and well and also when they need to escalate the level of support they need irrespective of the time of the day or week.  When they do so, they will do so to a provider able to respond to all their care needs, and in which all the participants are working with a common goal: maximising outcomes  as efficiently as possible. 

 

NHS Nottingham City CCG

Patient population: 340,000

Nottingham City CCG covers a registered GP population of 340,000 and 62 GP practices. The Vanguard application as made up of Nottingham CityCare partnership, Nottingham University Hospital NHS Trust, Nottinghamshire Healthcare Trust, Nottingham City Council, AgeUK Nottingham and Nottinghamshire and local primary care providers.

The Vanguard will develop a structured and pro-active approach to care, with coordinated health and social care teams working together supported by a range of ‘in reach’ services. This will be delivered through a whole system approach and services will be commissioned based on outcomes. 

It will mean that, 88 year old Helena, who lives in a care home, will be able to set agreed goals around her health and care needs, with support from the care home and full family involvement. She will be less likely to be admitted to hospital, due to telemedicine providing fast and effective access to clinical and specialist impact in her home. If she is admitted, there will be an effective discharge pathway to support a return to home as early as possible 7 days a week.

 

Readers' comments (7)

  • Spencer Nicholson

    http://www.realestate.com.au/property-house-qld-little+mountain-119148719

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  • Vinci Ho

    Not surprisingly , many descriptions about these Vanguards are politically correct and rhetorical . Of course, nobody wil dare to talk about any 'contingency plan' if funding became insufficient and dried up.
    Time will tell and judge..........

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  • 'Blah blah ... Care plan ... Blah blah ... Care coordinator .. Blah blah .. integrated .. Blah blah ... Frequent hospital admissions ... Blah blah telehealth .. Blah blah social care .... Blah blah multidisciplinary team.'
    I am sure it will still be GPs who get dumped with the patient when things deteriorate, and I am yet to find any demonstration of care plans improving outcomes that are not due to regression to the mean.

    Beware hospital or GP attendances becoming the main route to accessing social care as all other services are cut.

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  • Totally agree with the above post.Alot of waffle in the descriptions.The GP will remain the ultimate dumping ground.

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  • Bulls**t bingo comes to mind from that lot I think I ve got a "full house".Its definitley full of somthing.

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  • It's about time that Primary Care got extra funding to innovate and pilot changes to see if there is anything else that works.
    Otherwise, we carry on with the same old ...

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