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Best care closer to home initiative


• Cockermouth Integrated Care Team – NHS Cumbria

• Advanced Planning in Care Homes – Northumberland Commissioning Group West Locality

• Basement Skin Service – Liverpool Central

Winner – Cockermouth Integrated Care Team

Cockermouth Integrated Care Team is an innovative whole-system design for care closer to home. It brings together the community hospital, general practice, nursing teams, adult social care and therapy teams in a ‘one team’ approach. The result of a full health impact assessment of patient need – including mapping forwards all major diseases for the next 20 years – is an organised, integrated and successful system.

An innovative partnership, Cockermouth Centre for the Third Age, links health and social care to the third sector. Earlier discharge from hospital is supported by a ‘virtual ward’ at home, giving structured and consistent support.

Patient benefits from the initiative are clear. Care is closely managed throughout a patient’s illness. If they are admitted to an acute hospital they are tracked with daily phone calls. Early discharge is promoted, and IV antibiotics and transfusions can be carried out at home. Rapid response teams can be deployed within an hour and hospice care can be provided at home around the clock.

The community hospital has a full range of therapy services and offers alternatives to acute hospital admission. All nurses and therapists in the town work in one team, using a common patient record on EMIS web. Nurses work to rigorous care quality indicators, and in the community hospital hand hygiene audits have virtually eliminated C. difficile infection.

Cockermouth’s devastating floods in 2009 resulted in a surge of community involvement and help from the Red Cross. The team aimed to sustain this community involvement through the creation of a centre to prevent unnecessary hospital admissions and promote good health in old age.

A recent slipper exchange marked Fall Prevention Week, regular social events are held, and befriending and volunteering is encouraged. Software enables the elderly to swap gifts such as dog walking in exchange for Sunday lunch, and school pupils help them to improve their IT skills.

Dr John Howarth, lead clinician for community services across Cumbria, says: ‘The approach in Cockermouth is an example of the wider approach we have taken across the whole of Cumbria to build a closer to home infrastructure.’

Results are impressive, with a reduction of at least 17% a year in non-elective bed days spent in the acute sector since 2008.

By delivering more care closer to home, Cockermouth has scored the lowest rate of non-elective admissions for the North West, and readmission rates benchmark in the lowest quartile in the region.The system has been associated with a large number of other quality and productivity initiatives – for instance, Cockermouth Hospital has seen a £250,000 reduction in nursing costs over two years and the average length of stay has dropped from 36 days in 2006 to nine days last year. In 250 community hospital beds across 13 sites, the team have:

• increased throughput per bed by 77% in three years

• reduced pressure sores by over 62% in the last 12 months

• reduced falls by 30 % in the last 12 months.


Judges’ Comments

Lots of innovation within the programme. We need more of this kind of work.

Dr Oliver Bernath, managing director, Integrated Health Partners


Cumbria has set the standards where they need to be.

Dr Charles Alessi, chair-elect, NAPC