The changes being made

The integrated care system is running a number of projects to deliver on its vision. Examples include:

Community hubs and integrated teams

Two community hubs are being piloted in Marlow and Thame to help patients take greater control over their care and treatment and avoid hospital admissions. The hubs offer:

  • Community assessment and treatment services including frailty assessments with a team of geriatricians, nurses, therapists and GPs;
  • An extended range of outpatient clinics including chemotherapy at Marlow;
  • More diagnostic testing including X-rays;
  • Support from voluntary organisations including Carers Bucks and Prevention Matters.

The team has produced a video for patients explaining more about the community hubs. In their first six months of operation (AprSept 2017):

  • There was a 37 per cent increase in outpatient appointments in the hubs in Marlow and Thame;
  • 642 people were referred, assessed and treated by the new community assessment and treatment service;
  • 92 people were seen in their own homes;
  • Only 6.6 per cent of patients seen in clinics went on to be admitted to hospital.

Locality integrated teams of community and district nurses have also been developed across the county to help those needing the most support, working closely with GPs and social care. Rapid response intermediate care is also available, providing short term packages of support to help people back to independence.

A community care coordination team has been established to give the GPs, hospital clinicians and other staff taking part in these initiatives a single point of access to organise specialist community services for their patients.

Transforming diabetes care

Health and care organisations are working together to deliver a single integrated pathway of diabetes care. The pathway offers improved support, advice and guidance for self-management of diabetes, with virtual clinics and a structured education programme, plus healthcare professionals specifically recruited to work with hard to reach groups.

The new service began in November 2017 and so far:

  • Eight of the county’s GP practices are now in the top 13 of 6,000 practices audited nationally for controlling diabetic glucose levels, making the service the best in the country;
  • 95 per cent of practices deliver the NHS diabetes prevention programme (NDPP). 670 patients were referred in the first four months, which should reduce the increase in diabetes in the long term;
  • More than 100 care home staff have been trained to check residents’ blood glucose, and study days have been arranged to create more than 300 nursing and care home diabetes champions as part of an initiative to develop standards for care in care homes.

In addition, plans are in place for an advice line staffed by a community nurse specialist for questions relating to Type 2 diabetes, and the services for both Type 1 and complex Type 2 diabetes are set to be moved from the acute hospital into the community.

Joining up musculoskeletal services

Buckinghamshire Healthcare is working with a number of partners on the phased introduction of an integrated musculoskeletal service across the county. This will include:

  • Teams of consultants and physiotherapists working together with patients to agree the best course of treatment to coordinate care for patients with complex needs before a hospital referral;
  • A single point of contact who understands a patient’s care plan and can liaise between different healthcare providers as required;
  • Self-referral (this will be tested in a small number of GP practices and rolled out if successful);
  • A system for patients with chronic conditions to access consultants without needing re-referral from a GP. This will result in reduced waiting times and patients requiring fewer appointments.

The new service will be rolled out alongside existing services until March 2019. It is anticipated that the new service will be fully live from April 2019.


The clinical commissioning groups, Aylesbury care homes and Immedicare (which provides clinical healthcare services via telemedicine at Airedale Hospital) are working together to introduce remote video consultation between healthcare professionals and patients to address rising numbers of emergency hospital admissions from care homes and ease demands on GP time.

There has been a significant and sustained reduction in emergency admissions since the care homes started to significantly increase their use of this service.