Sandwell’s iCares scheme flags people with long term conditions at high risk of hospital admission to a team of 100 staff who make sure they are seen as early as possible.

Patients or carers can ring one line if they need help and are triaged with urgent referrals seen in three hours by a part of the team dedicated to hospital avoidance.

Previously, patients were coping at home until in some cases they needed hospital admission.

The majority of people living in Sandwell have multiple long term conditions, are likely to live their final 20 years in ill health and are likely to die younger.

Dr Karen Kirkham, NHS England’s National Clinical Advisor for Primary Care, said: “As we develop a ten year plan for the NHS it is innovative schemes like this that are showing how practical new ways of working can help patients live better lives and also deliver efficiencies for health organisations to reinvest.”

Ruth Williams, Clinical Directorate Lead at Sandwell and West Birmingham Hospitals, set up the iCares scheme five years ago after realising how difficult it was for patients to navigate the system and the waste created by multiple teams working in silo.

She brought people from three teams under one roof and consolidated 16 different points of access to care. Staff now work in neighbourhood teams, based on the patient’s locations, and work on all types of patient from neuro to palliative, dementia and diabetes.

“iCares is based on need and not diagnosis,” she said. “If a patient has a long term condition and develops an infection for example it could stop them swallowing or walking and that would make them housebound and unable to cope at home.

“Previously, the small team of three people saw urgent cases as well as possible at home but the patients they couldn’t see were admitted to hospital. What we’ve done is make the system simpler: one phone number, everyone can ring and one team which works together and navigates the system for the patient keeping 93% of urgent cases out of hospital. Most importantly of all people only have to tell their story once.”

Across the NHS, 14 Integrated Care Systems (ICS) and 30 Sustainability and Transformation Partnerships (STPs) are seeing NHS and local government join forces to pool resources and budgets and simplify systems for the patient across primary and secondary care. Spreading this approach will be a key part of the 10 year plan for the NHS that is being drawn up over the coming months. The iCares scheme comes within the Black Country STP.

If patients develop urine infection, chest infection, flu, coughs, colds or cellulitis, it can lead to frailty and falls, resulting in less independence, swallowing problems, not eating and drinking enough and feeling unable to cope at home, as well as an increase in stress for both the patient and carers.

So far they have reduced hospital admissions by 2,478 per year – 93% of patients who access the service stay in the community after an urgent visit rather than being admitted to hospital.

It has also contributed to a reduced length of stay in A&E, reduced length of stay in hospital from 10 days to seven days and reduced readmission rates.

The team is made up of physios, occupational therapists, advanced clinical practitioners (ACPs), community matrons, nurses, speech and language therapists and many more.

The ACPs can prescribe to clear up infections and the team can organise extra equipment to help people manage safely at home. If an extension to a social care package is needed they have a hotline to the team which sorts it out straight away.

They also start rehab immediately with patients helping them to prevent deconditioning from too much bed rest – or pyjama paralysis.

While part of the team take urgent referrals the others see to routine visits and do proactive work to keep people with long term conditions well at home.