Organisation

Integrated Care System (ICS): Derby and Derbyshire – all 15 Derbyshire Primary Care Networks

The aim

30,000 people in Derbyshire are living with moderate or severe frailty and every year it costs £100 million. In 2019-20 people living with frailty needed 96,605 hospital bed days – the equivalent of about 10 wards. By 2043 Derbyshire’s population aged 90 and over will more than double.

Team Up Derbyshire wanted to create more capacity without creating a new service by:

• promoting a team approach to looking after people with frailty, supporting them at home for longer
• ensuring the care and support people receive is based on their wishes
• offering support to their family members
• developing more rapid community response teams
• offering more NHS support in care homes

The solution

The team brings together services that provide preventative care – anticipating health problems – and reactive or urgent care. They address a wide range of issues for people with frailty including any immediate or long term physical and mental health problems or social care problems. This includes:

• an acute home visiting service – continuity and support to release pressure on GPs
• an urgent community response service – crisis response care within two hours of referral and reablement care within two days of referral.
• enhanced health in care homes
• anticipatory care
• step up and discharge pathways
• visits, using Personalised Care and Support Planning and Respect forms, for all housebound patients
• connecting people with third sector organisations for wider issues such as debt management, housing problems, isolation and loneliness or difficulty shopping

Patients who have recently been discharged from hospital receive a follow up call within one or two days to pick up any early concerns.

Structure and partners

The Primary Care Networks (PCN) regularly hold multi-disciplinary team meetings including care coordinators, mental health workers, social care workers, advanced care practitioners, and GPs. Care coordinators often act as the central point for patient management plans, proactively sharing information that can be accessed by patients, families, carers and professionals. Local residents have also been engaged through Citizen’s Panels and webinars.

The team is made up of people with a shared purpose but who are employed by different organisations including:

• PCNs
• Derbyshire community services
• Derbyshire County Council
• Derby City Council
• Derbyshire Health United (DHU)
• Local voluntary organisations

Challenges

• Delivering services that have the patients at the forefront, being mindful of NHS England targets
• Bringing stakeholders together when operational teams are stretched
• Availability of key groups of staff slows recruitment and delivery
• PCNs are developing at the same time as change is required
• The need for clinical systems to work across the system
• Lack of joined up thinking regarding estates, and need to co-locate teams
• Delivering transformative change during COVID crisis

The results: what was the outcome?

They are evaluating the programme using data from Home Visiting Services, from the Urgent Community Response monitoring and community services dataset, an Ageing Well dashboard and surveys. Initial results show:

• 95% of staff recommend the service
• 93% recommend the service as a place to work

For the over 65 population compared to the previous 12 months:

• the Home Visiting team has made 24,259 visits
• there have been 2,367 fewer category 3 ambulance responses
• the number of people staying one or two days in hospital has reduced by 1,467
• 6,982 people seen who needed a 2-hour UCR rapid nursing and therapy response

Quotes from patient families

• “I just want to congratulate you on an excellent department within the NHS. My Father is 96 and requires quite a lot of care now but is still living alone in his own home, where he wants to be.”

Quotes from staff:

• “It allows people to stay in their own homes, in familiar surroundings near family or friends and it stops filling up hospitals, allowing more urgent care to happen in hospitals or allow space for elective care.”

Learning points

• Ensure learning is shared with new staff from all organisations
• Current management plans should be visible and coordinated using shared records or a central point.
• Patient level information needs to be accessed across the system, with all main providers using the same electronic medical record system.
• An investment in time is needed to see long-term results
• The importance of data to show the difference being made and the need to invest in this

Next steps and sustainability

In 2023-24 Team Up Derbyshire and Ageing Well aim to invest up to £13 million in the development of these integrated community teams across the system. This investment will continue to enable work to integrate services and ensure that high quality services are available for patients.

Want to know more?

Contact kate.brown12@nhs.net

Publication reference: PRN00573