Newcastle and Gateshead Clinical Commissioning Group

The vanguard and the people it serves

This care home programme will support the health and wellbeing of older people by speeding up improvements in care for residents in Newcastle and Gateshead.

Newcastle Gateshead Clinical Commissioning Group is working with a range of partners including care homes, local authorities (both Newcastle and Gateshead), NHS foundation trusts, independent sector care providers and the voluntary and community sector.

More than 2,500 people live in residential and nursing care homes in the area.

What is changing?

The programme is building on an extensive range of services to work together to support people in care homes, to improve patients’ experience and reduce unnecessary hospital admissions.

The new ways of delivering care will allow for more joined-up care designed to meet individual needs, and this in turn will help prevent ill health and avoidable hospital admissions. Patients will also be offered more control of their care and support for independence, enabling them to make informed choices about their care, including their preferred place of care.

GP practices will become a link to a specific care home, making it possible to offer greater continuity of care and more effective prevention of illness through regular care home visits.

The new care model will also consider the contracting and payments associated with supporting the new ways of delivering care and will support the development of a ‘provider alliance network’, linking all parts of the system together.

Mark Adams, Chief Officer at Newcastle Gateshead Clinical Commissioning Group, said: “Becoming a vanguard will allow us to go further and faster in improving the health of people living in care homes, with specialist support at national level.”

Key benefits

  • There has already been a 14 per cent reduction in avoidable hospital admissions
  • By working together, services will deliver more co-ordinated health and social care
  • A focus on preventing ill health will improve care home residents’ wellbeing and reduce the reliance on health services.

Contact Gateshead Care Home Project


Case studies

1.    New team working improves services in care homes

The multidisciplinary care team delivering services as part of the new care model in Gateshead is already making a real difference to the health and wellbeing of care home residents.

The team, which includes an old age psychiatrist, geriatric consultants, hospital consultants, old person specialist nurses and the GPs who work with the care homes , meets once a week.

Karen Franks, consultant in old age psychiatry, said: “We are overhauling the way we help people in residential care. This new way of working together and supporting each other means that care home staff get greater support and a quicker response to their concerns and patients have quicker access to specialist care.

“Previously there could be up to 14 different GP practices for a home with only 70 residents and the on-call doctor would not know the patient or background – everything was very disjointed for people with complex needs.

“There is now one GP practice allocated to each care home and although this means some patients have had to change doctors, most people are happy to do this.”

The GPs visit for a ‘ward round’ once a week, supported by a nurse specialist who helps with care planning and liaises with relatives.

Liz Bowers, a specialist nurse who visits care homes with the GPs, said: “For many of the residents, going into hospital can be a distressing experience so we try to avoid this wherever possible. I undertake geriatric assessments, and look at residents’ needs proactively to ensure they get all the services they need and that where appropriate, they receive care in the care home instead of going into hospital. We can also develop emergency care plans to help individuals stay out of hospital.”

Karen Franks added: “This way of working is extremely valuable in terms of providing joined-up holistic care – for me as a mental health professional, to be able to work hands-on, closely with primary care colleagues means we can deliver the best holistic care to complex individuals within residential care. It is very rewarding and really making a difference to people’s lives.”

2.    Managing care at home for residents to reduce hospital visits

An 84-year-old care home resident has benefitted from joint working and care planning by her GP, care home, hospital staff and family to develop a management plan to reduce hospital admissions.

As well as suffering from dementia, this frail resident has problems with her heart and blood pressure, and was being admitted to hospital frequently to treat problems with her bowel and a catheter.

Her family were very keen for her to be admitted to hospital less often and for her health to be managed within the care home as much as possible. Since the integrated care team jointly developed a care plan, the patient is now being successfully monitored and treated within the home. In the last two years she has only been into hospital four times, compared to the previous five months when she was admitted six times.

Liz Bowers, specialist nurse, said: “This is a really good scheme and just carrying out the proactive work makes a big difference – I feel it is a privilege to work with these patients and their families.”