In March 2015, NHS England and its national partners announced the first of 29 new care model vanguards.
There are 14 multispecialty community provider vanguards which will move specialist care out of hospitals into the community.
These vanguards were selected following a rigorous process, involving workshops and the engagement of key partners and patient representative groups.
Multispecialty community providers – moving specialist care out of hospitals into the community.
- Calderdale Health and Social Care Economy
- Erewash Multispecialty Community Provider
- Fylde Coast Local Health Economy
- Modality Birmingham & Sandwell
- West Wakefield Health and Wellbeing Ltd
- All together better Sunderland
- Dudley Multispecialty Community Provider
- Encompass (Whitstable, Faversham, Canterbury, Ash and Sandwich)
- Stockport Together
- Tower Hamlets Together
- Better Local Care (Southern Hampshire)
- West Cheshire Way
- Lakeside Healthcare (Northamptonshire)
- Principia Partners in Health (Southern Nottinghamshire)
The vanguard is made up of: Pennine GP Alliance (represents 23 out of 26 Calderdale practices); Calderdale and Huddersfield Foundation Trust; Calderdale Clinical Commissioning Group; Calderdale Metropolitan Borough Council; South West Yorkshire Partnership Foundation Trust; Local community partnerships (NHS); Voluntary Action Calderdale (represents 128 health-related third sector organisations).
The Vanguard will be focused on two localities, one urban and one rural, representing 50% of the population and it will initially work to deliver integration across all services delivering care outside of a hospital setting through a single point of access. The current providers will work in joint community based multi-disciplinary teams in all parts of Calderdale made up of an expanded team of community, social care, primary care, mental health and pharmacy services.
This means that patients who, for example, currently need support from a district nurse, social worker and a local pharmacist will be able to access this range of support in one place through a co-ordinated approach to ensure their needs are met.
Patient population: 97,000
Erewash multispecialty community provider covers a registered GP population of 97,000 and provides 12 GP practices.
Derbyshire Community Health Services NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust, Erewash GP Provider Company, Derbyshire Health United (Out of Hours Service and 111) and NHS Erewash Clinical Commissioning Group made a joint application to become a Vanguard site.
The Vanguard will develop a prevention team made up of health and care professionals including GPs, advanced nurse practitioners, mental health nurses, extended care support and therapy support.
It will deliver services to people who do not require hospital services and can be treated for their conditions in a community setting. This will include care planning for people with long term conditions including diabetes, chronic vascular disease and chronic lung conditions. There will also be focus on extending access to GP services.
‘RightCare’ records detailing treatment plans for the most vulnerable people will be made accessible on A&E and out of hours computer systems. This will help A&E and out of hours staff to talk frail and vulnerable people through their concerns and support them to remain in their homes when they do not require specific hospital treatment.
The vanguard is made up of Fylde and Wyre Clinical Commissioning Group (CCG), Blackpool CCG, Blackpool Teaching Hospital NHS Foundation Trust, Lancashire County Council, Lancashire Care NHS Foundation Trust and Blackpool Council. It also encompasses services provided by the voluntary sector.
The vision for the vanguard is to create new models of care, wrapped around local people, spanning across all health and social care services.
It will mean that integrated teams of community nurses, allied health professionals, social care, mental health and third sector will be fully implemented by April 2016.
By this point, one thousand people will be cared for within newly designed extensive care teams for the frail and elderly population.
This means that patients (for example an elderly man with diabetes, angina and high blood pressure) will have their condition/s managed by a co-ordinated and integrated health and social care team. The team will have access to one care record to support the patient in their treatment.
Patient population: 70,000
The vanguard is made up of a single, local GP partnership called Modality Birmingham & Sandwell, which operates from 15 practice sites across Birmingham and Sandwell and serves a registered population of 70,000 patients.
The vision for the vanguard is to develop a health and social care system accessible through GP practices, with a care-coordinator to support patients on their journey. This will be achieved by delivering medical services from a number of primary care centres across Birmingham and Sandwell.
The larger centres will expand the range of social, mental, community and enhanced secondary care services on offer to patients by delivering community outpatient and diagnostic services.
This will mean that, for example, a person who has diabetes and suffers from high blood pressure will benefit from being treated in a familiar environment that is close to home and will be supported by a care co-ordinator to help manage their care plan.
Patient population: 63,000
West Wakefield Health and Wellbeing Ltd is a federated network of GP practices in West Yorkshire. Other partners include: NHS Wakefield Clinical Commissioning Group; Wakefield Council; Wakefield District Housing; South West Yorkshire Partnership NHS Foundation Trust; Healthwatch Wakefield; Mid Yorkshire Hospitals NHS Foundation Trust; NOVA (voluntary community sector representative body); Yorkshire Ambulance Service and Local Care Direct.
It is currently responsible for around 63,000 patients. Under vanguard, West Wakefield are working in collaboration with two other GP practice networks in the area covering a patient population of 152,000. As a multispecialty community provider, West Wakefield Health and Wellbeing Ltd is working to provide a larger, more diverse primary care team locally. A wide variety of workstreams, all aimed at developing alternative and sustainable models of care, are being developed alongside interventions and pathways that modify on-going demand into the future.
A key element of this vanguard’s programme is improved physical access to care. It is working to improve its care navigation system, directing patients to the help they need faster. Over 100 care navigators, the majority of which are administrative staff who generally have first contact with patients, are working in practices and are trained to direct patients to the most appropriate care. An extended operating hours service has been running since October 2014, and the plans to work with two other GP networks under vanguard will expand the number of both clinicians and patients. Meanwhile the HealthPod, West Wakefield’s mobile clinic, is improving engagement with ‘hard to reach’ groups such as members of the gypsy/traveller community.
Another key element of the vanguard is the continued development of integrated community teams; the combined skills of different professionals including physical health, mental health and social care will redesign the way in which the most vulnerable people are cared for in the community. Development of 24/7 technological connectivity will allow those most at risk to feel more secure and receive early proactive management from the integrated community teams all coordinated through a command and control centre approach, which can deploy tactical teams to proactively assist people both to prevent hospital admission and to support earlier discharge from hospital following admission.
The vanguard is also creating more ways for people to digitally access healthcare. This includes an online directory of local services, which pulls information from a variety of sources online including social media and a library of helpful health apps on its website. The vanguard is also engaging primary school pupils in health using a competition to design health apps. One app has already been built and launched based on the idea of last year’s winning team with another now in development. Self-service kiosks in practices will help patients to access these and other helpful resources, pointing to appropriate care before a patient enters a clinic room. The vanguard is also looking at the potential for use of email/instant messaging and video consultations.
Patient population: 284,000
The NHS Sunderland CCG and Sunderland City Council vanguard covers a population of 284,000 people, and is made in partnership with: GP Federations – Sunderland GP Alliance and Washington Community Health Care; South Tyneside Foundation Trust (provider of Sunderland community services); City Hospitals Sunderland Foundation Trust (acute trust); Northumberland Tyne and Wear Foundation Trust (provider of mental health services in the city); Sunderland Care and Support Services (which provide much of the previous local authority direct provision for adults); Sunderland Health-watch, Sunderland Local Medical Committee; Cumbria and North East Area Team; Voluntary and Community Action Sunderland.
The vision for All Together Better Sunderland will transform out of hospital and in hospital care, and help to enable self-care and sustainability. Staff will work as part of a multi-disciplinary team, focussing on more proactive, patient-centred care and prevention.
This means, for example, that elderly patients will be encouraged to recover in their own homes, or be placed in supported accommodation including care homes if that better suits their needs. Instead of ending up in hospital, patients will now have person-centred, co-ordinated care, and will have more input into the care that they receive.
Patient population: 318,000
The team behind the vanguard application from Dudley is led by Dudley Multispecialty Community Provider and includes Dudley Metropolitan Borough Council, Black Country Partnership NHS Foundation Trust, Dudley Group NHS Foundation Trust, Dudley and Walsall Mental Health Partnership NHS Trust, Dudley Council for Voluntary Services and Future Proof Health Ltd.
The multispecialty community provider model proposed by the partnership in Dudley aims to develop a network of integrated, GP-led providers across health and social care, each working at a level of 60,000 people, reaching a total population of around 318,000 across Dudley. This system will see the frontline of care working as ‘teams without walls’ for the benefit of patients, taking shared mutual responsibility for delivering shared outcomes.
Under the new provider system patients (for example a lady with frailty and long-term conditions registered with a GP in Dudley) will have care overseen by a multi-disciplinary team in the community including specialist nurses, social workers, mental health services and voluntary sector link workers.
This will ensure holistic care that better meets all of their medical and social needs at one time in one place, but allows them to access advice and support for the isolation they can feel living alone far from family, and combatting episodes of anxiety.
When patients need help urgently there is a 24-hour rapid response and urgent care centre which provides a single coordinated point of access so they don’t need to call 999.
As a result of the health and care system working better together in this way, patients are not only receiving the coordinated support necessary for their health needs but they are also linking to the wider network of care and social interaction in their community to help them to live more independently for longer.
Patient population: 170,000
Encompass is a group of 16 GP practices in Whitstable, Faversham, Canterbury, Ash and Sandwich who have agreed to work together to provide more services for patients in their local communities. This new way of working will mean that patients can receive more of their care from their local surgery, without the need to travel to hospital.
The Encompass GPs are working in partnership with all sections of the health and care system to develop and deliver new models of care, as set out in the NHS Five Year Forward View. Partners include NHS Canterbury and Coastal Clinical Commissioning Group, East Kent Hospitals University NHS Foundation Trust, Kent Community Health NHS Foundation Trust, Kent and Medway NHS and Social Care Partnership Trust, South East Coast Ambulance Service NHS Foundation Trust, the Kent Health and Wellbeing Board, Kent County Council, Pilgrims Hospices and voluntary and community organisations.
This will ensure that health and social care is integrated and based around local needs. Patients will receive more of their treatment in their communities, rather than having to travel to hospital.
By developing extended primary care and community services through the expansion of community health and social care teams we will reduce hospital admissions and length of stay.
Patient population: 300,000
The Stockport together vanguard is an active partnership including: Stockport Metropolitan Borough Council; NHS Stockport Foundation Trust; NHS Pennine Care Foundation Trust and NHS Stockport CCG.
The vision for the new model of care builds on the GP registered list and will be integrated around the GP practice at neighbourhood level (20-30,000 population), at locality level (80,000 population) and at borough level (300,000 population). Hospital urgent care will be redesigned, with a single point of access that is integrated with community teams. People with complex conditions or at the end of life will have an integrated team working with them to support them and help them make the best decisions about their plan of care.
This would mean, for example, that a patient with a serious long term condition will have an integrated team working with them to help them realise the best possible quality of life, and supporting them to make the best decisions about their end of life care.
Patient population: 270,000
The Vanguard is Tower Hamlets Integrated Provider Partnership and it will cover 270,000 people.
It is made up of a collaboration of partners that include Tower Hamlets GP Care Group Community Interest Company (representing primary care); Barts Health NHS Trust (the local acute and community health services trust); East London NHS Foundation Trust (local mental health trust) and London Borough of Tower Hamlets (local council and social care).
A patient in Tower Hamlets will benefit from having straightforward easy to access health and social care services and a positive patient experience.
This new model of community care will now ensure a single shared assessment and plan for patients. It will enable social care, primary, community and acute health services to truly co-ordinate their services around the patient, rather than the patient and their carers having to navigate themselves through numerous health and social care services.
A key part of the Tower Hamlets proposal is to have a greater focus on a positive patient experience and, as such, patients can expect an improved experience of care across all health and social care services in the local community.
The current collaboration of four organisations will be broadened to include both local voluntary and community sector organisations, as well as patient and service user groups, to share experiences and skills in the best interests of patients.
Patient population: 220,000
Southern Health NHS Foundation Trust is working in partnership with 16 local NHS, local government and voluntary sector organisations to develop their vanguard multispecialty community provider across Southern Hampshire.
The multispecialty community provider aims to improve the health, well-being and independence of people living in Southern Hampshire by delivering higher quality, more accessible and more sustainable out-of-hospital care.
It will serve a population of nearly one million, with the initial focus on launching three rapid implementer local sites covering South West New Forest, Gosport and East Hampshire.
These sites will include 27 GP practices with a combined population of 220,000 and cover a rural area with an aging demographic (South West New Forest), an urban population with high levels of deprivation and significant pressure on local GPs (Gosport) and an aging population in a semi-rural area with difficult transport links (East Hampshire).
The multispecialty community provider will support people to take a more active role in self-managing their care and offer access to improved care when needed.
For example, an older patient leaving hospital after an episode of pneumonia will be supported to stay at home. Their GP practice will work with them to co-develop a care plan that will help them to maintain their independence and stay at home as they continue to manage their existing health conditions such as diabetes.
They will have regular check-up appointments at their local practice or hospital but will also be able to access urgent appointments at their practice when they need them. Their integrated care record will mean that they will not have to remember and repeat their medical history and that staff will understand their needs wherever they go for help.
Patient population: 330,000
A new multispecialty community provider will now be developed in West Cheshire, an area in North West England with a population of 330,000. The lead partners for developing this model locally are NHS West Cheshire CCG and Primary Care Cheshire (a single entity). They are being joined by a further three participating partners: Cheshire & Wirral NHS Partnership Foundation Trust; Countess of Chester NHS Foundation Trust and Cheshire West and Chester Council.
Under the plans put forward, patients can expect better and more integrated support from different local health and care services, with a particular focus on young children, managing long-term conditions and supporting elderly patients.
To this end, the new partnership will be launching three new programmes as part of their model: ‘Starting Well’ will focus on ensuring the best start in life for babies, children and young people in the local area; ‘Being Well’ will enable greater collaboration between local services and the several clusters of GP practices, supported by integrated teams, to help people manage long-term conditions, and; ‘Ageing Well’ will focus on excellent care for the frail/complex wherever they are living (including those in care homes).
Patient population: 100,000 – plans to expand to 300,000
Lakeside Healthcare in Northamptonshire is one of the largest GP ‘super-practices’ in the country. By merging four practices (Lakeside, Corby; Rothwell and Desborough; Albany House, Wellingborough; and Headlands, Kettering), 100,000 patients are brought together in a single list. Through further planned mergers, both within and outside Northamptonshire, the intention is to expand the reach of the ‘super-practice’ to 300,000 patients, creating the largest GP-led primary care practice in the NHS.
By working in close partnership and collaboration with several local NHS providers (including: Kettering General Hospital; Peterborough and Stamford Hospital; University Hospitals Leicester; Northampton General Hospital and Northamptonshire Healthcare Trust) and also with key elected authorities (Northamptonshire County Council and Corby Town Council) and with Celesio (Lloyds Pharmacy), local social service providers and the voluntary and community sector, Lakeside Healthcare plans to deliver a multispecialty community provider (MCP) service that will offer patients a number of new services including: (i) a nationally acclaimed and respected urgent care model (the ‘CorbyCare’ model – delivered both in community and front-of-hospital locations); (ii) an ambulatory care service, particularly designed to relieve pressure at the ‘front door’ of hospitals; (iii) a bespoke and effective long-term condition management service for the frail elderly and other vulnerable patient groups which might include admission to short-stay community beds managed by Lakeside; (iv) a highly focused GP-led complex-care management service; and (v) a number of hospital outpatient and planned care services, including dermatology, ophthalmology, MSK, geriatric medicine and mother and baby services.
Lakeside Healthcare aims to provide ‘extended primary care services’ to most patients, working in multidisciplinary teams that provide convenient care every day of the week. The most vulnerable 7% of patients, who are intensive users of services, will be provided with ‘extensivist primary care services’ through which they will have access to longer, in-depth consultations with enhanced continuity of care. The Lakeside team will work alongside hospital consultants to provide better and more integrated access to specialist care, and Lakeside will also employ its own consultants in key specialties.
For example, an elderly, frail man lives alone and was previously of good health but now has high blood pressure and is prone to falling. He will benefit from registering with Lakeside because through the Lakeside ‘extensivist’ service he will be provided with a far greater degree of support than previously available.
The practice will link up other services that can help this patient manage his hypertension better and that will also provide more rounded support to help him to stay safe at home.
However, should the patient suffer a fall, the Lakeside-run Corby Urgent Care Centre will be available to deal with all his minor injuries, providing X-rays and other tests that are usually only accessible in hospitals.
If required, the patient can be admitted to a Lakeside observation bed for several hours so that staff can monitor his progress or be treated in an ambulatory care unit run by clinicians from Lakeside, providing enhanced continuity of care and avoiding unnecessary admissions.
This is a far better package of care for the patient, in a setting that will be more familiar to him and provided by a team of doctors, nurses and other healthcare professionals that will see him treated appropriately and then conveyed back to his home where the joined-up support will continue.
Patient population: 126,000
Principia is constituted as a community interest company and has three stakeholder classes: Rushcliffe GP practices; Rushcliffe community services providers; and the 126,000 registered population of Rushcliffe. GP practices in Rushcliffe have come together and are establishing a new and unique primary care partnership and organisation, which will lead on and indeed own the transformation of general practice and develop the progressive model which will be the base component and platform of the MCP. Principia and Partners Health will also be joined by health and social care partners who have committed their enthusiastic support as part of our local South Nottinghamshire transformation work. NHS Rushcliffe CCG is the sponsor, and the programme has the support of the patient and voluntary sector groups, which represent the local population.
The proposal is to establish an MCP defined by a culture of mutual accountability, commitment and pride. This will accept contractual responsibility for the health, and the quality and costs of care for the local population within the capitated resource allocated. This will be achieved through a new model of integrated care which is focussed on early intervention, living well at home and avoiding unnecessary use of the hospital. The impact will be a reduction in fragmentation, delays, duplication and inefficiencies experienced by patients and carers. Care will be delivered closer to patients’ homes resulting in an enhanced experience and improved clinical outcomes, and better use of available resources. The MCP will move to have a capitated outcomes based contract which will cover health and social care.
So patients for example an elderly married couple who live in a small rural village outside of West Bridgford and have done so since they retired will benefit when the new accountable care organisation is in place. The couple, who both have multiple long term-conditions, can expect to have a proactive care plan in place which is discussed with their local health and care team on a regular basis. This conversation will build confidence and capability for them to make good decisions about what they do to keep themselves fit and well and also when they need to escalate the level of support they need irrespective of the time of the day or week. When they do, a provider will be able to respond to all their care needs, and all the participants will be working with a common goal: maximising outcomes as efficiently as possible.