In March 2015, NHS England and its national partners announced the first of 29 new care model vanguards.
There are nine integrated primary and acute care system vanguards which will join up GP, hospital, community and mental health services.
These vanguards were selected following a rigorous process, involving workshops and the engagement of key partners and patient representative groups.
Integrated primary and acute care systems – joining up GP, hospital, community and mental health services
- Wirral Partners
- Mid Nottinghamshire Better Together
- South Somerset Symphony Programme
- Northumberland Accountable Care Organisation
- Salford Together
- Better Care Together (Morecambe Bay Health Community)
- North East Hampshire and Farnham
- Harrogate and Rural District Clinical Commissioning Group
- My Life a Full Life (Isle of Wight)
Wirral Health Partners is made up of: Wirral University Hospital NHS Foundation Trust; Cheshire and Wirral Partnership NHS Foundation Trust, Wirral Community NHS Trust; Wirral Clinical Commissioning Group; GPs on the Wirral; Wirral Metropolitan Borough Council; Cerner UK Ltd, Advocate Physician Partners ACO (USA based); and the King’s Fund.
Wirral Health Partners will accelerate a new model of integrated care across primary and secondary care providers, supported by a technology enabled population health model. Integrated care teams will be expanded to reduce readmissions and support people to remain at home through primary/secondary care collaboration. Following implementation, the new model will work by identifying older people who are at potential risk of serious fracture following minor falls that result in emergency admission. With approval of the patient, care plans will be developed, home assessments carried out and aids added to reduce the probability of falls happening. With this support, patients are able to stay in their home and potentially avoid a serious fracture.
The Better Together Programme Board partners are: Mid Nottinghamshire Clinical Commissioning Groups (Mansfield and Ashfield and Newark and Sherwood CCGs); Aspirant Accountable Provider Alliance (Sherwood Forest Hospitals NHS Foundation Trust, Nottingham University Hospitals NHS Trust, United Lincolnshire Hospitals NHS Trust, East Midlands Ambulance Service, Nottinghamshire Healthcare NHS Trust, Central Nottinghamshire Clinical Services, Circle); Voluntary Sector Special Purpose Vehicle (three district council CVSs); General Practice Provider Clinical Cabinet (facilitated by the Local Medical Committee); Nottinghamshire County Council.
This PACS will deliver a whole system integration of hospital, community, social and primary care within a single outcomes-based capitation contract. This will be enabled through moving from a predominantly reactive hospital-based system of urgent care, to one of home-based proactive care. Specific service interventions include a single front door and integrated triage at ED, locality based integrated care teams, specialist intermediate care teams, community based crisis response teams, referral GP review and speciality triage for referrals. This will all be underpinned by improved data sharing between primary and secondary care providers, and integrated data sharing between ED and out of hours GP services.
Following implementation of the new care model a patient, for example a frail gentleman who lives alone, and was discharged from hospital after a bout of pneumonia, would be given a wrap-around care package which included both integrated care team support, and support from community based crisis response teams. This means he could stay at home, in his preferred location, rather than being admitted to a care home.
This vanguard is a partnership of Yeovil District Hospital NHS Foundation Trust, Somerset CCG, South Somerset Healthcare GP Federation and Somerset County Council that will be working to deliver an integrated primary and acute Ccare system.
The hospital trust and GP federation are joining together to establish a joint venture which will hold a single budget for the population and target resources to parts of the system where they can make the most difference to patients.
This will initially focus on approximately 1,500 South Somerset residents who have multiple long term conditions, providing integrated care in three hubs that bring together primary, secondary and other sorts of care in one place.
The hubs will provide care co-ordination, senior medical input and a single personalised care plan that helps people to look after themselves.
Other GPs will increasingly provide ‘enhanced primary care’, offering support such as health coaching to patients with less complex conditions, and ultimately the PACS model will benefit the whole community by improving surgical processes and networking better with neighbouring trusts.
Under the new joint venture scheme a patient who suffers, for example, from diabetes, hypertension and depression, will see improvements in the way people work together to meet their needs. Their treatment will be guided by a care plan that they will design with their care co-ordinator, setting out what they want from their care.
When the patient visits the hub, their team of different professionals will work together to deliver the plan.
In between visits, the patient will be supported by remote monitoring of their condition, and will use the ‘Patients Know Best’ web platform to view their plan and keep in contact with the hub team.
Under the new joint working patients will see improvements in the way people come together to meet their needs, with less duplication, fewer delays and more proactive health and care services.
GPs, hospital consultants, community staff and social workers will work as a single team to share information about patient care needs, and deliver a more integrated set of services which meet their individual circumstances and prevent unnecessary admissions to hospital.
Working together, health and care staff will also be able to respond to patients’ wider care needs so they can enjoy an independent and healthy lifestyle.
The Northumberland Integration Board is made up of Northumbria Healthcare NHS Foundation Trust (Lead Partner); Northumberland Clinical Commissioning Group; Healthwatch Northumberland; Northumberland County Council; Northumberland primary care practices; Northumberland Tyne and Wear NHS Foundation Trust and North East Ambulance Service.
This vanguard will help communities to live long and healthy lives at home. This will be supported through the opening of the Northumbria Specialist Emergency Care Hospital, an extension of primary care to create ‘hubs’ of primary care provision across the county seven days a week. This redesign of community and acute services will ensure patient care is delivered increasingly in community settings, and bring together commissioning responsibility across the whole health economy.
Following implementation of the new model, patients will be able to access their GP over the weekend, preventing the need to go to the Emergency Department when symptoms worsen. The model cuts across organisational boundaries and includes enhanced access to community nursing services, fully coordinated discharge and shared IT that will support better care in a number of health settings and in the home.
Patient population: 230,000
The Vanguard is made up of the following organisations: NHS Salford Clinical Commissioning Group; Salford City Council; Salford Royal NHS Foundation Trust and Greater Manchester West Mental Health NHS Foundation Trust, which together form the Salford Together Partnership. In addition, there is active support and engagement from Salix Health, the local GP provider consortium.
Salford intends to create an integrated care organisation. It believes that by pooling its expertise into one organisation, residents will receive more coordinated care as it will be provided by health and social care professionals working within the same organisation.
The integrated care organisation will be established giving Salford Royal lead responsibility for meeting the health and social care needs of the population through both direct provision and contracts with other local providers.
During 2015, Salford started work to combine health and care services for the entire adult population, including preparation to transfer adult social care services to Salford Royal and to establish arrangements for adult and older people’s mental health services.
At the same time, Salford is also rolling out a new model of care. This has three parts; first, the establishment of multidisciplinary groups to identify people who are at most risk of becoming more unwell and to coordinate services around their needs; second, working with the voluntary sector it will build supportive networks for individuals who are at risk of becoming socially isolated; third, it will create a single centre for people to contact to guide them to the right support or services, as well as providing health coaching for people with long term conditions.
The partners of this vanguard are all members of the Better Care Together Programme, working on behalf of the population of Morecambe Bay, which has 365,000 residents.
They include four NHS trusts: University Hospitals Morecambe Bay NHS Foundation Trust; Cumbria Partnership NHS Foundation Trust; Blackpool Teaching Hospitals NHS Foundation Trust; Lancashire Care NHS Foundation Trust.
The vanguard also includes North West Ambulance Service NHS Trust (NWAS) and two clinical commissioning groups: NHS Lancashire North Clinical Commissioning Group and NHS Cumbria Clinical Commissioning Group.
Two Local Authorities, Lancashire County Council and Cumbria County Council, are also in the vanguard, together with two GP provider federations, the North Lancashire Medical Group and the South Cumbria Primary Care Collaborative.
The Vanguard will create a system that will take responsibility for the whole health and social care needs of the population within a single budget.
This will mean a smaller, more productive hospital service working hand-in-hand with integrated out of hospital services.
It will focus on keeping individuals, families and communities healthy, developing capacity in general practice and community services, and focusing the hospital on the services only it can deliver.
This means that patients who work full time office hours, for example, should have greater access to services at times that suit them, as the Better Care Together programme will develop more services and capacity in a setting closer to patients’ homes.
Patient population: 220,000
The Vanguard is made up of providers and commissioners of health and social care for a population of 220,000 in North East Hampshire and Farnham.
It will focus on the development of an integrated health, social care and wellbeing system which will put the person at the centre of their care.
NHS and social care services will share resources and skills to support people to stay healthy and well at home.
Care will be provided by local multi-disciplinary teams working together, across physical and mental health services and in partnership with the voluntary sector to provide a personalised service.
The Vanguard will support people with respiratory and cardiac problems and people who have fallen. For example, a patient with a long term respiratory condition, waiting for many long assessments to be completed by different parts of the health and care system will, in the future, have a single assessment, together with their family and carers, to help them stay healthy and well.
The Vanguard is made up of the following organisations: Harrogate and District NHS Foundation Trust; Harrogate and Rural District CCG; North Yorkshire County Council; Tees Esk and Wear Valley NHS Foundation Trust; Harrogate Borough Council; Yorkshire Health Network.
The vanguard will deliver access to advice and information for individuals in crisis 24/7 without defaulting to A&E as the first point of contact. The aim will be to provide support to remain independent, safe and well at home with care provided by a team that the person knows they can trust and encompassed in a universal care plan. This service will be provided by community hubs and an integrated team which includes GPs, community nursing, adult social care, occupational therapy, physiotherapy, mental health and the voluntary sector.
This means that patients who, for example, have multiple long term conditions and live alone, will have an agreed care plan going forward that people involved in their care share and understand. Patients will be able to access advice and information in times of crisis 24/7, and will be supported to stay in their own home whenever possible.
Patient population: 140,000
The Isle of Wight covers a registered GP population of 140,000 and 17 GP practices. The vanguard application team known as ‘My Life, a Full Life’ is a partnership consisting of Isle of Wight CCG, Isle of Wight NHS Trust, Isle of Wight Council and the GP collaborative One Wight Health.
The Vanguard will develop person-centred, coordinated health and social care services for the island. This will support better outcomes for people, working with local communities to build capacity and resilience of people, families and carers.
This will be achieved through a greater use of digital technology coordinated through a single point of access. It will include patient-led monitoring and will be supported by primary-care-led integrated locally-based services, delivering care out of hospital right across the island.
This will mean a patient with multiple long term conditions, such as diabetes, will be supported to manage their condition to enable them to live the life they want to lead. This will include monitoring their condition and working with their GP practice to ensure they receive out of hospital care and are able to remain at work.