Integrated primary and community services

When you’re really ill, or require emergency care or treatment, it is important that you get it quickly without delays. But we know that once people are over their acute illness then hospitals are not usually the best place for their longer term rehabilitation. This is especially true for older people or people who are living with frailty, where any delay spent in a hospital bed over and above what is clinically required can have a really negative impact on their recovery. So unless someone really needs to be in hospital, they shouldn’t be there.

We will continue to invest in our primary and community services to make we can help people to stay well, and when they are ill can provide a larger range of services in peoples own homes in order to prevent a hospital admission or when people do have to go to hospital we can enable earlier discharge. This means we are supporting many more people with the care and treatment they need in their own homes which is better for the patient and their families.

For the first time we have developed teams across our communities which bring together District Nurses, Therapists, Social Workers and GPs. These teams work together in a more joined up way to provide more proactive and responsive care to people in their own homes. They have been in place for over 12 months now and we have been working to put these teams in place and ensure they have the skills and resources to see a reduction in repeat GP appointments and avoidable hospital admissions.