This section contains
Aims
Helping people to remain well at home is crucial.
To do this, the new integrated care systems (ICSs) should aim to:
- identify vulnerable people at risk of hospitalisation
- provide timely, preventative care
- help people avoid hospitalisation where appropriate.
Context
Services within each ICS must help people to:
- stay well
- maintain a healthy lifestyle
- avoid hospital admission where possible.
Local services need to be able to recognise and react to a decline in people’s health in a timely way. It is essential to be aware of emerging risks and needs for the individual and at a wider system level.
Services should use risk assessments and appropriate forms of monitoring. They can then use this information to plan personalised care. Care plans could include referrals to local, non-clinical services through social prescribing. For example, in cases where people are at risk from social isolation. Early access to community services is crucial so people can get advice and support they need.
Services should also be able to refer people to other parts of an ICS quickly and efficiently. Including referrals to a dentist.
Across England, COVID-19 has compounded pressures on dental services. In May 2021, CQC published COVID-19: Dental access during the pandemic. It reported that the reduction in capacity due to the pandemic had significantly impacted access to dental care. Similarly, Healthwatch England’s Annual Report for 2020/21 (published February 2022) reported a 452% increase in feedback about NHS dentists. Access and affordability were people’s two main concerns.
Key suggestions
- Local services should monitor the health of vulnerable people in their communities so they can:
- recognise and react to deterioration in people’s health
- provide early support to prevent unnecessary hospital admission.
- Run effective falls prevention programs in all ICS communities.
- Increase the role of voluntary organisations. So they can provide support and assistance to vulnerable people. For example, those at risk of loneliness and social isolation.
- Index conditions like COPD (chronic obstructive pulmonary disease), frailty and heart failure. So, they are better supported by clinicians working across primary, secondary care and community services.
- Consider widescale use of urgent community response teams (UCRs) to respond to category 3 or 4 emergencies from 999 calls.
- Carry out regular system reviews to identify people who attend urgent care services multiple times. Develop additional support and care for those people to help them stay well and prevent avoidable hospitalisation.
Examples of good practice and innovation
Pre-transfer clinical discussion and assessment
Leicester, Leicestershire and Rutland ICS
For some people, assessment in a hospital setting can be avoided. Nursing teams can proactively take ownership of people. Reassessment and support can then be provided as needed through visits in the community.
‘Ageing Well’
Frimley ICS
Frimley ICS has created a steering group called 'Ageing Well'. It aims to help people living with frailty at home. The group focuses on delivery of:
- Enhanced health in care homes
- Anticipatory care
- Urgent community response (UCR).
It provides various types of support, including community rehabilitation and inpatient resources. They also have a virtual frailty ward that helps prevent unnecessary hospital admissions.
Urgent treatment centre
West Cornwall Hospital, Royal Cornwall Hospital NHS Trust
This urgent treatment centre has a team of proactive GPs upskilled in several additional clinical areas. This means the centre can provide a service that prevents patients from needing transfer to the emergency department in Truro. It can also provide other tests and observations on site.
Local falls teams
North Yorkshire, Mid and South Essex, South Warwickshire
Where local falls teams exist they can be highly effective. They can provide:
- urgent support
- falls prevention training for social care providers
- education on how to support people before an ambulance arrives on site.
See these NHS confederation case studies for more information:
Collaboration between primary and community services in North Yorkshire
Urgent community response across Mid and South Essex
Reducing conveyances of older patients in South Warwickshire.
Association of Ambulance Chief Executives’ (AACE) repository
The AACE repository is a great resource for good practice case studies.
Clinical support networks for adult social care services
Senior clinical staff of all professions could offer a support network for adult social care services in their area. Members can be from NHS hospitals or the private sector, but should represent all relevant disciplines.
The group could provide advice and guidance to services that care for:
- people living with frailty
- people with a learning disability or autistic people
- disabled people.
Early intervention and support can help people stay well in the community and reduce avoidable hospital admissions.
Collaboration between care homes and dental practices
There are pilot projects that link dental practices to care homes:
- to provide oral health training
- be a single point of contact for care homes, so they can share concerns about the oral health of people who use their service.
This is an excellent example of different services sharing skills and providing preventative care. Early interventions like these can reduce the likelihood of people experiencing dental pain and improve quality of life.
Escalation plans made available to all health and social care professionals
Some GP shared records make treatment escalation plans available to all health and social care professionals. This helps services to provide care that respects the advanced directives of the person needing care. For example, it means hospital admissions only occur if in line with the person's agreed wishes.