Imagine it’s the middle of winter, the health and care system are busy – but it feels easier now, easier than it was a few years ago. People are supported in their homes where possible, those with frailty and multiple long term conditions have targeted proactive care provided by a local neighbourhood team, this has reduced the number of days they spend in hospital. A&E is quieter, the multi-neighbourhood provider, that developed from a GP federation, is responsible for the urgent care hub which people prefer to access, knowing they get timely care, and still referred to a specialist if needed. The urgent care hub has diagnostic facilities so people are reassured they will get tests if needed without visiting A&E.
Helen Northall
GPs have time to spend with people where continuity of care is important, to proactively manage their conditions. Group clinics are held in practices helping people support themselves more where possible. Patients who need hospital care know the consultant has their information before they are seen, they are not being asked the same questions every time they see a new person, and they have already had the tests they need in the neighbourhood health centre before seeing the consultant.
When people stay in hospital they feel supported to return home, they are reassured by the planning that starts just after they have been admitted considering their health and social care needs, and how they will be supported to leave hospital. Most know they will go back to their own home, but supported care is available for those that are well enough to leave hospital but not yet able to return home.
Can this happen? We think it can, and the opportunity to make this happen is neighbourhoods. The conditions need to be right, commissioners need to be enablers, the health and care system needs to collaborate across shared areas of interest, there needs to be a focus on outcomes and getting the pathways right to achieve the outcomes.
In this edition of PCC Insight we consider the conditions needed for commissioners to facilitate the environment to enable changes such as these. We consider how single neighbourhood and multi-neighbourhood providers may wish to work, we look at how to “work with” not “do to”, a cultural shift needed. We have a neighbourhood health story from South Sefton PCN and offer tips for away days to bring teams together, essential to support the changes needed. We also consider capital grants and share tips on getting started in neighbourhoods.
Contact us to discuss how we can work with you to turn your vision into practice enquiries@pcc-cic.org.uk.
