New era of integrated health and care to better support people to lead healthier lives

Health and care services across Staffordshire and Stoke-on-Trent are embarking on a new era of integrated working to ensure people are better supported to lead healthier and more independent lives.

Integrated Care Teams (ICTs) are being introduced by the Together We’re Better partnership of NHS, local government and independent organisations – with each one serving a community of between 30,000-70,000 people based around neighbouring GP practices.

Each team will bring together a range of primary, community and mental health services, alongside social care professionals and the voluntary and independent sector – enabling a coordinated approach to improving the health of the community they serve.

ICTs will provide care that:

  • Helps more people lead healthy, active lives
  • Enables more people to remain independent for longer
  • Reduces the need to attend or stay in hospital
  • Reduces the length of time people spend in hospital
  • Predicts personal needs and plans care to prevent problems before they arise
  • Makes greater use of technology and home adaptations
  • Supports families and carers in their role

Rather than adopt a ‘one size fits all’ approach, the make-up of each team will be determined by the needs of the population they serve. Teams will support people to remain independent at home for as long as possible and will also place a close focus on supporting people to self-manage their own condition(s).

Furthermore, they will work with residential and nursing homes to support patients to remain within their place of residence by supporting advanced care planning and delivering services to support patients at the end of their life.

Integrated Care Teams will be launched in four early adopter sites – Leek/Biddulph, Lichfield/Burntwood, Longton/Meir and Stafford – prior to being rolled out across the rest of Staffordshire and Stoke-on-Trent.

In Lichfield, integrated working is already making a difference through the successful Care Home Project. GP practices are working in a more cohesive way with community teams from Midlands Partnership NHS Foundation Trust and University Hospitals of Derby and Burton NHS Foundation Trust, alongside commissioners to better support elderly residents in care homes.

The project sees a dedicated GP and/or community matron act as a conduit to more effectively manage the demand on local health and care services. This has led to a reduced demand on GP time from nearby care homes, lower hospital admission rates and enhanced care for residents, who also have more direct access to a range of services.

Dr Shammy Noor, Chair, South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group, said of the project: “The beauty of the Care Home Project in Lichfield is that it has simplified what previously had been a somewhat complex system. This has led to better outcomes for the residents and their relatives and demonstrated how integrated working can make a big difference.”

Dr John Oxtoby, Joint Clinical Lead for Together We’re Better’s Enhanced Primary and Community Care Programme, said: “By having health and care services that talk to each other more effectively, it breaks down any barriers that exist for the service user and results in Integrated Care Teams that are able to address the specific needs of the communities they serve. This not only benefits the people of Staffordshire and Stoke-on-Trent, but also health and care professionals who are working to ensure we lead healthier lives.”

Simon Whitehouse, Together We’re Better Director, said: “As the health and care needs of the communities we serve become more complex, with access to more than one type of service often being required, we need to be meeting that demand. Integrated Care Teams offer that solution, with GPs working alongside community and mental health services, social care professionals and the voluntary and independent sector to provide a more cordinated approach that works seamlessly to meet local needs.”

Marcus Warnes, Lead for the Enhanced Primary and Community Care Programme, said: “There are great examples throughout Staffordshire and Stoke-on-Trent where integration of health and care services is delivering better outcomes for people and we are excited about the impact Integrated Care Teams can have on local communities.”