Paving the way for integrated services that are closer to home

Updated on 28 June 2016

Paving the way for integrated services that are closer to home

Conversations with the local community and our engagement work with local providers are paving the way for the integrated health and care in the Vale of York.

The community told us that they wanted a better integration and co-ordination of services which is why our five year plan sets out a strategy for locally based, integrated services that put GP Practices at the centre of the health and wellbeing system.

We have created three integrated care pilots - one each in York, Selby and Pocklington. The pilots have made it possible to put individuals at the centre of a team that includes a care co-ordinator, a GP, physiotherapist, occupational therapist, community nurse, holistic care worker and a practice nurse wrapped around them.

                               

We are testing approaches to deliver proactive, community-centred care for populations of around 50,000 to 100,000.The schemes are currently testing alternative ways of combining and integrating the resources of the public sector, independent sector and community assets to deliver joined-up care and improved outcomes for the population they serve whilst developing approaches to share data and care plans.

The pilots are responsible for assessing, diagnosing and delivering care to enable individuals to remain at home or return there as early as possible following ill-health or crisis. Initially they will focus on the frail elderly and those with Long Term Conditions, but will ultimately expand to be the focus for care for the whole population.

Ultimately the aspiration is for the pilots to develop into a full multi-specialty provider model to pull in wider services such as mental health, police, housing and employment to ensure we deliver what our population tell us they want “telling their story only once” and “care co-ordination”.

The aim is to deliver seamless care that:

  • wraps around the individual;
  • provides care outside of hospital settings wherever possible to deliver reduced hospital admissions, and rapid discharge after admission to hospital;
  • holistic delivery of care and support;
  • better end of life care;
  • an increased collaboration across organisations. 

The pilots involve the following partners – Beech Tree Surgery, City of York Council, East Riding of Yorkshire Council, North Yorkshire County Council, Pocklington Group Practice, Posterngate Surgery, Priory Medical Group, Scott Road Medical Centre, Sherburn Group Practice, South Milford Surgery, York Teaching Hospital NHS Foundation Trust and partners from the voluntary sector.

Supporting information

What is integrated care? This short animation by the Kings Fund brings integrated care to life.

National Voices’ ‘A narrative for person-centred, co-ordinated care’ provides a definition of what good integrated care and support looks and feels like for people.