The first phase of work to join up health and adult social care services in north Cumbria has enabled more people to be treated closer to home and spend less time in hospital.

As people are living longer and have increasingly complex health conditions demands on health and care services across the country are rising. In 2018 plans were set out in north Cumbria to change the way health, adult social care, third sector organisations and communities work together. Eight Integrated Care Communities (ICCs) were developed to enable closer working, help people to stay well and provide more out of hospital care.

The first phase of ICCs aimed to increase the capacity of community teams to keep more people at home and support people to leave hospital sooner.  This has already had a significant impact with around 190 people avoiding a hospital stay thanks to the new ways of working.

This initial focus was on a specific group of patients who could previously have avoided a hospital stay, if more support had been available in the community. Between July and December 2018 there was a 4.8% reduction in the number of emergency hospital admissions for those patients supported by ICCs compared to the previous year and the average length of stay in hospital fell.

Dr Niall McGreevy, GP Partner and Deputy Clinical Lead for Allerdale, explained:

“The progress we have made so far is really encouraging. There are lots of reasons why hospital is not always the right place, especially for older people. Long hospital stays can reduce people’s strength and independence, the unfamiliar environment can cause confusion and sleep deprivation and there is an increased risk of developing infections. If someone is medically well enough, home is usually the best place and the new ways of working are allowing us to treat more people out of hospital.”

For example one patient in Carlisle was independent but had a fall. There was no medical need for them to be admitted to the Cumberland Infirmary, but they were too frail to manage at home without support. The ICC arranged an assessment by an occupational therapist and care was put in place until the patient had recovered, avoiding an unnecessary hospital admission.

In Alston, Maryport and Wigton overnight beds were closed in the community hospitals which has also enabled teams to provide more community care. In Alston the number of community visits has tripled since the bed closures and in Maryport the team are now able to provide a wider range of services, such as blood transfusions, that would previously have been delivered in the acute hospitals.

This new service supported a Maryport resident to return home from the West Cumberland Hospital and visit Maryport Community Hospital daily to receive a 40 day course of IV medication. It allowed the patient to recover in the comfort of their own home and saved the family a daily drive to visit at the acute hospital.

The progress supports the NHS Long Term plan which was announced in January to ensure health services are fit for the future by enabling everyone to get the best start in life, helping communities to live well and helping people to age well. It focuses on preventing ill health, improving services and joining up care to ensure people are treated in the best place for their needs. This includes more out of hospital care and health and adult social care services working closer together.

Professor John Howarth, Director of Service Improvement and Deputy CEO for Cumbria Partnership NHS Foundation Trust and North Cumbria University Hospitals NHS Trust, added:

“The work we have done so far puts north Cumbria in a strong position to deliver the government’s long term plan and transform the way health and care services are delivered. This is the start of an exciting journey and the results suggest we’re on the right track. It’s all down to the hard work, dedication and creative thinking of staff across the health and care system and those who use our services – so I’d like to thank everyone who has been involved so far as we continue to work together.”

The next phase of ICCs will focus on improving the health and wellbeing of people in north Cumbria by identifying the health priorities for each ICC, reducing health inequalities, promoting independence and introducing social prescribing – connecting people to community groups and statutory services for support.

Integrated Care Communities – what’s happened so far?

• Teams of health (including GPs and community teams), adult social care, third sector and community groups working much closer together in each area.
• Co-ordination hubs – each ICC has a hub ran by trained administration staff who take referrals and coordinate care from different organisations. Coordinators are also based in the acute hospital to help people get home sooner.
• Lead professional of the day – a health professional within the hub decides on the most appropriate response for each referral.
• Rapid Response – each ICC has a team of health and care staff such as nurses, physiotherapists, occupational therapists and adult social care who can quickly put support in place to help people stay at home or get home sooner.
• Recruitment – new roles have been created in community teams to ensure there is enough out of hospital support. A recruitment drive in 2018 secured additional staff to community health teams and recruitment to the ICCs continues.
• Frailty co-ordinators – identify people who need support to stay well before their condition worsens.
• New ways of working in Alston, Maryport and Wigton to deliver more care in local communities.
• Coproduction – using their knowledge and experience of those who use services to make improvements.