People with complex needs should get more support at home or close to home

Local care is the phrase we are using to describe health and social care provided outside of a main hospital, at home, in a clinic, GP surgery or in a community hospital.

To deliver our plans we need the right staff, in the right places with the right skills. The workforce workstream makes sure we co-ordinate how this happens.

Every day, we know there are 1,000 people in an acute hospital bed who could be cared for better in the community if more support was available.

We want to work better together to provide this care so more people can stay independent, at home, for longer.

We aim to:

  • prevent ill health by helping people to stay well
  • deliver excellent care, closer to home, by connecting the care you get from the NHS, social care, community and voluntary organisations
  • have health and social care delivered by one multi-disciplinary team.
  • support multi-disciplinary teams to work together effectively and for the benefit of local people ( Download our document: Top tips for multi-disciplinary working v5.5)
  • give local people to right support to look after themselves when diagnosed with a condition
  • intervene earlier, before people need to go to hospital.

So far you’ve told us you:

  • want to improve your health
  • think bringing health and social care together is a good idea
  • want more time with the health and social care professionals
  • want to use new technology, but you want face-to-face contact too
  • are concerned about travel times to centralised health centres.

What we have done so far

Older people with long-term conditions need more support so we have concentrated on looking at how we can improve their care first.

Working together, we have developed eight ambitions for older people to:

  • give more support to help them look after their health
  • provide care navigators or case managers to help organise their care
  • keep people safe and independent at home through housing, social care and health working better together
  • have health and social care skills all in one team
  • have one number for people to contact to arrange their care
  • provide a rapid response if a person’s condition deteriorates
  • provide increased support to get people home from hospital sooner
  • improve access to expert advice and diagnostics, such as x-rays or CT scans, for GPs and professional working in the community.

Through the listening events, we are currently talking to the public and colleagues to get feedback about this model of care for older people.

What are the next steps?

We are talking to local people and staff about what they think about these through the listening events and coming up with options of how to make this vision a reality.

We are also looking at what investment is needed in terms of capital, workforce and social care to make the vision a reality.

Our long-term plan is to focus on how we could deliver care in better ways for:

  • adults with chronic conditions
  • children
  • people who are mostly healthy
  • people with serious and enduring mental illnesses.

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