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Out of hospitals

The NHS Five Year Forward View reinforces the need to join up primary care, community health services, mental health services and adult social care, to work alongside specialists in hospitals.

These services need to tackle causes, not just symptoms; to treat the whole person, not just an individual ailment; and to be more proactive in supporting people with long-term health conditions to manage their health and avoid unnecessary hospital stays.

In order to deliver this we have developed a whole new approach and named this the Primary Care Home. This new model of delivering care was developed during 2018/19 with the aim of enabling:

Programme achievements during 2017/18

People told us what they thought of our services:

“Nothing could be improved. I wish everyone who came was like her” and “the matron was for my husband but supported me as well, she was always happy and helpful and nothing was too much bother. She always did what she said she would do” and “bent over backwards for us – they really are stars

 It was really helpful to have a visit. The ideas suggested made it easier for me when I came out of hospital” and [Worker name]… has helped me enormously by pointing me in the right direction, offering sound advice and to be honest I don’t like to think what I would have done without her, she has been a real godsend and a credit to the team”

 really listened to what I had to say and tried her best to help me” and “Didn’t just visit once. Made sure I was OK afterwards too” and “you have not used technical talk, you have been patient

 Pleased to be seen in my home. My son would have had to take time off work to take me to the doctors” and “Husband is ill and I cannot leave him. Good that nurse can come to house.” And [worker name]… was wonderful taking blood and did not hurt me at all, I am usually very difficult to bleed. He came back to my home later in the day after having no access earlier in the day as he understood the urgency of getting my blood that day. Thank you

 Plans for 2018/19

In 2018/19 the Out of Hospital Programme will continue its work to support people to remain independent living in their own homes for longer and to improve their experience of care, when they need it.  We aim to support people to be happy, healthy and at home, and through 2018/19 plan to:

Star ratings

Health inequalities

1 star

One star - worse than the english average

The frequency of people being admitted to hospital for long term conditions, from our poorest communities, is much higher than other areas in England.


Carers with a Long-Term-Condition

1 star

One star - worse than the english average

0.60 score for carers reporting they feel supported to manage their long term conditions, this result is lower than the England score and we need to improve.


End of life

2 star

Two stars - similar to the English average.

Of the 2,795 people who died, 200 people had three or more admissions in the last three months of life. This result is similar to admission levels across England.

Delayed transfers of care (DTOC)

3 star

Three stars -  better than the English average.

We have the best result in England for people delayed transfers of care.  Delays of just 2 days on average this result is lower than the 3 ½ day national target and much lower than the national average delays of 11 ½ days


Falls: injuries from falls in people aged 65 and over

1 star

One star - worse than the English average.

During July to September 2017 there were 2,941 per 100,000 population emergency admissions following injuries from falls for people aged 65 years or older. This result has remained high over time and is amongst the highest in England, showing we are in greatest need of improvement.