Learning from practice

Using practice-based commissioning to facilitate joined up working between health and social care

A practice in South West Staffordshire PCT is using practice-based commissioning to set up community teams to cope with cases which require a mix of health and social care expertise. This integration of the primary and secondary care workforces has given the area new impetus in helping patients to avoid hospital admissions.

Consultants in mental health, geriatrics and a host of other specialities are now based within a primary care setting - this includes all the associated workforce and other facilities traditionally associated with secondary care services. A practice-attached social worker is also part of the community team.

A team of community nurses has been seconded to the practice to form an integrated nursing team with the practice’s own team. This skill mix has significantly increased the capacity of the practice’s workforce, enabling it to take a much more robust approach to delivering integrated patient care.

Care is initiated by the member of the team which best knows the patient, who works with the medical team to set out a care plan which covers all aspects of medical involvement. The practice has set up a list of people in the area who can help to provide care for patients in their own homes.

The practice has also purchased the local residential home, which means daytime respite care is easily accessible. A grant from the Alzheimer’s Society gave them the financial impetus to get this started.

Prof David Jolley, a consultant in older peoples mental health is also helping the practice to trawl through its QOF databases to set up an at risk group of dementia patients. The practice’s health visitor has taken the lead in changing her role to screen these patients and offer them anticipatory care packages where appropriate. Voluntary organisations have also been involved and have set up an eldercare patients charity called Living for the Future which facilitates befriending and peer support. The practice is pushing for direct payments from social services but would ultimately like to have a social services PBC arrangement.