Background;Weymouth and Portland, is a seaside town in West Dorset, with a population of 74,000 people, and areas of significant deprivation. Historically, teams worked in silos, which led to handoffs, but since 2014, integrated working between Primary and Community Care across the locality has led to a significant improvement in patient outcomes.
Key features/developments; The locality partnership of primary care and community services in Weymouth and Portland has been a powerful driver for;
People with frailty and complex needs;
- Weymouth integrated care hub - a locality hub as a single point of access to support of people with frailty and complex needs.
- Evolution of beds at Westhaven Community Hospital, with 50% step up beds, and decreased length of stay
- Proactive support of Weymouth's 21 care homes, with aligned primary care, therapy and district nursing to each care home - a 'team around the care home'
- Development of a locality wide GP visiting service
People with moderate and rising needs;
-Development of a frailty toolkit to
- identify people with increasing needs
- develop a system wide 'dorset care' plan
- maximise the use of practice MDT meetings
- provide self help training and information for staff and carers
- Community pharmacy support to practices
- Integrated 'team around the practice' approach to community services
- Care navigation and health coaching for people with lower level targetted needs
People with universal needs; - Development of a locality wide Treatment Centre, which balances the needs of supporting A+E/acute care with supporting general practice. This forms the core of GP streaming for neighbouring Dorset County Hospital
- Collaborative approach to extended access to primary care - urgent and routine primary care provided at scale, in collaboration with community services.
- Physiotherapy practitioners within practices
Impact; The impact of these changes has been;
- 17% reduction in A+E admissions for minor and intermediate presentations
- 10% reduction in acute bed days
- Reduction in 65 acute admissions
- Reduction in over 65 acute readmissions
- Reduction in community bed occupancy of 20% (enabling closure of a community hospital and reinvestment into community services.
- Weymouth Urgent Care Centre has been awarded status of one of the first 150 urgent Treatment Centres across the county. Sir Bruce Keogh and Jeremy Hunt recently visited to acknowledge this.
- Weymouth and Portland Integrated Care Hub has been been recognised by NHS England, and forms the basis of a film 'now we have care'. The hub has been shortlisted for two HSJ awards - 'Primary care transformation' and 'Improving care with technology'
- The models (Integrated Care Hub, Frailty toolkit, Care home proactive support, Urgent Care Centre) that have been developed in Weymouth, via primary/community care partnership are being rolled out across the county.
Summary; Strong partnership working and trust in Weymouth and Portland between Primary and Community Care since 2015 has led to significant impact on provision of health services, and better, more cost effective services for local people.