Case Study Archive – Long Term Conditions and Community Care

Inpatient to Community Services

Project overview: A review and rationalisation of inpatient and community mental health services for adults across Devon.

DPT Community Services


Improving Asthma Management in Bristol

Project overview: To improve asthma management in Bristol through: • Improving healthcare professionals and patients’ knowledge of asthma • Improving patient access to advice and asthma medication reviews • More cost-effective prescribing • Better management of inhaler devices and improved patients’ use of inhalers • Targeting resources at areas of high risk e.g. areas of deprivation, ethnic minority groups.

NHS Bristol Asthma



Project overview: The Telehealth service in Cornwall was initially a Whole System Demonstrator and was the largest trial of Assistive Technology of its kind in the world. The system allows patients to take daily biometric readings, such as blood pressure and pulse oximetry, at home. These are then transmitted to a clinician for monitoring. Appropriate action can then be quickly taken if there are signs of deterioration or a change in the patient’s condition. The project is being nationally evaluated with the results due in Spring 2011.

NHS COIS Teleheath


Developing the clinical service line for stroke care for Plymouth

Project overview: It was recognised that there was a need for fundamental improvements to the Stroke Pathway in the Plymouth Health Community. This was a strategic aim of NHS Plymouth, but was also a high level target initiative following the publication of the National Stroke Strategy in December 2007, and the independent review into stroke services commissioned by the SHA in July 2008.

A clinical service line for stroke was agreed as a concept in January 2009 and formally launched in April 2009, to coordinate the development of stroke services with the two healthcare providers Plymouth Hospitals NHS Trust and Plymouth Primary Care Trust provider arm.

NHS Plymouth S Care


Somerset Community COPD Service

Project overview: Research by the NHS Institute for Innovation and Improvement showed a potential 20 per cent reduction in emergency admissions for people with chronic obstructive pulmonary disease when comprehensive community services were in place. NHS Somerset redesigned community COPD services with full involvement from patients, carers and professionals. The service is the first in the country to deliver a comprehensive community COPD service designed around the needs of the patient and delivered through a partnership between the public and private sector.

NHS Somerset COPD


Intravenous Antibiotics Service

Project overview: The Intravenous Antibiotics Service was the first community based IV service in the South West when it was launched. Initially, a few patients were being seen by the Intermediate Care Team if capacity was available. The Primary Care Trust was aware that other areas of the country had established IV services through separate specialist teams and wanted to provide a robust service embedded within community nursing. This will enable community nurses to provide holistic care to their patients, including Intravenous Antibiotic therapy as an additional treatment option to support patients to remain in their own homes.

NHS South Glos IVT


Transforming the role of the Community Matron through the implementation of the Virtual Ward

Project overview: An opportunity was identified to refocus the role of the Community Matrons in NHS Swindon in order to:

  • Provide more intensive multi-disciplinary care management of specifically identified high intensity users
  • Improve the quality and consistency of care for these patients
  • Reduce readmission to hospital where appropriate
  • Develop the virtual ward concept using the community matrons as the orchestrator of care.

The very high intensive user project was launched to pilot an integrated model of care across primary care and the Community Matrons. The project was led by the Practice Based Commissioning GP across one of the three localities. The project was launched in January 2010 and the implementation was phased over three months with plans to roll out across all three integrated teams within nine months.

NHS Swindon V Wards


Neighbourhood Teams

Project overview: Neighbourhood Teams are a new way of delivering community based health services in Wiltshire. The 11 multi-disciplinary teams consist of nursing, therapy and support staff, co-located with social care staff, who together provide care for patients and service users, seven days a week. By providing modern, responsive, accessible health and care for patients – normally in their own homes and certainly within their community areas – the teams have reduced inpatient hospital stays and enabled many people to maintain their independence and to enjoy a better quality of life for longer.

NHS Wiltshire Teams


Reablement – Contract Monitoring QIPP

The Somerset Clinical Commissioning Group (SCCG) led the review and redesign of reablement services over the last two years to help improve outcomes for patients.  We worked with local authority colleagues to lead a joint programme to review existing services and implement a redesigned service model based on systems thinking methodology.  We also worked with a range of stakeholders from the NHS, adult social care providers, and independent and voluntary sector organisations.  The programme has been discussed and supported by the Somerset Health and Wellbeing Board.

Compass Disability was commissioned to bring together focus groups and develop a questionnaire giving people the opportunity to feedback their experiences of reablement services.  They held extensive stakeholder events with representatives from NHS, adult social care providers, independent and voluntary sector organisations and undertook a ‘deep dive’ exercise to understand what was happening in existing systems.

A pilot integrating health and social care teams at one GP surgery has been in place for 18 months.  It has been rolled out to 15 practices in the Taunton and Area GP Federation with plans to phase in the service across the whole of Somerset.

A clear message from the service users was: “I want to maintain my independence:  help me to find the solutions to do the things that matter to me”.  The key difference with this model is that we are asking patients what they feel is important to them and what goals they want to achieve.  The teams have flexibility to find solutions centred on these goals.  This is a fundamental shift from the ‘one size fits all’ approach often seen in existing services.


Improved patient experience and quality of life as care delivered in a more appropriate setting; 1{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} reduction in emergency admissions 7{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} reduction in readmissions

Contact details and further information

Ann Anderson

Director for Clinical Commissioning Development

01935 384190


COPD Monitor

The solution featured here is Message Dynamics’ ‘COPD Monitor’ which uses interactive voice technology to monitor patients’ wellbeing.  It is designed to improve patients’ quality of life, improve disease management, reduce admissions and reduce costs.


The COPD monitor phone calls patients twice a week to record their state of health. Between September 2011 and February 2012, almost 1,500 calls were completed (a response rate of 91 per cent). Of these, 13 per cent generated an alert which starts an automatic escalation process. An initial follow up call by the unit’s nurses resolved 80 per cent of issues and the remaining 20 per cent required home visits. These home visits prevented nearly forty emergency admissions (representing a saving of at least £80,000). The investment in this project by the SHA has been £48,775. However, excluding this initial development cost the cost of  delivering this service is £375 – ie 25p per call. The return on investment ratio of this pilot is in excess of 200:1.

An unanticipated benefit is that patients like talking to a computer; they do not feel they are wasting people’s time and patients report feeling less isolated. Clinicians are also noting that patients are becoming better equipped to understand and manage their own conditions.

Information, tools and techniques used:

SBRIs start with a ‘problem space’ which can be defined quite closely to respond to a specific issue.  Prince project management underpins the thinking of the programme management team and helps provide a balance between process, structure and outcome foci.


SBRI was launched in July 2010 and companies were given six weeks to bid. Sixty-nine companies from the UK and overseas responded in September 2010 and in November, Message Dynamics was one of four companies that received funding to take their proposal to a ‘proof of concept’ (POC) by February 2011. The product was adopted in September 2011 and is now offered to all patients referred to the specialist COPD service at Heatherwood and Wexham Park Hospital.

Contact details and further information:

Duncan Goodes:


Reablement programme, Somerset

The Reablement programme helps patients or their carers to be experts in their own care and maintain independence for as long as possible.  By giving tailored solutions that don’t foster dependence and supporting people to remain in their own homes, it ultimately aims to reduce health inequalities and build a cost-effective service that meets demand.

The programme takes a systems approach. This has meant taking a long hard look at the way that services are delivered and has led to fundamental changes in service provision, rather than simply ‘doing the wrong things righter’, as one programme manager put it.

Listening to patients and collaborating across professional and organisational boundaries are both central to what makes the reablement programme work. In Somerset, the PCT and the county council jointly reviewed all their services that might be termed ‘reablement’. They worked in partnership with private and voluntary sector organisations and the new CCG to deliver better, more coordinated services.


In Somerset, the reablement programme has led to an increase in collaboration across the healthcare sector and made significant changes in how patients are assessed and what services are provided. An example is a patient with a history of sciatic pain who had a fall. Previously, he would have been hospitalised, but his GP contacted the reablement team, who quickly established that he would prefer to be at home. The team devised a personal support package that enabled him to gradually increase his mobility without being admitted to hospital.

Ultimately, the programme has delivered a number of real gains in service quality, patient outcomes, productivity and staff motivation. This includes significant reductions in hospital readmissions and the cost of social care.

Information, tools and techniques used:

The programme used Vanguard Consulting’s change methodology for systems thinking.


The Somerset Reablement programme started in spring 2010 with a pilot in Taunton. From January 2012 Reablement was mainstreamed in Taunton and rolled out in another large federation in Somerset.

Contact details:

Ann Anderson and Sue Glanfield were both members of the project team.

Community response and reablement service (Bracknell Forest)

The community response and reablement service programme, undertaken by Bracknell and Ascot CCG commissioners jointly with Bracknell Forest Council, pursued an alternative to hospital-based intermediate care.  It worked across health and social care in areas where the lead commissioner for the service is the local authority via a Section 75 agreement.

The core purpose of the programme was to set up a joint service for the provision of bed based reablement. Some beds in a community hospital were decommissioned and a formal application was made by the clinical commissioning group (CCG) to invest in more local bedded reablement in a social care setting.  The change happened concurrently with a continued shift in patient flow.  Previously almost all acute non-elective admissions to hospital were to one district general hospital (DGH).  Now admissions are split between 3 neighbouring acute hospital trusts.


A number of outcomes have been recorded in relation to the performance of the health and social care system.  These include minimal delayed transfers of care and an encouraging rise in admissions directly from home to the new service via GP referral.  People using the service report high satisfaction with the service.

Information, tools and techniques used:

No specific change management methodology was used.  Instead the programme took a pragmatic approach to engaging with stakeholders with a common purpose.


The programme involved local community health services provided by Berkshire Healthcare NHS FT, the CCG for Bracknell Forest and Ascot; Bracknell Forest local authority and three acute hospitals.


The programme started in July 2012 and is still on-going.

Contact details and further information:

Mira Haynes, Chief Officer: Older People and Long Term Conditions, Bracknell Forest Council –

Mary Purnell, Assistant Director of Commissioning, NHS Berkshire East –

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