Our CCG has been identified as a national integrated care pioneer site. It is developing new models of care so people in the CCG’s area receive individual seamless care, and reduce their need for urgent and unplanned care by proactively managing their physical, psychological and social care needs. 

Why do health and care services need to change?

You may have seen stories in the newspaper about the growing pressures on hospitals and other health services.

People are living longer, which is good news, and so the number of older people is increasing. Advances in medical treatment means that more people with disabilities, long-term conditions or serious illnesses or injuries are surviving longer.

This means that the number of people who have more than one health condition and who need extra help to live independently is increasing – we say that these people have ‘complex needs’. 

The NHS has to save £20 billion by 2016 and if we are going to do this and cope with the growing pressures on health services, we need to find new ways of working and this is being referred to as new models of care.

How will services be different?

We know when older people spend too long in hospital after illness they find it harder to recover and become independent again.

So we need to do more to help people live healthy lives to avoid them becoming ill in the first place and we need to support people to look after their health (known as self care).

We need to provide better support at home and earlier treatment in the community so people don’t end up needing emergency care in hospital.

We know that people with complex care needs are often ‘handed off’ from one service to another. Each health condition is treated separately, rather than looking at the whole person.

So we need to make sure that care is individual to the needs of each person, not a one size fits all approach.

We know people sometimes have to repeat information to different professionals and services are often working in isolation, so there is duplication between them. People and their carers have told us that they find it frustrating trying to get services to talk to one another and work together.

We need to bring different services together – like hospitals, social care and GPs – so that they work in a more joined up way.

What happens next?

The new models of care programme is looking at new ways of working in different areas of health and social care, including the four projects below:

Evidence and research

We have done a lot of work to decide whether these new ways of working will have a positive impact for patients in our area.

There is a lot of national and local policy about the need for services to be more joined up (known as integration) and for care to be better quality and for patients to have a better experience of their care. The work that we are doing is in line with the national and local policy.

We have looked at the local data on who uses the most health services, how they use health services and how much is being spent on health services. This has helped us to decide which patients would benefit from more support.

We have also looked at examples from across the UK and internationally of services that have been set up to support people with complex needs and long term conditions.

How this links to the National Pioneer programme

NHS England is running a national Pioneer programme. Airedale, Wharfedale and Craven is one of 25 of the national Pioneer sites. This means we can access advice and support and share learning with other areas who are taking similar approaches to join up health and social care services.