Our challenge:

To ease the pressure on the whole NHS system by deflecting care away from extremely busy hospitals and providing enhanced urgent care in the community.

How we tackled it:

Through a community enhanced care (CEC) service Pennine Care NHS Foundation Trust is able to provide urgent care within six hours for patients at risk of a hospital admission. It also delivers specialist, enhanced care packages for up to 72 hours in the patient’s own home. The service includes a range of staff covering several specialisms.

Patients can be referred to the service by their GPs, paramedics, hospital consultants, and community matrons. The service also includes enhanced care neighbourhood teams that provide ongoing care for patients with a long-term condition, conditions associated with ageing, or complex needs.

Among the people the service has helped so far is 87-year-old David Silver from Hale. David has a number of long-term conditions, including chronic obstructive pulmonary disease (COPD), bronchiectasis, kidney failure, chronic back pain and problems with his circulation.

David had been a regular visitor to the local hospital until he was referred into the CEC service. Since then, he has not been readmitted once.

He said: “Now, the community nurses help me to manage my condition at home. They taught me a set of exercises that I can do at home to help improve my breathing, which has made a huge difference and is one of the most significant changes. They also set me up with the equipment I need to help keep me well and mobile. It’s not just physical care – the nurses also provided emotional support to me and my wife, Sheila, to help us cope.”

What changed:

The initiative prevented an estimated1,900 admissions (between April and December 2014). This reduced pressure on busy local hospitals and saved an estimated £1.3m.

Devolution focus:

One of our strategic objectives is to improve the health and wellbeing of all of the residents of Greater Manchester from early age to older people and recognise that this will only be achieved with a focus on the prevention of ill health and the promotion of wellbeing. One of our early priorities is to provide more community-based care to help reduce the number of people needing to be admitted to hospital.