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Health Matters - Community Hubs update

paul bowen
Health Matters - Community Hubs update
08 December 2017


Dr Paul Bowen, clinical chair of NHS Eastern Cheshire CCG, and GP with McIlvride Medical Practice, Poynton

Regular readers of this column will know that the Caring Together programme is joining up health and social care services across Eastern Cheshire.

Its aim is to provide community-based care that helps people to stay well and supports people with long-term conditions to live independently at home – where they want to be.

But what you might not know is that Caring Together has recently established community hub prototypes in two localities to test new approaches to joined-up care. 


Known as Team Knutsford and Team Bollington, Disley and Poynton, the two hubs have made important progress since June – and Eastern Cheshire’s other three localities are in discussions about how to create hubs in their areas.

Team Knutsford has been progressing with the following projects:

The dementia pathway project has seen consultants and GPs working together to provide clinic appointments in a GP practice in Knutsford which reduces the travel for people. Also where people’s needs are stable their care is provided by general practice which should release specialist time to make it quicker for people with complex dementia to see a consultant.

A unified nursing project is testing out joint working between practice and community nurses to provide joined-up care that also makes better use of health workers’ time.

Another project is bringing together health and social care partners, third sector organisations and the public to develop a standardised approach to end-of-life care.

A local care service directory will signpost to a range of community and voluntary services, helping people manage their own care.

At Flu clinics in September people were offered the opportunity to have a quick test for atrial fibrillation, an irregular heart rhythm which is hard to detect and is a leading cause of stroke.

A care home project has seen a community paramedic and matron making twice-weekly visits to a care home to train staff and reduce avoidable emergency call-outs.

Meanwhile Team Bollington, Disley and Poynton have been busy with projects of their own.

Healthcare staff and patients have worked together on plans for a unified approach to management of diabetes.

A whole-system approach to older people’s services focussed on 15 people who received a lifeline personal alarm. Their level of frailty was assessed and where relevant they were provided with a bespoke care plan to avoid and help manage any future care crises.

A medicines management hub has trained GP practice staff in efficient, cost-effective repeat prescribing.

Finally, a number of teams have been working together to create a single list of carers across health and social care and offer assessments and support services for carers.

The learning from these small test projects will be considered for spreading out across Eastern Cheshire over the next few months.