Integrated Management and Proactive Care for the Vulnerable and Elderly

The number of people who are elderly, vulnerable and living with a long-term condition in South Tees is increasing.  Over the next seven years the number of people aged 65 will increase by 20%.

It is good news that people are living longer.  However older people experience more ill health than other groups.  This represents a challenge for us as a Clinical Commissioning Group (CCG) but also an opportunity to improve the way we care for our elderly population.

Since 2014, we have been working with the public and other key partners in Health and Social Care to redesign the way we deliver care.

Our vision is that more people who can be treated in the community will be, and those who do require a hospital stay for medical reasons will be given the additional support they need to regain independence.

Between April and July of 2014, we undertook a formal consultation with those living and working within South Tees around a number of proposals including:

  • Improved stroke services
  • Better utilisation of our community estate
  • Delivering more care in community venues and patient’s homes, (rapid response teams, improved therapy support and more out-patient and day treatments delivered in community hospitals)
  • Changes to the way we deliver minor injury services by consolidating existing services in Redcar onto one site with a doctor-led service, longer opening hours and improved x-ray provision

In October 2014, our Governing Body made a number of proposals based on the results of our consultation:

  1. The proposals from the consultation are taken forward in a phased approach:
    • Centralisation of stroke rehabilitation services to Redcar Primary Care Hospital by April 2015
    • Closure of the two minor injury services in East Cleveland and Guisborough Primary Care Hospitals.  Consolidation and enhancement of minor injury services onto one single site (Redcar Primary Care Hospital) by April 2015
    • Closure of Carter Bequest Hospital and transfer of services within the community by April 2015 alongside the progression of improved community infrastructure
    • Part closure of Guisborough Primary Care Hospital (main building), removal of the bed base subject to implementation of improved community infrastructure by April 2016
    • Redevelopment of the Chaloner building in order to house transferred services as well as additional community based services by April 2016
  1. Work with key partners to monitor and assure phased implementation, providing and receiving regular update reports
  2. Agree that a system-wide group is established in order to explore the potential to influence travel plans and routes to take into account future patient flows
  3. Agree a public campaign to raise awareness around eligibility for the Patient Transport Service
  4. Develop a public communication plan to support understanding of what is urgent care and where to access services
  5. Agree to pilot a weekend district nursing clinic within East Cleveland Primary Care Hospital to commence by April 2015 in line with consolidation of minor injury services

We have begun work to implement these recommendations, working closely with The James Cook University Hospital as well as Middlesbrough and Redcar and Cleveland Local Authorities.