NHS Kirklees pioneers integrated care


A model of integrated care developed by NHS Kirklees for people with long-term conditions, deploying telehealth monitors and electronic patient records, has been praised by Health Secretary Andrew Lansley.

The NHS Kirklees system, developed through joint working between health and social care teams, involves using an online ‘emergency care plan’ for each patient to prevent and manage acute episodes.

This initiative has reduced ambulance trips by 16% and saved NHS Kirklees £1.09 million in a year.

Lansley commented: “The NHS can work more efficiently to improve care for their local communities, as they have shown in West Yorkshire. People with long-term conditions have some of the most complex health needs in the country and we need to personalise services to suit their needs, not fit them around how the NHS is organised.”

Strategies used by NHS Kirklees include: telehealth monitors to help patients keep track of their own health; ‘generic workers’ to support health and social care needs in the home; a single point of access to services; electronic patient records; and an emergency care plan developed by each patient with paramedics, hospital staff and community matrons.

Dr Jeremy Till, Consultant in the Emergency Department at Dewsbury and District Hospital, explained the emergency care plans: “The plan clearly highlights symptoms which are the ‘norm’ for that patient and can be managed by a health professional in the comfort of the patient’s own home or in the community. It also highlights at what point a hospital admission may be required.”

Robert Flack, MD of Kirklees Community Healthcare Services, added: “We are rolling out a new way of working with each long-term condition patient and their family at the centre of a Community Care Team. This team comprises the staff needed for that particular patient and includes their GP, community matron, district nurse and generic worker, therapist etc as appropriate. They work closely together with the aim of supporting the patient to stay at home wherever possible rather than being admitted to hospital.”

A Department of Health statement declared that NHS Kirklees was “leading the way” in joint working between paramedics, hospital clinicians, GPs and community nurses to support people with long-term conditions – an integrated healthcare model that could help over 15 million people in the UK to manage their health and avoid hospital admissions.