An innovative idea to treat people earlier for illnesses like flu and chest infections has led to patients in one area avoiding 17,000 nights in hospital and the NHS saving £7 million to be reinvested back into patient care.
The iCares system in Sandwell in the West Midlands flags people with long-term conditions who are at high risk of hospital admission to a team of 100 staff who make sure they are seen as early as possible.
Previously, patients were coping at home until in many cases they needed to be admitted to hospital.
But now patients or their carers can simply call a number if they need help and are assessed and then seen in as little as three hours by a team dedicated to hospital avoidance.
So far the scheme has reduced hospital admissions by 2,478 a year and 93% of patients who access the service stay in the community.
The move has also contributed to reduced lengths of stays in A&E, reduced lengths of stays in hospital from 10 days to seven days, and reduced readmission rates.
The team is made up of physios, occupational therapists, advanced clinical practitioners (ACPs), community matrons, nurses, speech and language therapists and many more.
The ACPs can dish out prescriptions to clear up infections and the team can organise extra equipment to help people manage safely at home.
The majority of people living in Sandwell have multiple long-term conditions, are likely to live their final 20 years in ill health and are likely to die younger, according to NHS England.
If patients develop urine infections, chest infections, flu, coughs, colds or cellulitis, it can lead to frailty and falls, resulting in less independence, swallowing problems, not eating and drinking enough and feeling unable to cope at home, as well as an increase in stress for both the patient and carers.
Ruth Williams, clinical directorate lead at Sandwell and West Birmingham Hospitals, set up the iCares scheme five years ago after realising how difficult it was for patients to navigate the system and the waste created by multiple teams.
She brought people from three teams under one roof and consolidated 16 different points of access to care and staff now work in neighbourhood teams, based on the patients' locations.
"iCares is based on need and not diagnosis," she said.
"If a patient has a long-term condition and develops an infection, for example it could stop them swallowing or walking and that would make them housebound and unable to cope at home.
"Previously, the small team of three people saw urgent cases as well as possible at home but the patients they couldn't see were admitted to hospital.
"What we've done is make the system simpler: one phone number, everyone can ring and one team which works together and navigates the system for the patient, keeping 93% of urgent cases out of hospital.
"Most importantly of all, people only have to tell their story once."
NHS England national clinical adviser for primary care, Dr Karen Kirkham, said: "As we develop a 10-year plan for the NHS it is innovative schemes like this that are showing how practical new ways of working can help patients live better lives and also deliver efficiencies for health organisations to reinvest."
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