Integrating health and social care services for patients and carers has resulted in substantial savings in the London borough of Sutton. A six-month pilot, based on just three medical conditions and a trial area of only 25,000 patients, reduced PCT admissions by 29 patients with long-term, high risk conditions and saved approximately £322,000.
At the same time, many of the patients involved were able to enjoy the security and independence of staying in their own homes where they were supported by a consistent team of professionals. The benefits of this pilot are regarded as being so compelling that the approach is now being extended to two new local care centres in the Sutton area.
Between August 2010 and January 2011, a multi-disciplinary team GPs and council staff piloted reducing hospital admissions through better integration of health and social care. Led by GP Dr Raza Toosy, the pilot targeted people who had presented at A&E or passed through A&E with heart failure, diabetes or chronic obstructive pulmonary disease.
Sutton Council installed monitoring devices in each patient’s home so GPs could use this equipment to check their client’s blood pressure, blood oxygenation and other indicators, then take early action. Each client’s needs were also discussed at weekly meetings by a social worker, psychologist, GP, community matron and district nurse.
When treating people with long-term, high risk conditions at home, the team also identified which patient’s carers could be assessed and advised. They found that many of the carers also had health and social care needs, which had not been spotted before. Joining up support for patients and carers therefore ensured that people could remain at home, in a healthy and sustainable situation.
People receiving the service did not have to provide information about themselves more than once and the multi-disciplinary team learnt about each other’s services, which aided a more integrated and complementary approach.