Summary of document:

This business case proposes making a significant investment in GP services and integrated multidisciplinary teams. These teams will include a number of different health and social care professionals. The overall aim is to ensure that care be delivered closer to home, with particular focus being given to those in the community that need the most support.

Stockport is divided into eight neighbourhoods, each serving the differing needs of the people within the areas. Operating a ‘neighbourhood model’ means that health and social care support will be organised at a local level.

The neighbourhood model will see services working together, with primary care (usually provided through a GP practice) at its centre. They will work with people and communities to achieve improved health and social care outcomes. There will be an increased focus on identifying the causes of poor health, such as an unhealthy lifestyle and helping people to address this.

This business case proposes that services will be operated by multidisciplinary teams, which bring together primary care, physical and mental health, allied health professionals, voluntary sector and social care services.

The multidisciplinary teams will support people in Stockport who have a long-term health condition (approximately 15% of patients) through:

  • Bringing health and care services together for the individual and/or their carers
  • Access to a single shared record and care plan
  • Drawing in specialist services and support including mental health when required
  • Considering a person’s physical, mental and social care needs
  • Creating greater independence with education and self-management where possible
  • Addressing the causes of poor health, care and wellbeing outcomes by working with the third sector

Neighbourhood leadership will be provided by a general practitioner (your family doctor), supported by senior nursing, therapeutic and social work colleagues, who will ensure that services meet the needs of local people. Services will offer seven-day access and support people to remain healthy, build independence and look at risk factors associated with developing a long-term condition.

The success of this business case relies on the system’s ability to ensure that the people most at risk of being admitted to hospital can more easily manage their care in a community setting. A number of new ways of working will be put in place to ensure that GPs have increased capacity to work with the people in Stockport living with a chronic health condition.

In brief, these new ways of working are:

  1. Direct access physiotherapy – the aim is to reduce the number of patients with Musculoskeletal (MSK) conditions having to have consultations with GPs before they access physiotherapy services. This will help to provide more timely access to support, improving patient experience, and freeing up GP capacity.
  2. Mental wellbeing – significant numbers of GP appointments are spent working with people who have low level social needs or mental health related conditions. Where no specific medical help is required, GPs will be able to refer the patient to a care navigator who will develop a personalised care and wellbeing plan. They will also help people to access a range of services such as self-help, mental health alliance and other voluntary sector groups.
  3. Find and prevent – this will focus on finding people who have yet to develop complex care needs, but whose lifestyle would suggest they’re at risk of doing so. People will be ‘found’ through patient data and reports. They will then be invited for enhanced health checks within the neighbourhoods. Once people have been identified through the find and prevent service, they will then be supported through other programmes to help meet their needs
  4. Self-care – support and coaching will be offered to people with a long-term condition or those with risk factors which increase the likelihood of developing a long-term condition. An assessment of people’s ability to manage their conditions will be made. This will identify the right level of support for that person, and allow support to be tailored.
  5. Medicine review – prescription management will be carried out by a neighbourhood prescription management service, which will be led by pharmacists. A combination of clinical and non-clinical staff will manage repeat prescriptions, provide medication reviews and monitoring. Prescription requests will be accepted by telephone or electronically using trained medicines co-ordinators.