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Out of hospitals programme

The NHS Five Year Forward View reinforces the need to join up primary care, community health services, mental health services and adult social care, to work alongside specialists in hospitals.

These services need to tackle causes, not just symptoms; to treat the whole person, not just an individual ailment; and to be more proactive in supporting people with long-term health conditions to manage their health and avoid unnecessary hospital stays.

In order to deliver this we have developed a whole new approach and named this the Primary Care Home. This new model of delivering care is being developed during 2017/18 with the aim of enabling:

Programme achievements during 2017/18

People told us what they thought of our services:

Plans for 2018/19

In 2018/19 the Out of Hospital Programme will continue its work to support people to remain independent living in their own homes for longer and to improve their experience of care, when they need it.  We aim to support people to be happy, healthy and at home, and through 2018/19 plan to:

Star ratings

Health inequalities

1 star

One star - worse than the English average.

The frequency of people being admitted to hospital for long term conditions, from our poorest communities is three and a half times higher than the England average.


Carers with a Long-Term-Condition

1 star

One star - worse than the English average.

0.61 score for carers reporting they feel supported to manage their LTC(s) ranks low amongst England’s CCGs and we need to improve.


End of life

1 star

One star - worse than the English average.

One in every 10 people at the end of life had three or more admissions, that is to say  of the 476 people who died 48 had three or more admissions in the last three months of life.

Delayed transfers of care (DTOC)

3 star

Three stars - Better than the English average

People were delayed on average by less than the three and a half day national target and this result was amongst the best in England, and much lower than the national average delays of eleven and a half days.


Falls: injuries from falls in people aged 65 and over

3 star

Three stars - Better than the English average

During July to September 2018 there were 1,409 per 100,000 population emergency admissions following injuries from falls for people aged 65 years or older. This result has reduced over time and is amongst the lowest rate in England.