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proactive and preventative

Joined up care closer to home


As an Integrated Care System we want to provide the best possible care within available resources, as close to home as possible and joined up around the people and communities we serve. Below you can find some of the work that has been happening to support this aim.

Delivering integrated Musculoskeletal services in the community

Health services across Coventry came together to provide a new way of delivering care for patients with a wide range of musculoskeletal conditions. Musculoskeletal (MSK) conditions are those which affect the joints, bones and muscles, as well as include rarer autoimmune diseases and back pain.

The service brings GPs together with community and hospital services to improve access to MSK services and help patients better manage their conditions, shifting the focus from specialist, hospital–based care into community focused provision, with greater emphasis on prevention, self-management and holistic therapy-led interventions.

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Dene and Stour PCN Multidisciplinary Teams (MDTs)

The introduction of Multidisciplinary Teams (MDTs) in Dene and Stour PCN has increased the scope of support that GP practices can offer to patients. Three new roles have been created, Health and Wellbeing Coach, Social Prescriber, and Care Coordinator, and they offer a range of services including support with issues such as housing, homelessness, addiction, bereavement, and debt, that would have previously required referrals to external services.

Prior to the creation of these teams within GP practices, a GP would have to refer the patient to several other health professionals, which would mean multiple appointments in different locations and often patients were waiting longer to receive the care they needed.

Patients are already enjoying the benefits of these new roles, including quicker, more flexible, and more holistic treatment that has been improved by the sharing of knowledge and skills between the MDTs.

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Coventry and Warwickshire Hospices working together to put patients first


In order to provide equitable hospice care across Coventry and Warwickshire that both provided the best possible care to patients whilst respecting their end of life wishes, hospice providers and local NHS services came together to coordinate services and agree a joint vision.

This joint vision will form the basis of hospice care across our system and demonstrates a collaborative approach to hospice services.

This partnership working is already underway in South Warwickshire where healthcare and hospice providers are working together to create a single point of access to hospice and palliative care services. This new model will ensure patients are at the centre of their care and will access the right services, in the right place at the right time.

By working together NHS community teams and hospice providers are in a better position to meet the care needs and wishes of end-of-life patients.

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Addressing health inequalities in pulmonary rehabilitation

The number of patients accessing pulmonary rehabilitation health services after being discharged from hospital diagnosed with COPD was found to be lower in rural areas. Historically, pulmonary rehab was delivered in population hubs, which may have been difficult for these patients to access.

In order to address this health inequality, the physiotherapy team at SWFT have developed a new service model to improve access for patients living in rural areas.

The approach had two main elements. The first is that the teams go into GP practices and offer 1:1 consultations with those identified as requiring pulmonary rehab, where baseline tests can be carried out and patients can ask questions about the service. Second, the subsequent pulmonary rehab classes are delivered locally to the patients, either in GP surgeries or local community premises, bringing care directly to the patients.

The model will now be evaluated to determine the impact of uptake of pulmonary rehab and has the potential to be applied to other health and care services.

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Using frailty virtual wards to prevent hospital admissions

The introduction of frailty virtual wards in South Warwickshire has meant patients who would otherwise be admitted to hospital can now be treated at home whilst still receiving the care they need to recover.

The Urgent Community Response team can offer face-to-face support to a patient, while also speaking to a range of other healthcare professionals, such as consultants and GPs, using the virtual ward.

Patients benefit because they are able to remain close to their support networks and do not have to be admitted to hospital, which can be a stressful experience. There are also benefits to the health service as demand on the ambulance service and hospital capacity is reduced.

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