Drive system integration by aligning formal services and connected communities, enabling local areas to effectively coordinate action on admissions.
The primary focus of High Impact Change Model: reducing preventable admissions is to reduce admissions to hospitals by remaining in or returning to the community.
G1: Joined up across formal services and connected communities
- The social care workforce in the UK is larger than that of the NHS, and both are outnumbered by the 5.8m unpaid carers. Being able to work effectively across health and care (including unpaid carers) will maximise the impact on people’s wellbeing and avoid crisis occurring.
- Engaging effectively with the VCFSE sector is also key – as outlined in other changes in this model they can play key roles. Covid demonstrated the effectiveness of volunteers and community activation in supporting people with their health and wellbeing.
- Factor potential drivers of acute admissions and what could be prevented or supported in the community into planning for the mid to longer term population needs (e.g. within JSNAs).
- Build awareness and ensure connections are made with local community level support when someone does have a crisis event. Access to information and advice about what is available in your local area is key to both individuals and staff. Alongside digital directories and access other examples might include community connectors, community developers and social prescribers.
- Put feedback loops in place – can local leadership see data on their area’s health outcomes and incorporate this into their local planning and then monitor progress?
- Support local places to find the right balance between addressing local variation and tackling the common causes of hospital admissions and disability-adjusted life years shared across the UK – the Risk Stratification in Outcome 1.1 should support this.
Maximising independence and preventing future crisis: suggested actions