Integrated health and care in Borth
Last updated: 2 August 2024
What is the project?
This project takes a patient-centred, multi-agency team approach to providing integrated health and care services to patients registered with Borth Surgery in Ceredigion.
The community of Borth and the surrounding area has a high population of older people, as well as a rural farming population. This group often access health and social care services a long time after their heath or social care need starts.
The community has a GP surgery and two community pharmacies, as well as a number of community health and care teams. The community teams are provided by Hywel Dda University Health Board and Ceredigion County Council, as well as a number of third-sector organisations.
Historically, there’s been little co-ordination between the different organisations in providing support to individuals in the community. This has led to duplication, more demand on statutory health and care organisations, longer waiting times, and a reduction in health and well-being.
The project was established to transform the way the various organisations involved in delivering health and social care worked together. By enabling the local community, including statutory partners in health and care, to collaborate, the project aimed to improve the health and well-being of the local population.
Why was it carried out?
The COVID-19 pandemic increased the overall health and care needs of the population, waiting times for planned care, and recruitment challenges in the health and social care sectors. The increased demand in general practice meant there were fewer primary care clinicians available to manage the health and social care needs of patients living in the community. This resulted in more referrals to additional healthcare and local authority services.
The project’s aim was to develop better multi-agency team working in the community. This was achieved by setting up a regular weekly multi-agency team meeting and employing a clinical care co-ordinator to co-ordinate patient care and chair the meetings.
The multi-agency team meetings are held on Microsoft Teams and take one hour. The aim of the meetings was to provide multi-agency patient-centred care that focused on what mattered to the individual. Any member of the multi-agency team could discuss any patient who was registered with Borth Surgery at the weekly meeting.
The patients discussed in the multi-agency team meetings were split into separate groups for evaluation purposes so that the effectiveness of the multi-agency team on each group could be seen. Patients were split based on the nature of their case or how they initially came into contact with the multi-agency team.
Where and when did the work take place?
The project has been completed, but the multi-agency team meeting continues to be held on a weekly basis. These meetings were first set up in June 2022.
The work is focused on the practice population of Borth Surgery in Ceredigion.
Who was involved?
The organisations involved include:
What have they learnt from the work?
The results have shown:
- a reduction in the complexity of the care needs of patients who’d been referred to social services
- an increase in the support patients received from the third sector
- a reduction in the duplication of processes in the different agencies
- an increased number of people receiving anticipated end-of-life care in the community rather than hospital
- an increase in patient mental health and well-being scores
- an increase in staff job satisfaction
- a significant reduction in length of stay for patients whose hospital discharge was managed through the multi-agency team meetings
- a significant reduction in GP appointments for patients whose needs have been met by the multi-agency team meetings
- an increased use of technology for patients to attend the multi-agency team meetings.
The team faced a number of challenges during the project. They overcame many of these, but some remain. These include:
- siloed working – multi-agency team working was challenging because of different systems and processes across organisations, which didn’t always match up. There was also some initial reluctance to change working practices. The team managed these by streamlining processes and encouraging positive risk taking
- funding silos – the team found that funding is often either health or care-focused, with little opportunity for organisations to pool funding for the individual’s benefit
- IT systems creating barriers to integrated working – organisational firewalls made the electronic sharing of project and patient information difficult
- Lack of resources – the project identified a number of services that either had limited capacity or no longer existed.
How to get in touch
For more information about this project, please visit the Bevan Commission website or contact project lead Dr Sue Fish on sue.fish@btinternet.com.
Find out more
Contact name:
Dr Sue Fish