1. Primary Care Home

2. Strengthening and redesigning primary care
Staff come together as a complete care community – drawn from GP surgeries, community, mental health and acute trusts, social care and the voluntary sector –  to focus on local population needs and provide care closer to patients’ homes. 

3. Four key characteristics of Primary Care Home
an integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care;
a combined focus on personalisation of care with improvements in population health outcomes;
aligned clinical and financial drivers through a unified, capitated budget with appropriate shared risks and rewards and 
provision of care to a defined, registered population of between 30,000 and 50,000

4. Hospital GP Pharmacy Mental Health Community Health Community*
Commissioners
Community Health
Pharmacy

5. High Intensity:Frail Elderly- Virtual Ward, Care Homes, Grand Ward Round
High Intensity:Frequent attenders - Liaison Psychiatry for medical unexplained symptoms
High and Rising Need: Profile and
Prevalence, Expert Patient,
Carer identification and support
Low Need / Stable: Mental Health awareness,
Community Pharmacy integration - annual reviews,
Diabetes pathway review, social prescribing, secondary care audit, Community dermatology / MSK services, online support (web / care plans)
General Health Maintenance: Collaborative flu campaign, patient education, schools health literacy, Women's Health clinical audit, HIPSTER Pre-diabetes, Veterans
Support, nursing capacity review
General Health Access: Urgent Care Team,
Online consultation, Online self care advice,
Capacity Modelling, Near Patient Testing