Derbyshire’s Flagship Team Up model prevents 1,000 unnecessary hospital visits

DERBYSHIRE’S flagship Team Up model which sees patients in or close to home, is preventing 1,000 unnecessary hospital trips and 700 unplanned admissions each year.

Team Up, which operates across all the Derby and Derbyshire neighbourhoods, provides reactive and proactive care to people unable to leave their homes.

It is not a new or ‘add on’ service but teams up existing services and creates additional capacity.

It means general practice, community care, mental health care, adult social care and the voluntary and community sector work together and with their communities.

This might include seeing a patient at home regularly for clinical care, taking time to understand their personal needs, providing proactive care, and linking them with other local services to help them improve their health and wellbeing.

Chris Clayton, Chief Executive of Derby and Derbyshire Integrated Care Board, said: “We’re so proud of the work Team Up is doing across our system. We’re already ahead of the game when it comes to developing a ‘neighbourhood health service’ and have built the Team Up model on science as well as engagement, listening and acting on what our population tells us matters to them.

“We’re now focusing on rolling out this way of working and the conditions which have made it so successful to other areas of our health and care service.

“Our workforce is the backbone of our NHS and I’d like to thank everyone who works so hard in the health and care service in Derby and Derbyshire for everything that you do every day.”

Ian Lawrence, lead for the Team Up programme, said: “Recently, the Health Secretary has talked about wanting to provide a Neighbourhood Health Service and in Derby and Derbyshire we’re well on the way to doing just that.

“Team Up is an ambitious transformation project and since 2021 has drawn heavily on behavioural and organisational science to understand what motivates people working in these teams and what makes change more likely to be successful in complex systems.

“We’ve created the conditions for our valued and skilled health and social care workers to find their own solutions to local problems; and we support them with flexible governance to do what works for patients increasing efficiency, effectiveness and motivation at work.

“We’re delighted that we’ve seen a reduction in the number of over 75s needing unplanned hospital care and we know it is due to the commitment of our workforce and the system as a whole to make care better for people and patients.”

Team Up incorporates at-scale Home Visiting Services, Rapid Response nursing, therapy and social care, falls prevention and response, and enhanced health in Care Homes.

It is also helping to integrate, or join these services together, to reduce duplication and ensure holistic care for vulnerable residents.

GPs and other professionals refer patients to Team Up if they believe the patient would benefit from on-going monitoring or additional time especially if they are identified as having high needs.

Team Up stands out from other integrated neighbourhood projects nationally through its scale – incorporating all 11 neighbourhoods across Derby and Derbyshire and by its breadth – and incorporating, as a minimum, community health, adult social care and crucially general practice.

The team has significantly slowed the growth in hospital attendances and admissions for people living with frailty over the past two years saving approximately 1,000 attendances and 700 non-elective admissions per year with national benchmarking data showing a positive change in Derbyshire.

Team Up has also released an estimated 3,500 hours a month back to core general practice and with the 25/26 planning guidance stating that “The evidence is clear that engaged, motivated staff improve productivity and patient outcomes” 93% of Team Up staff recommend their service as a place to work and 93% of general practice staff would recommend Team Up services for their patients.

Angela Pownell, Operations Manager in the High Peak, said: “Working for Team Up gives us the opportunity, in challenging times, to continue to be close and adaptive to the needs of our patients. I thoroughly recommend this model and we know it benefits patients, general practice and the system more widely.

“We are hopeful that we have helped to reduce the workload of our colleagues in primary care allowing us all to positively support our community. Furthermore, we are thankful for the opportunity that we have been given to collaborate and integrate with our system partners across health and social care.”

Read more about the impact of Team Up on patients.