What will the MCP do?

The proposed MCP model is made up of four key elements. Whilst some of these elements are already in the early stages of implementation thanks to the All Together Better programme, the MCP model will bring about closer integration at every level.

More effective prevention – where appropriate, patients will be given more control over managing their own care. Bringing health and care together in one coordinated response will give providers a deeper understanding of the links between health and well-being in an individual. In many cases this approach could avoid long term treatment and life-long dependency on health and social care.

Focusing more closely on area and community – All Together Better has demonstrated the importance of better coordination of care across teams and organisations. When community based care and recovery teams work with GPs they have access to more information and can benefit from each other’s skills and experience and understanding of the person needing the support. This means they can take a more proactive approach to healthcare where the patient’s social and emotional needs are taken into account when considering medical needs.

A focus on maintaining the patient’s stability and preventing escalation to more hospital based care by making greater use of community and voluntary services. The All Together Better programme has already increased the number of community-based care and support services for many higher risk patients. This has resulted in fewer emergency admissions and A&E attendances for the targeted patients and a reduction in delayed transfers of care and fewer permanent admissions to care homes across the population.

The new Recovery at Home hub, a 24/7 multi-agency service, which has been created to offer alternatives to hospital admission. This hub is used when patients are at real risk of serious decline in their condition and/or being admitted as an emergency to hospital.

Improvements are being made at General Practice through Enhanced Primary Care, such as making GP appointments available at evening and weekends and better links between a General Practice and a Care Home and older people community nurses, so the staff in the home are able to work more closely with one or two Practices and the Practice can give a better level of support to the home as a result.