Our projects at a glance
There are four key programmes of work that, between them, will take on a number of projects to transform care in Sunderland.
Project 1 - Social prescribing
Social prescribing is a means of enabling GPs, nurses and other health and social care professionals to refer people to a range of local, non-clinical services. Recognising that peoples’ health is determined primarily by a range of social, economic and environmental factors, social prescribing seeks to address peoples’ needs in a holistic way. It also aims to support individuals to take greater control of their own health. This project will design a city wide social prescribing model which will support people with a wide range of social, emotional or practical needs and will focus on improving mental health and physical wellbeing.
Project 2 - Promoting employment, education, training and meaningful activities for people with mental health needs, autism or a learning disability
This project will develop work, education or training opportunities that will contribute to peoples’ recovery and wellbeing, supporting people to recognise their own talent and resourcefulness in order to become experts in their own self-management, make informed choices and achieve the things they want to in life.
Project 3 - Development of a frailty model
Frailty is a term used by professionals to describe the loss of body resilience, which means that in the case of a physical or mental illness, an accident or other stressful event, people living with frailty will not bounce back quickly. Frailty is related to the ageing process however not all older people are frail and not everyone living with frailty is older. This project will develop an integrated frailty model to cover both community and acute hospital services as well as looking at our strategy and approach to prevent falls.
Project 4 - Redesign of podiatry services
This project will review the current podiatry model with an aim to prioritise patients with high clinical needs, avoid more costly interventions which carry greater risks and give patients a better quality of life for a longer period of time.
Project 5 - Respiratory service review
This project will review the approach to supporting people with respiratory (breathing) problems with the aim of improving health outcomes and optimising the length and quality of life for people with and at risk of respiratory disease.
Project 6 - High intensity users
A relatively small percentage of patients are known to generate a disproportionately high percentage of emergency department attendances and unplanned hospital admissions. This project will develop a new service model to support people in Sunderland to reduce their need to use unscheduled care, freeing up front line resources and reducing admissions into hospital.
Project 7 - Review of recovery at home service
This project will review the current citywide recovery at home service with the aim of maximising independence, improving quality, using resources more effectively to get best value for money whilst improving and simplifying the system for patients and health and social care professionals.
Project 8 - Delivery of the general practice strategy
GPs play a pivotal role in community health services and this project will implement the requirements set out in the national GP Forward View, NHS Long Term Plan and Sunderland CCG’s general practice strategy.
Project 9 - Support the development of primary care networks
Primary care networks (PCNs) aim to bring together health and care professionals in local neighbourhoods to improve integrated ways of working, provide more joined up experiences of care for local people and embed population health approaches. This project will support the development of PCNs in Sunderland and continue to enhance local services outside of hospital by working closely with GPs and community integrated teams.
Project 10 - Medicines optimisation and pharmacy services
Medicines optimisation is about enabling prescribers and patients to make the most appropriate, agreed treatment choices together. This project will seek to enable high quality, patient centred access to medicines across health and social care and integrate pharmacy services to engage with and support the new ‘primary care networks’.
Project 11 - Development of an integrated neighbourhood operating model
ATB will implement a new integrated neighbourhood operating model. This new neighbourhood operating model will seek to fundamentally reshape mainstream delivery, bringing together the skills, knowledge and experience needed to deal effectively with demand in a specific neighbourhood, ensuring services and staff in that neighbourhood share a common purpose and work in a holistic way with people and communities. The integrated neighbourhood operating model will aim is to wrap care around a person and their family, tailoring services to different community requirements across Sunderland.
Project 12 - Enhanced health in care homes
This project will seek to develop a clear vision for working with care homes across Sunderland to provide more joined up support and care to residents of care and nursing homes. The aim is to improve and empower the ability of the care home sector to support residents and reduce unnecessary admission into hospital, via a range of ‘in-reach’ services.
Project 13 - Urgent care strategy implementation
This project will implement the agreed urgent care strategy enabling the residents of Sunderland to access urgent care which meets both their physical and mental healthcare needs in the right place and at the right time.
Project 14 - Delivery of the mental health strategy
This project will implement the requirements set out in the national Mental Health Five Year Forward View (MHFYFV) now in its fourth year of implementation and the NHS Long Term Plan which reaffirms a national commitment to transform mental health services and put mental health care on a level footing with physical health services.
Project 15 - Review of Section 117 aftercare support care packages
This project will review the Section 117 aftercare policy operating in Sunderland with the aim of ensuring financially suitability and to ensure Section 117 aftercare plans are designed and developed with promoting service users’ independence and recovery in mind.
Project 16 - Alternatives to hospital care for older people with mental health needs
This project will develop alternative options to hospital care for older people with mental health needs and dementia. Our aim is to ensure appropriate services are in place to account for the expected increase in demand on these services, as well as developing alternative non-medical models to support greater control, self-management and autonomy.
Project 17 - Care packages
This project aims to review the approach for NHS Continuing Healthcare (CHC) assessment in order to reduce variation, deliver improved performance and patient experience and ensure a financially sustainable model through an integrated approach to funding of complex care packages.
Project 18 - Review of community acquired brain injury service (CABIS)
This project will develop cost effective specialist community rehabilitation services for people with a mild, moderate or complex acquired brain injury. Our aim is to support people through local services to improve their long-term potential.
Project 19 - Alternatives to detention
This project aims to develop a much clearer understanding of the use of the Mental Health Act in detentions across Sunderland in order to ensure a least restrictive approach is applied across health and care services. The aim is to reduce the number of detentions from the community and ensure the Mental Health Act is used appropriately.
Project 20 - Transforming community equipment services
This project aims to ensure the delivery of sustainable care equipment services, including wheelchairs, to order to improve access and meet national waiting time standards.