Community Based Model Of Care

There are six localities within Bristol, North Somerset and South Gloucestershire.

There are 18 Primary Care Networks bringing GP practices together across BNSSG.

Our plans meet and add to the specifications published by the Commissioners:

  • Locality Hubs
  • Integrated Network Teams
  • Acute and Reactive Services
  • Specialist Support and Advice

You can read the specifications here.

These will be our front door for you to be able to access all services.

There will be a focus on Health and Wellbeing with advice and signposting to services, links with Third Sector organisations within each locality and this will be both an actual physical presence but also virtual as we will be using the best digital technology too.

Services will be together including some outpatient clinics.

There will be 18 across BNSSG all linked to GP practices.

Teams will be made up of multi-disciplinary practitioners which means bringing nurses and therapists together so services are integrated. They will offer flexibility and ensure you receive continuity of care.

Community pharmacists and health visitors for older people will also be part of the team and we aim to link these with our partners in Social Care, Mental Health and Third Sector.

We will also offer enhanced support to care homes across the area.

This is the focus of urgent care in the community aimed at keeping you at home wherever possible as we know that is where people recover best. We also know sometimes people need diagnostic tests such as x-ray or blood checking and we will have day assessment units within the hubs and will work closely with hospital teams.

There will be a Single Point of Access for clinicians with one number and email address and we plan to ensure the Minor Injury Units and Walk-in Centres have consistent hours.

There are also community beds across BNSSG which will be used in three ways:

Step up for those who need monitoring and care best provided in a clinical setting for a short period of time but are not acutely unwell.

Step down for those who need intensive support before being able to be safely discharged home but are medically well

Safe Haven for those who need care because their carer has taken ill or similar.

Providing support in key areas -Respiratory, Diabetes, Continence, Tissue Viability, Dermatology, Heart Failure, Parkinson’s Disease, The Haven, Health Links, Lymphoedema, Falls, Learning Disabilities, MSK & Podiatry, End of Life – across BNSSG.

  • To continue conversations alongside existing work we know is also taking place with partners, Commissioners and NHSE.
  • To be inclusive and accessible – all voices are important to us
  • To redesign services with you and other partners
  • To ensure you are informed and involved
  • To listen and learn

Introduction

Our Values

The Human Tower or Castell

Integrated Care Approach

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