Suffolk & North East Essex Integrated Care System

Out of hospital and community-based care

WHY this is important for people in Suffolk and North East Essex

Local community health and care services working together, to care for people in their own home wherever possible is essential if everyone in Suffolk and North East Essex is to live well and age well.

As an Integrated Care System we will ensure that:
  • People in health crisis or recovering from ill-health have the health and care support they need, within their own homes wherever possible
  • Care and support is provided in the local community and by integrated services
  • People living in care homes have access to healthcare support when they need it


NHS England (2019) ‘Breaking Down Barriers to Better Health and Care’ highlights:
  • The number of people aged over 65 (which includes nearly two-thirds of people admitted to hospital) rose by 21 per cent between 2005 and 2015, and is expected to do so again between 2015 and 2025. There are half a million more people aged over 75 than there were in 2010 – and there will be 2 million more in 10 years’ time.
  • People are living in ill health for longer – between 2015 and 2035, the number of older people with four or more diseases will double, and at least two-thirds of the extra time people live beyond 65 will be spent with four or more diseases.
  • More people are living with at least two long-term conditions – 15 million now and a further 3 million by 2025. Treating these conditions accounts for half of all GP appointments, 7 out of 10 overnight stays in an NHS hospital bed, and around £7 out of every £10 spent on health and care.
  • Mental wellbeing should not be considered in isolation – around one-third of people with a around one-third of people with a long-term physical condition also have a mental health concern such as anxiety or depression.
    • For further information see

Out of Hospital
What do we know about people’s local experiences?
      • People want access to a full range of primary care services and want to know where to go for help with their conditions.
      • Support people to maintain their well-being by signposting to appropriate support and opportunities such as self-help groups, community and voluntary groups.
      • Improve availability of, and access to urgent, same day, out-of-hours and weekend appointments; and make booking systems easier to navigate.
      • Enable people to see the same doctor to prevent having to repeat their histories, and to build trust and confidence, especially with sensitive issues such as mental health.
      • Support better integration of health and social care, physical and mental health services, NHS and voluntary services, hospital and community services etc.
      • Improve communication and support around hospital discharge and in particular involve families in discussions about discharge.

For further information see and

HOW we plan to make a difference 

    1.1 People and their carers are supported through ill-health crises within their own homes wherever possible. We will enable this by:

  • Ongoing development of our neighbourhood team model to improve integrated community-based health crisis responses, including NHS community, social care and intermediate care packages, delivering person-centred services within two hours of referral where clinically appropriate. This will build on our award winning Early Intensive Team (EIT) and REACT Service through ensuring we have a consistent model across the ICS. Prompt crisis community-based services help prevent unnecessary admissions to hospital or residential care. Integrated support will be delivered in line with NICE guidance, integrating health and care and wider public services such as housing, DWP and education. Voluntary services can provide wider support to prevent illness or injury such as making homes safer.
  • Developing personalised health and care plans with people and carers which provide information and guidance on how to respond to a deterioration in ill health.
  • GPs, ambulance services, community teams and social care making referrals for urgent community health services through the single multidisciplinary Clinical Assessment Service by March 2020.
  • The Discharge to Assess Programmes now embedded at locality level continuing to play a key role in facilitating swift discharge to appropriate community settings with home first wherever possible.

    1.2 People are supported to recover from ill-health in their own homes wherever possible, regardless of the level of their needs.

  • People will continue to be supported to transfer from hospital care at the earliest opportunity once acute care has completed for assessment of their ongoing needs at home through the ongoing development of proactive 7 day a week responsive homecare services at locality level joining up health and care teams.
  • Person-centred reablement care will be delivered within two days of referral to people who need it by April 2021. Prompt reablement support helps prevent further deterioration minimising risk of admission to hospital or residential care, and ensures timely transfer from hospital to community.
  • Extra recovery, reablement and rehabilitation support will wrap around core services to support people with the highest needs. Intensive person centred support will maximise efforts to ensure people can stay in their own homes, even if they have very high level and complex needs. Reablement will be integrated between statutory and community-based voluntary services.
  • Carers will have support in the reablement process through investment in carers support services around primary care.

    1.3 People’s support is co-ordinated between hospital and home, delivered by a skilled team working together to meet all of their health and wellbeing and social needs.

  • Flexible teams will work across primary care and hospitals, including GPs, allied health professionals, district nurses, mental health nurses, therapists and reablement teams; supported by voluntary sector organisations. An integrated multi-agency response ensures community teams have the right skills to provide high quality care and support, and services are flexible to meet changing needs.
  • We will collect data on the reasons for people going to Emergency Departments, to identify possible solutions. Monitoring the reasons that people need crisis support enables more effective targeting of resources to prevent avoidable admissions.
  • Admission avoidance services will continue to evolve at locality level integrating health and social care services to provide a joined up 24/7 response.

    2.1 People access the support they need through a local network of health and wellbeing professionals and services, located in one place wherever possible. We will enable this by:

  • Expanded neighbourhood teams will integrate GPs, pharmacists, district nurses, community geriatricians, dementia workers, allied health professionals, social care and voluntary sector. Primary Care Networks will enable fully integrated personalised and co-ordinated care to reduce duplication and overlap in service delivery, supported by trusted assessment. People should have equality of access to services, accessing community support without the need for formal referral wherever possible.
  • Training and development of integrated multidisciplinary teams in primary and community hubs, including health and wellbeing hubs. Integrated hubs bring care closer to home for local people, and enable person-centred care and support, focusing both on prevention and care. They help create resilience in communities to support the care needs of local people.
  • Domiciliary care providers will support people to access local health and care services. Care agencies are a valuable resource to support people to access services, and share information with health and care services. Integrated working helps improve the quality of care they provide. Work with care providers in provider forums supports ongoing dialogue and ensure a buoyant market; the forums are led by local government with active involvement from health teams.
  • Improved access to diagnostics closer to home. This includes improved access to testing locally, and quicker access to results, which will be delivered through our ambition to be an early implementer of a rapid diagnostic centre through the regional Cancer Alliance.

    2.2 People needing health and wellbeing services receive the most appropriate support to meet their needs. We will enable this by:

  • NHS111 booking directly into GP practices and refer on to community pharmacies to promote people to self-care and self-manage their condition, beginning in 2019.
  • Pharmacy connection schemes for people who do not need primary medical services.
  • Supporting people to understand and use new primary care structures and systems. Helping people understand these, and improved access to the most appropriate services, ensures that people receive help promptly from professionals with the right skills for their needs.
  • People have the right equipment for their needs and can return it easily as their needs change.

    3.1 People living in care homes have expert health input into all areas of their care needs.

  • Enhanced Care in Care Homes support is available to every care home resident who would benefit from it, including oral health, hydration and nutrition, and rehabilitation support, by March 2024. This programme ensures stronger links between Primary Care Networks and care homes, and consistent healthcare support including named general practice support. Ongoing training and development, and access to timely multidisciplinary support for residents who would benefit from it, will support the care home workforce to improve their quality of care.
  • Regular clinical pharmacist-led medicine reviews for care home residents where needed. These reviews will help ensure people are taking the right medication for their needs.
  • Care home staff will have access to NHS email to enable easier, secure communication with NHS teams caring for their residents. This will enable more efficient information sharing, better communication and professional relationships, more effective responses when people are unwell.

    3.2 People in care homes have urgent healthcare support when they need it.

  • We will provide emergency advice and support including out of hours and medications for those at end of life. Access to just in case drugs out of hours through development of 100 hour pharmacies initiative.

    3.3 People have healthcare in their care homes which is based on best practice.

  • Healthcare in care homes will be developed in collaboration with care homes and the people who live in them and their families. Co-producing healthcare in care homes with people, families and the homes themselves helps ensure services are designed in the most effective way

We will know we are making a difference because we will see:

  • Improved quality of care and support, capacity and health outcomes of health and social care delivered in the community
  • Fewer incidences of C.difficile infection in community based care

REACT was set up in January 2018 to reduce rising emergency admission levels and brings together hospital and community-based staff from East Suffolk and North Essex NHS Foundation Trust (ESNEFT), Suffolk County Council, Suffolk Family Carers and the British Red Cross. More recently, it has expanded to include Norfolk and Suffolk NHS Foundation Trust’s dementia intensive support team (DIST).

The Reactive Emergency Assessment Community Team (REACT) combines consultant geriatrician, nurse, therapist and social care colleagues to deliver an integrated admission avoidance service.

The team of staff from the NHS, social care and voluntary sector work 24/7 to carry out comprehensive home assessment when a patient has reached crisis point before putting the right care in place to prevent an admission to hospital.

They also assess patients in the hospital’s ED and emergency assessment unit and provide appropriate support to allow them to be discharged, wherever possible.

REACT have continued to go from strength to strength over now reducing emergency admissions by 20 per day. During 2019, REACT has expanded to include and the DIST team at Sandy Hill Lane are now co-located at Sandy Hill Lane. Funding has been approved to increase establishment for DIST and Mental Health to deliver a 7 day service. The REACT team have recently been shortlisted for an HSJ Award.

Last Updated on December 10, 2020

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