Sunderland has been chosen as a Vanguard site and allocated Government funds to develop and deliver multidisciplinary support to patients under the Government ‘Out Of Hospital’ agenda
Led by NHS Sunderland CCG and Sunderland City Council, “All Together Better - Better Health and Care for Sunderland” aims to deliver:
• Transformed care out of hospital through increased integration of services and more ‘person centred care’ • Transformed care through increased collaboration and an increase in the number of services being provided • Multidisciplinary teams established in five geographical areas across Sunderland
Key strategic aims of the programme: • An enhanced citywide Recovery at Home service, to support people’s recovery after discharge from hospital and prevent future emergency admissions. This service will be improved with 24/7 working, a single point of contact for patients and professionals with all appropriate nursing and social care teams being based in one building with a shared management arrangement and the GP out of hours service based on the same site.
• Community Integrated Teams (CIT) - bringing together district nursing, community matrons, social workers, GPs, Age UK Living Well Link workers and Carer Centre workers into multi-disciplinary teams for each of the city’s five localities, wrapped around groups of GP practices so that care can be provided in a more coordinated, planned and proactive way particularly for the most complex patients at risk of avoidable emergency admissions.
• GP practices will be supported to work more collaboratively through development of the federations and provide enhanced care, over and above the normal agreed GP strategy.
Age UK Sunderland’s PPE team
The PPE Team is currently communicating with patients and the general public across the City of Sunderland to inform about “Better Health and Care for Sunderland” including the newly formed Community Integrated Teams working in 5 geographical areas across the City and the wider integrated care agenda Age UK Sunderland is arranging and delivering a number of structured events within the local community to ensure that everyone understands the new way of working and what it means to them. The events are also used to gain patient and public feedback to help shape services as they develop.
The team is also targeting patients and the public directly in their community via GP surgeries, pharmacies, community events and via shopping and leisure activities.
“Better Health and Care for Sunderland” is about improving how health, social care and community services work together to provide a better service to patients.
Services working together will mean people only have to tell their story once.
It will also mean that people with long term or complex health issues will get better care.
This new way of working will help patients to live life to the full and be as well as they can be.
What is it?
• “Better Health and Care for Sunderland” have created 5 Community Integrated Teams covering the whole of the City.
• Each team has GPs, district nurses, social workers, community matrons and people to help you live life to the full.
• They will be working together in new ways to make it easier to plan and deliver care and support.
• Other health and social care professionals will join the teams in the future.
• This new way of working will help patients, their families, and the people that care for them be involved in decisions about care and support.
• The aim is to ensure people are safe and supported in their own home.
•Providing more services outside hospital means better value from limited health and social care budgets in the future. What will it mean for patients? • A better experience with you getting the right treatment and support from the right service at the right time
• A more joined up service delivering your health care and support
• Greater independence and choice over the support you receive at home.
The Community Integrated Teams are currently based in: • Bunny Hill Primary Care Centre (Sunderland North) • Grindon Lane Primary Care Centre (Sunderland West) • Houghton Health Centre (The Coalfields) • Washington Primary Care Centre (Washington) Riverview Health Centre (Sunderland East) If you are interested in hosting an event or for further information about the PPE Team please contact:
Contact the Patient and Public Engagement Manager on 0191 514 8322 or email: