My Care, My Way – The Model

Introduction and Context

NHS North Staffordshire CCG and NHS Stoke-on-Trent CCG plan, buy and oversees the delivery of healthcare for nearly 500,000 residents within Northern Staffordshire and have a duty to commission the best services they can for their local populations to deliver the best possible outcomes.

Historically within Northern Staffordshire, services have been based around beds and too many patients are admitted into hospital when they could stay at home and be treated within the community. Available clinical evidence tells us that there are better ways to provide care and deliver better outcomes for many people currently admitted to community hospital and as a result, over the past two years there has been an investment of £12million in a range and quality of community health services (such as district nurses, intermediate care teams and specialist nursing teams) to ensure that support and care are based around the individual patient with the ultimate aim of delivering high quality care, closer to home. To date we have seen a significant increase in the numbers of nurses, therapists and support workers within the community and a growth in the number of patients accessing care within their own homes with patients reporting positive outcomes and experiences.

This has culminated in the development of a New Model of Care, known as My Care My Way – Home First. The implementation of the proposed model of care should ensure that a patient’s journey is supported from the point of acute (hospital) admission to discharge home, delivered by a single organisation to ensure that the journey is integrated, smooth and trouble-free without the delays currently being experienced. The CCGs intend to further increase the provision of more intensive care within people’s homes and look to ensure that patients who can be treated within the community without the need for a hospital admission will be able to access high quality and timely care when required.

It is expected that the benefits of the proposed new model of care would provide a focus of rehabilitation with more patients returning or remaining within their own homes with support during periods of illness. Clinical evidence demonstrates that a person’s condition deteriorates if they spend more time in hospital than needed.  One study found that the muscles in a person over 80 will suffer the equivalent of ten years of ageing over a ten day spell in hospital. It’s not just that though - it’s the effect on someone’s independence that matters as well.  We know that patients who spend too long in hospital find it much harder to cope physically and emotionally when they get back home again and through the proposed model of care, we hope to change this to enable patients to continue to lead full and independent lives wherever possible.  

Over the next few months, we will be working with other NHS bodies, local councils and patient groups to consult on our plans for change within the local NHS, seeking patient and public views on how best to deliver health services across Northern Staffordshire.

What does the My Care, My Way – Home First model of care look like?

We have developed a plan in line with national guidance on how urgent and emergency care should develop in the future. Part of this would see GPs becoming more involved in coordinating care for their patients at home. We think this will create more responsive, effective and personalised care outside of hospital including district nurses working closely with GPs and specialists to plan care for people who are frail or vulnerable.

We also want to ensure patients get intensive support and rehabilitation in their own home, close to home where possible, so they don’t need to go in to hospital unnecessarily. 

It is proposed that for patients who require an admission to a bed, Royal Stoke University Hospital will be responsible for a patient from the moment they are admitted to hospital through to their final assessment and discharge, including their recovery at home or, if necessary, in a community hospital bed. The plans involve the Royal Stoke University Hospital taking on the management of the beds at Bradwell and Cheadle Hospitals. The Trust will also have the ability to discharge people home with community-based care and support in place, reducing the number of days a patient will need to stay in hospital.

By making sure one team is responsible for a patient throughout their care, it will give people a more seamless experience and reduce the need for them to be assessed several times and to be transferred between teams. This model of care has been implemented in other parts of the country successfully with positive patient outcomes reported and an increase in the numbers of patients being treated within their own homes.

Our key focus is to ensure patients get intensive support and rehabilitation in their own home and close to home where possible, so they don’t need to go in to hospital unnecessarily.  As part of the proposed reconfiguration of care, we will pay for less community hospital beds in the future and instead, invest in better ways to care for patients in their own homes.

We think it is really important that a variety of healthcare services are available in the community and we'll carry on paying for healthcare in the community and services like district nursing and specialist nursing teams which offer care closer to home and stop people from having to go to hospital if they don’t have to. We are working with local doctors, hospitals and community hospitals to design optimal pathways of care.

What will this mean?

The CCGs have undertaken an exercise to understand what services are needed in the community to ensure the successful implementation of the My Care, My Way – Home First model of care is achieved.

We will require 4845 Intermediate care packages to be delivered within patients’ own homes to both prevent admissions but to also ensure patients can be discharged directly home without a further stay in a hospital bed. The likely impact is that fewer community intermediate care beds will be required.

Commissioners are also working closely with the Staffordshire and Stoke-on-Trent Partnership Trust and the Royal Stoke University Hospital to develop a service within A&E to ensure that patients are discharged home from A&E with the right clinical assessment, and with support where required and therefore reducing the requirement for an admission into a bed. 

The first phase of engagement commenced in December 2014 and involved the widespread sharing of a comprehensive briefing, developed with support from Healthwatch, to targeted individuals including MPs, through the media, existing third sector, general practice and local authority networks.

We wanted to make sure that we could involve patients and local people to help shape the future services provided.  We began talking to people in December 2014 and then again throughout this year. As part of the engagement we also had an online survey and paper questionnaires available. On the whole feedback has been very positive with the key themes being that:

  • Patients benefit from being at home
  • Patients prefer to be at home
  • There is support for the proposed model in principle

But survey respondents also requested assurance that:

  • There is capacity in community services to support this
  • We reassure the public about the future of community hospitals
  • There will be support for spouse/family/carer
  • Patients will be followed up in the community
  • This is carefully implemented
  • The investment is made to support the changes to the model of care

As a result of this feedback, the CCGs have prepared media briefings outlining our plans and have also provided information of workforce numbers, investment and the shape of the workforce to deliver the new model of care.

We have also set up a Stakeholder Communications Group in which a number of representatives from Healthwatch and other patient groups attend to support the development of patient events and patient and public facing documentation.

In addition, representatives of the North Staffordshire and Stoke-on-Trent CCGs have attended existing meetings of overview and scrutiny committees (OSCs), patient groups, voluntary sector groups and primary care localities. Alongside all of this activity interviews have taken place on local radio.

Healthwatch Stoke-on-Trent, in partnership with the CCGs, held 24 awareness events during August 2015, to promote their organisation and the work they do locally. Venues for these sessions included supermarkets, health centres, Bentilee Neighbourhood Centre and Longton Market. As part of these events, HealthWatch was able to share information about My Care My Way – Home First and ask questions.

Summary Report

Please download the My Care, My Way (MCMW) summary report below:

My Care, My Way Home First Summary Report

Background documents

Annex A Case for Change MCMW October 2015

Annex B Evidence Base for Step up Step down Jan 2016

Annex C Communications Plan MCMW Inc Case for Change Mar 2016

Annex D CE Plan MCMW activities and events P2 Feb 2016

Annex E Engagement & consultation document Sep 2015

Annex F Communications sub group terms of reference July 2015

Equalities Impact Assessments

Annex H North Staffs by Nine Protected Characteristics Jan 2016

Annex G Ethnic Minorities Needs Assessment for Stoke Jan 2015

Equality Impact Assessment September 2016 (update)

Overview and Scrutiny

Annex L Health & Wellbeing Overview & Scrutiny meeting Jul 2015

Annex M Briefing to SoT AOSC MCMW Sep 2015

Annex N Stoke Overview and Scrutiny Committee Feedback Mar 2016


Annex O Age UK Feedback Response to New Model of Care May 2015

Annex P Healthwatch Frail and Elderly Discharge response Mar 2015 

Annex Q Pensioners convention feedback MCMW Feb 2016

Annex R North Staffs & Stoke CCG Phase 1 Feedback Mar 2016

Annex S Pensioners convention and UNISON retired members Mar 2016


Annex T Moat House MCMW Engagement Oct 2015

Annex U Bentilee MCMW event report Nov 2015

Annex V Cheadle Guild Hall event report Nov 2015

Annex W Fenton Manor MCMW event report Nov 2015

Annex X Leek MCMW event report Nov 2015

Annex Y Longton CoRE MCMW event report Nov 2015

Annex Z Longton Cottage Hospital article Aug 2015

Annex AA Tunstall Market MCMW event report Jan 2016