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Case Study
Improving Lives – launching a single point of access model in Coventry
The challenge
Coventry, one of four places within the Coventry and Warwickshire Integrated Care System, like much of the country, found its urgent health and care services under significant pressure meaning that the residents of Coventry were not always receiving an optimum service or the best possible outcome.
In response to this, in 2023 a place-based partnership consisting of Coventry City Council, University Hospital Coventry and Warwickshire, Coventry an Warwickshire Partnership Trust and other system partners including PCNs and the West Midland Ambulance Service began working on the Improving Lives programme with support from Newton.
The programme builds on the findings from an assessment of Coventry’s urgent health and care services which found significant opportunities to improve along the entire pathway. The assessment, led by Newton, found that there was a tendency to make hospital conveyance the default option for people with urgent need. The drivers of this were identified as lack of awareness of services available in the community, paired with fragmented and unnavigable services in which frontline and clinical staff had low confidence. There was a clear opportunity to come together across Coventry place to unlock organisational boundaries, improve relationships across the system, and create a more integrated model of care.
Impact
The Improving Lives programme is about fundamentally changing the way in which people with urgent need in Coventry are supported. By implementing a new model for the system, the programme has enhanced the visibility and awareness of available services in the community, enabling better decision-making and more effective use of resources across all system partners. Health and care is now tailored to a patient’s specific needs rather than being constrained by the limitations of current service offerings.
“With an aligned workforce and collaborative leadership we can unblock things that have previously been unfathomable. This programme has a voice and allows us to do things that the workforce have been wanting to do for years.”
Integration Lead Coventry and Warwickshire Integration Trust
A new integrated model for the system
At the heart of the Improving Lives programme is a single, local integrated team which is fully equipped to respond in a coordinated way to urgent health and care needs across the city. This group is split into 3 locally integrated teams, with the capability to support all of its residents needs, ensuring that decisions are made based on individual need rather than the services available. This includes providing urgent response services which are tailored to the needs of each patient, proactive discharge planning for patients admitted to hospital, through to step-down, community-based services providing ongoing support in the community or at home. This team has one urgent health and care caseload, reducing duplication across multiple organisations, enabling the best use of skillsets and resources, and ensuring that a person’s urgent needs are responded to in a tailored, coordinated way.
Enablers of the new model
This is an ambitious, complex model which requires robust supporting mechanisms and tools to be in place order to realise its potential and become sustainable. The new model has been designed, trialled and iterated, with involvement from across the health and care system, including PCNs and the ambulance trust, in the design of interfaces with the local integrated team, ensuring a more streamlined service for residents. The partnership has embedded the following key enablers:
Hospital visibility and accountability
Really embedding the basics through well-defined roles, responsibilities and accountabilities across the hospital pathway, and providing frontline staff and leaders with live visibility of data to drive the right behaviour and evidence-based decision-making.
Pull model
Commencing the discharge process as soon as someone is admitted to hospital, led by the local integrated team which has deep knowledge of and connections with services in the community and is able to actively pull residents out of hospital.
Workforce and leadership
Integration at all levels across the three main organisations, with a single leadership structure to help hundreds of staff work collectively in the new model.
Digital and data
Building a single intermediate care record system with shared access to holistic care plans for patients and enabling effective resource planning. Creating a suite of dashboards providing live visibility of activity across the urgent care pathway to enable evidence-based decisions, both at a patient level by frontline staff, as well as at a system level by executive leadership.
Outcomes
The Improving Lives programme has seen many positive outcomes, from the creation of a locally integrated model that effectively supports residents, the introduction of a pull model which allows patients who are being discharged from hospital to have their care plan before they’re medically optimised, and improvements to the visibility of the services within the system. Most importantly, the experience of the residents in Coventry has improved significantly with a personalised approach to health and care supporting them in achieving the best outcomes.
As of January 2025, the programme is having the following impact on outcomes across the UEC pathway in Coventry:
- 18% reduction in older adult admissions to base wards with people being better supported by primary care or the urgent community services
- A reduction of 1.1 days in P0 patient length of stay (20%)
- 50% reduction in the number of people moving to a long-term bedded setting
- Reduced demand for short-term bedded care from 85 beds to 39 beds, with this group having more independent outcomes in their own homes
- Successfully moved 158 members of staff from 8 different services into one new organisation
- Built a care record that hosts a case load of 700+ people and connects community, adult social care, and acute data
- This performance translates to ~£17m annual financial benefit for Coventry.
“Newton leave us with a lasting legacy and we’re a much stronger system because of your support – thank you!”
SRO Improving Lives