Winner: Torbay Care trust

Integrated teams provide holistic care to patients in Torbay, with services accessed through a co-ordinator who takes referrals and fixes problems

Five integrated frontline teams - made up of district nurses, social workers, occupational therapists and physiotherapists working to support a group of GP practices - provide health and social care services at Torbay Care trust.

Each team has a single point of contact, staffed by health and social care co-ordinators. These experienced support staff take referrals from GPs, professionals, patients and carers and can often sort out a problem immediately. They also co-ordinate the care of the trust's most complex patients.

Launched in 2005, the health and social care co-ordinators contribute to holistic needs-led assessments and provide short-term management of caseloads of varying complexity.

This ensures the monitoring, delivery and review of care packages that comply with all statutory and trust requirements, including the newly adopted Kaiser model approach.

Able to order simple pieces of equipment, organise meals on wheels or arrange temporary nursing home placements, the co-ordinators provide a seamless service and an invaluable continuity of care.

The care co-ordinators are considered the axis around which activity in each team revolves. Patients, carers and staff report on how valuable the role is. Having the role allows people, particularly those needing end of life care, to be treated at home. Torbay is working with its partners to explore how the role can be expanded to further streamline access and improve response times.

Torbay, the judges agreed, was where they would want to live if they were in need of support to manage and live with a long-term condition. The approach is making a real difference to how patients experience local health and social care services.

Integration in action, contact paula.wakeham@nhs.net

Finalist: Brighton and Hove City teaching PCT

Brighton and Hove City teaching primary care trust is undertaking the nurse-led quality care review project in close partnership with the city council, nursing home owners, residents and families and the Commission for Social Care Inspection.

It aims to improve clinical care for nursing home residents and support local people to make choices about long-term care.

The joint PCT and city council preferred provider list will rate homes for their clinical services alongside the CSCI rating.

Quality care review project, contact cat.tardif@bhcpct.nhs.uk

Finalist: Leeds PCT musculoskeletal service

The Leeds incapacity employment project was designed and implemented by Leeds musculoskeletal service and Leeds city council, in partnership with other agencies. The programme aims to improve the coping skills and physical fitness of participants and boost their confidence.

Using graded exercise and group work, the programme is delivered in local leisure and community centres and has produced significant improvements in physical, functional and mental health.

Leeds incapacity employment project, contact billy.mcclean@nhs.net

Finalist: Leeds University and Leeds PCT

This is a joint initiative between the University of Leeds, Leeds Teaching Hospitals trust, Leeds PCT, Takeda UK and general practices.

Its aims include working with the regional cardiology referral centre to identify patients with undiagnosed type-2 diabetes admitted with acute myocardial infarction, to reduce their cardiovascular risk. The project has improved cardiovascular risk factors and cut acute myocardial infarction rates.

Leeds cardiovascular risk project, contact charlotte.day@leedspct.nhs.uk

Finalist: Shires Healthcare

The multiprofessional Shires Healthcare team has developed a programme for elderly patients with long-term conditions and complex needs that ensures they get a joint health and social care assessment within 24 hours of referral. The resulting patient-centred care plan can then be implemented promptly.

Benefits include: using existing specialist nursing skills to support the rest of the workforce to develop; supporting more people to live at home; and achieving preferred place of death in 99.9 per cent of cases.

Smart management support, contact wendy.sunney@nhs.net

Finalist: Walsall teaching PCT

Chronic disease reporting system intelligence enables the proactive primary prevention of long-term conditions in Walsall. The system uses data exported daily from GP clinical systems.

Practices can generate lists of patients at future risk of long-term conditions and invite them in for review, initiating clinical and lifestyle interventions where appropriate.

The system provides the information platform for a primary care cardiovascular disease prevention programme pilot.

CDR Intell, contact martin.turner@walsall.nhs.uk