Supported by Abbott


  • Ian Rutter, former chief executive, North Bradford PCT
  • Dr David Woodhead, HSJ columnist and public health specialist
  • Michael Sobanja, chief officer, NHS Alliance

Winner Croydon PCT

Croydon PCT takes care outside the hospital in a very literal way. A team of health professionals manage their 'ward' just as if it were in a hospital, but the patients never need to leave their own home

Croydon primary care trust's virtual wards mimic the working patterns of a hospital ward while delivering care at home.

The trust offers groups of 15 GPs the chance to commission a 'virtual ward' with 100 'beds', based on calculations about which patient is most at risk of an unplanned hospital admission.

The day-to-day clinical work of the ward is led by a community matron, and the team includes a social worker, health visitor, pharmacist, and community nurses. A ward administrator plays a key role collecting and passing on information between patients, carers, and health services.

Each patient is assessed by the community matron on admission to the virtual ward. This record, along with the GP's summary, is entered into a shared set of electronic notes.

The community matron talks daily to the duty doctor at each GP practice to get medical input, and can book an appointment for any of the patients to see their usual GP.

Each ward develops close working relationships with hospices, drug and alcohol services and the voluntary sector.

The virtual ward team holds an office-based ward round each working day. The frequency with which patients are discussed depends on their condition - five are discussed daily, 35 weekly and the rest monthly. Patients can be moved between these different intensity 'beds' as their circumstances change.

Each night, an automatic e-mail listing each virtual ward's patients is sent to local hospitals, NHS Direct, GP out-of-hours co-operatives and social services departments. This means that if a patient uses any of these services, staff will automatically be alerted to their status, and can contact the virtual ward administrator for up-to-date care details.

If a patient has been cared for uneventfully for some time in a monthly review 'bed' they may be discharged, with the GP reviewing their condition on a quarterly basis for two years.

And the virtual ward concept is a good example of partnership working between health and social services to bring care closer to home, as outlined in the healthcare outside hospitals white paper Our Health, Our Care, Our Say.

Virtual wards, contact

Finalist Sandwell PCT

Sandwell hospice at home (H@H) helps terminally ill patients who wish to die at home

Sandwell's hospice at home service is a person-centred, community-based specialist palliative and supportive care service for patients dying from cancer, heart failure, and respiratory or neurological conditions.

Sandwell is a relatively deprived area, yet there is no local hospice unit or home-based palliative care service, with residents expected to make costly journeys to neighbouring boroughs.

H@H is made up of 11 statutory and voluntary organisations. These include representatives of carers and older people, who have helped steer design and delivery. Staff work together across organisational boundaries to provide a seamless service. From January 2005 to January 2006, 149 patients were admitted to the service and 97 were able to spend their last days in their own homes. Most received a daily visit by a specialist palliative care nurse, and 179 night sits were provided.

Sandwell hospice at home service, contact

Finalist Nottinghamshire County Teaching PCT

The action team brought together the NHS, social services and the voluntary sector to help reduce emergency admissions for people with long-term conditions

The Gedling action team offers people with long-term conditions expanded service hours and rapid response, and within two years of it starting in 2004, emergency admissions had dropped by 8.7 per cent. In October 2005 the model was extended across the entire PCT, to provide a year-round, multi-professional approach.

The initiative embeds multidisciplinary working, increases access, lowers hospital admissions and improves needs assessment. A key part of the strategy is to develop 'localist' clinical leadership. Nursing leaders - rather than managers - have been appointed, and will get delegated budgets. There has been comprehensive staff consultation and patient satisfaction, response time and hospital admissions are all being monitored. The results will help steer the new borough-wide model.

Creating an 8am-8pm model for health and social care in Gedling, contact

FinalistSouth West Dorset PCT

South West Dorset PCT has broken new ground by adopting the quality and outcomes framework for prison healthcare

Since April 2004, South West Dorset PCT has commissioned and provided healthcare in five prisons. The scheme focused on a general practice model and developing a strategy for secondary care. Problems encountered included the fact that prisoners have few chances to exercise and limited access to healthy food. There is also a high turnover and no clinical data or access to previous GP records.

To address these issues, a clinical forum was set up and three priority areas identified - coronary heart disease, asthma and hypertension. Care pathways and protocols for these areas have now been adopted in all five prisons. Patients now have more services available and access to primary care that is the equivalent of national best practice.

Delivering excellence in primary care, contact

Finalist East Devon PCT

The primary care trust has supported a move towards teams which are closer to local needs and can commission services around them

Three pilots have been established in Seaton, Exmouth and Axminster. Each integrates health and social care, and has a wide consultation group made up of representatives from health, social services, the voluntary sector and the public.

These groups meet regularly and identify commissioning priorities for each area. Advantages include local ownership, patient-centred care, and bringing services closer to home.

Each of the three pilots has developed a slightly different model, depending on how many GPs are based in their area, for example.

The PCT will monitor the pilots over the coming year and evaluate public engagement and response to local need.

Project blue sky, contact