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Planned Care Innovation Exemplars

Borth Integrated Health and Care

Dr Sue Fish – GP Partner Borth Surgery – Project Lead
Claire Bryant – Advanced Nurse Practitioner and Clinical Care Co-Ordinator

Hywel Dda University Health Board


The COVID 19 pandemic has led to waiting times for planned care, increased health and care needs of the population and recruitment challenges across the health and care sector. Consequently, there is an increased demand in general practice, which has reduced the availability of primary care clinicians to manage complex health and care needs for their patients in the community, resulting in an escalation of referrals to secondary care and the local authority. Through improving the coordination of care between the different organisations who provide individual patient support in the community, there will be less duplication and the care will be more patient centred.  This will make better use of resources and improve the health and wellbeing of the population.


The project intends to transform the way that general practice, community pharmacy, community health services, local authority services and the third sector work together to provide integrated patient centred care. Through enabling the local community (including statutory partners in health and care) to deliver more effectively, the resilience, health and wellbeing will be improved for all residents and visitors and their families in the locality.

A clinical health and care coordinator based in general practice will case manage integrated multi-disciplinary team working between primary care, Hywel Dda University Health Board, Ceredigion County Council and the third sector. Through shared decision making with the patient anticipatory care will improve the health and wellbeing of the population reducing both unscheduled and planned referrals to secondary care and social services. This will also ensure improved patient health and wellbeing whilst on long waiting lists and establish an effective community led discharge planning process.

The Approach

  • Clinical Care Coordinator, band 8A employed in Borth Practice
  • Admin support
  • Terms of reference established
  • Weekly 1 hour long MAT meetings to discuss patient’s registered with Borth Surgery
  • Roll out to second federation practice in January 2023

Outcomes / Benefits

  • Reduction in average number of GP appointments for frail regular attending patients
  • Marked reduction in hospital length of stay
  • 553 bed days saved
  • Resource releasing calculated to be £250,000 net benefit
  • Increased referrals to third sector
  • Correlation with reduced hospital mortality rates

What Next?

  • Role embedded in regular service
  • Support scale and spread to other federation practices
  • Promote wider adoption

View project posters and slides from the PCIP National Showcase Event