How is Bucks ICS making improvements?

The main approach for the ICS is a ‘community care model’. This means that they will consider the whole of the Bucks population when running and making improvements to services. The aims of this model are to:

  • Improve outcomes
  • Reduce inequality
  • Address social issues that can affect people’s health

The ICS will use data to understand the health needs of the people. They will also use the data to predict and deliver the support required to communities and individual patients. In addition, This data will help them identify areas where quality and efficiency could be better.

Please note: this is not a full list of successess from the ICS. They can be found in this document.

Successes so far

Meeting your needs

The Public Health Team have analysed the “burden of ill health” across Bucks. From this, they have made ‘Locality Profiles’ so that each locality can understand the health needs of their people.

Access to preventative services

The ICS has identified social isolation as a key priority in Bucks, especially in the Aylesbury Vale North area. In this area, isolation will be tackled through local volunteers, community groups, and local community champions. These are all already in place. This locality has also set up a Patient Support Service.

The people in this team are trained in motivational counselling. They visit patients in their homes and assess a wide range of health and social needs. They also signpost people to relevant agencies. The range of support is broad and includes access to mobility aids and personal alarms, health interventions and benefits advice.

The team is made up of 6 individuals and 32 befriending volunteers. They currently (November 2018) have a case load of 37, with another 219 people supported by the volunteers through follow-up phone calls.

24/7 Primary Care Access

Since April 2018, the primary care out of hours service has been running. This has led to the development of an Urgent Care Treatment Centre in High Wycombe.

In Aylesbury, the primary care Out of Hours base in the same place as the A&E GP streamer. This has made for a smoother, more integrated service.

The ICS will also be setting up a new Out of Hours centre in the Southern locality to support patients along the M4 corridor. They will set up an engagement group to make sure this service work well all-round.

Improved Access

Each area has increased the amount of bookable appointments by 270 hours a week across Bucks. This includes an increase in digital appointments and group sessions. This has encouraged practices to work together and develop their skills.

Enhanced health in care homes

The ICS is also aiming to reduce the amount of time frail elderly people spend in hospital. There is evidence that shows people like this are best cared for in their usual setting. Also, transferring these people to

hospital can cause disorientation and deterioration. In order to reduce the need for such transfers we have in place a 24/7 tele-health advice line, implemented in 30 homes across Bucks. This allows care home staff to access advice about a patient they are concerned about, without the need for the patient travelling to A&E or a surgery.

The Red Bag scheme is another popular initiative. Care home staff use the red bags to transfer the patients care plan, personal information and belongings to hospital. It lets hospital staff know that the patient is from a care home. It also means doctors and nurses can update care plans and give them back to the care home via the bag.

Personalised Care Service

There are several people across the county who frequently contact services. They may contact ambulances, A&E, and general practices, because they do not know how else to get help. Many of these people are reluctant to engage fully with services. The Personalised Care Service is in place in three localities – Aylesbury Central, High Wycombe and Southern. It employs care co-ordinators who have time to build up trust between them and the service user and help the service user work out what is driving their frequent requests for help.

The service works in with all providers. Currently it has received 52 referrals and is actively supporting 26 clients. The hope is that as the service develops it becomes part of the integrated team within the locality. But it will keep its focus for supporting a small number of clients who require more time and care.

Long Term Conditions

The ICS has developed a care model to support people living with long-term conditions. Diabetes is the first condition to have a care model fully put in place. The care model has been short listed for the Health Service Journal Improving Patient Digital Participation in Diabetes Education awards.

The model starts with prevention. This means supporting practices to identify people at risk of developing diabetes and helping them improve their health and wellbeing.

Then, anyone that is newly diagnosed is signposted to locally based programmes. The programmes will help them understand their condition and how to manage it. Each patient has a Care and Support Planning meeting with their GP once a year. This will give them the chance to discuss their condition and whether their care is working for them.

As a result, approximately 800 extra patients now have their care managed in the community freeing up 1100 outpatient appointments.


To find out more about the Bucks ICS successes, and what the next steps are, you can read the full report here.

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