Care Management

The NHS has introduced a new service for people who are more at risk of an unplanned hospital admission in an emergency situation and who would be likely to benefit from more tailored, active support from their GP surgery.

We believe personal care planning could help improve your health and wellbeing, as well as help to reduce the risk of unplanned hospital admissions.

As a member of this programme, you will be assigned  a ‘usual GP’ and they will have overall responsibility for the care and support that our surgery will provide you. We will also make sure that you have a named care coordinator, who may be your named GP or another health professional involved in your care and is likely to be the person you see the most.

Your named care coordinator will be responsible for sharing information with you/your carer and if you are happy for us to do so with other health professionals involved in your care. Information would only be shared with other care organisations (e.g. hospitals, emergency services and if you have one, your social care team) to help coordinate your care. These new arrangements do not prevent you making an appointment or seeing any doctor, of your choosing within the surgery, as you would normally do.

Your named GP or named care coordinator will work with you to develop a personal care plan and review / discuss with you any changes needed. We will also invite, with your agreement, other health or care professionals involved in your care to help develop and keep your personal care plan up to date.

Your care planning discussion will help us (you/your carer, your named GP and named care coordinator) to think about your health and care needs. With your agreement, your personal care plan will include information like:

  • your NHS number
  • details of your named GP and care coordinator
  • details of any other health or care professionals who are involved in your care
  • confirmation that you have agreed to sharing your care plan with relevant health and care professionals
  • details of your condition(s) and significant past medical history
  • details of any medication(s) you are taking and plans for reviewing them
  • any allergies you may have
  • the action that you are taking to help manage your health
  • how you can detect any early signs that your health may be worsening and what you should do if this happens
  • who to contact if you think you need to see a doctor urgently

Your named GP and named care coordinator will work with you to review your health needs as often as necessary. They will ensure that you receive support from us and others to help you manage your health. We may also be able to help you find local community resources that you may find helpful.

We will also make sure that, whenever you have an urgent need to see or speak to a GP or nurse, as soon as possible on the same day one of our GPs or nurses will phone you back to help deal with your problem.

The NHS has introduced a new requirement that all patients over 75 years of age be given a named doctor.  As a patient in this age group, you will have <GP Name> as your named GP.

This new arrangement does not prevent you making an appointment with or seeing any doctor of your choice, as you would normally do.