The PAC, launched as a pilot in May 2021, has supported over 450 individual patients across Kingston and Richmond and has been so successful that it has recently made it through to the national finals of The Future NHS Awards, which will be announced in Westminster on 6 July 2022.
Under PAC, each patient is the focus of a weekly multi-disciplinary team meeting which includes GPs, community, social care and hospital-based services working together to provide more proactive and coordinated care. This approach helps patients to stay healthier for longer, reduces the need for reactive health care and supports work to address the wider determinants of health, helping to find ways of keeping local people well, for longer.
Local Kingston GP, Dr Annette Pautz explains: “We identify people in the community who would benefit from this model of care and establish the perfect plan for them. We look at all elements of their health and wellbeing, working with them, their families or carers, to come up with a plan of action, linking them in with the most relevant services for them and helping them to stay independent for longer.”
Local resident, Diana, had suffered a decline in her health over recent months which culminated in her having a fall and ending up in hospital before being placed under PAC. Her niece, Clare, lives 100 miles away and was struggling to manage her aunt’s care remotely.
Clare explains: “Living so far from Diana made making sure she was looked after really difficult and stressful. When Diana fell again, she was under PAC and I could immediately tell there was a difference.
All of a sudden people swooped in and helped organise things which felt much more controlled and made sense of a system that can seem to be quite chaotic.”Diana’s neice, Clare
Clare has confidence that the PAC team has Diana’s best interests at heart and works together with her.
She said: “This is so reassuring as the responsibility as a next of kin for someone old and frail can be overwhelming, especially when she is so far away. PAC is the whole package and covers Diana’s physical, mental health and practical needs. Having a care coordinator means Diana always sees someone who is familiar with her care needs, they are very hands on.”