The team's vision was to improve patient care through integrated team working with flexible patient-centred care underpinned by timely communication. The aim of the pilot project was to deliver a safe, cost-effective reduction in inappropriate hospital admissions.

The team felt that the existing service was too fragmented and not targeted at meeting patient needs which resulted in individuals attending A&E and being inappropriately admitted to hospital.

Key information blockages were identified and redesign work with the ambulance services and hospital trusts was undertaken to improve information flows to improve patient care.

A ‘cluster' group structure was developed, enabling involvement in service redesign and development across services and key workers. District nurses, joint-care managers and advanced practitioners were recruited.

The interest in avoiding hospital admissions and developing case management has spread within the PCT and a group of health visitors are now undertaking a piece of work looking at assessing and case managing families who are frequent attenders of A&E.