The team secured top-level buy-in for the pilot from within the PCT and their partners in Essex County Council and Social Services.

They identified two practices which refer patients into two different acute trusts and established a series of fortnightly practice meetings with a multi-disciplinary team at each, including social worker input.

The team identified patients with potentially the highest needs so that proactive management could begin immediately.

The practices wanted more ownership of their patients once admitted to hospital and wanted to move to a position where the practice could be informed of any emergency admission within a 24 hour period.

Early studies highlighted a seven-day delay, from the time a patient was admitted to the time the practice was informed, and a similar delay in discharge information occurred. The PCT agreed to work with their secondary care colleagues to reach agreement that a 24 hour timeframe of admission and discharge could be established.