Enfield Clinical Commissioning Group has developed a number of initiatives to improve care for their residents and help people to stay at home with appropriate support when they are ill.

The following is an illustrative example:

Mrs S is 86 years old and has a number of medical issues that are usually well managed by her GP and community matron. Mrs S also has some help from social care to live at home.

Mrs S has begun to feel unwell and is visited by her community matron. There appears to be a number of things making it difficult for Mrs S to manage and it is agreed that she would benefit from coming into the local outpatients assessment unit.

Transport is arranged and she is seen by the team the same day. She has a chest infection and is given antibiotics. The social worker is able to increase the help that she is having at home and the community matron schedules a visit for the following day to assess how she is getting on. Mrs S is able to go home and doesn’t have to stay in hospital