Integrated teams transforming care for patients living with frailty and long-term conditions across Wirral
Thursday, 4 December 2025
People in Wirral are avoiding A&E attendances and living well at home thanks to a proactive integrated care programme.
Figures show fewer A&E attendances, unplanned hospital admissions and a 15% reduction in GP appointments for people with frailty and long-term conditions, with 1000 people now being supported in their own homes.
Wirral’s integrated care teams - principally made up of NHS community services and Primary Care Network (PCN) staff working with other NHS colleagues, adult social care and voluntary partners - proactively reach out to patients following a referral from their GP, or community team, followed by home visits to develop a personalised care and support plan.
The service also helps people who have recently been discharged from hospital, identifying patients who would benefit from follow up support to avoid a readmission.
Referrals often come following a home visit from the PCN Acute Visiting Service, identifying needs which the integrated team can effectively address. In some PCNs, Acute Visiting staff are part of the core team.
At the heart of the model are integrated multidisciplinary teams, including community trust matrons, nurse practitioners for older people, early intervention assistants, paramedics, pharmacists, and PCN care coordinators.
Launched as a pilot in January 2024 following work with Moreton and Meols PCN to design a shared model of integrated care, the programme has since expanded across four of Wirral’s six PCN footprints, with the remaining two expected to join by the end of 2025.
By bringing together teams from Wirral Community Health and Care NHS Foundation Trust, PCNs, and wider partners, the service is providing increasingly personalised and holistic support for people with frailty and chronic conditions.
David Hammond, Deputy Chief Strategy Officer at Wirral Community Health and Care NHS Foundation Trust said:
“Integrating teams to provide care for patients makes a real difference. By working as one team, we’re able to spot issues early, provide personalised support, prevent crises, and help people stay well and independent at home.
“This is helping to reduce unnecessary hospital stays and provide continuity for those with the most complex needs.
“By supporting patients in their own homes, we’re not just responding to illness - we’re preventing it, improving quality of life, and making our local health system more sustainable.”
Professor Rowan Pritchard Jones, NHS Cheshire and Merseyside’s Medical Director, said:
“Wirral’s proactive care programme is bringing together the teams who support people with frailty and chronic disease to provide increasingly personalised and holistic care.
“This is a real example of how strategic planning and joined-up working can deliver better outcomes for people across Wirral. This work also embodies the NHS 10-Year Plan’s vision of shifting care from hospital to the community and moving from sickness to prevention.”