Creating a Collaborative Care Service in the Community


GP Care Services helps make care within Heywood, Middleton and Rochdale accessible for all patients.

We spoke to Zalan Alam, Primary and Intermediate Care Director, about their journey providing a collaborative care service at scale within the local community.

Creating a collaborative care service

It began in 2015 with a contract from the HMR CCG to address the needs of the local population. This was a result of an audit by the Acute Trust of patients coming into the local hospital, which identified that a large percentage of patients could actually be managed in settings alternative to hospitals.

The CCG therefore collaborated with Pennine Acute Hospital Trust, GP Care services, Rochdale Council, BARDOC the local out of hours service, and the third sector.

“The idea was to bring together multiple services under one collaborative provider and create one team across organisations. For example, the GP side, through GPCARE services, would provide GP input, the hospital would provide medical infrastructure, Rochdale Council would mobilise care for patients, out of hours would provide telephony for referrals and the third sector would focus on social isolation to bring all teams under one umbrella.”

The service launched in September 2015. This new referral pathway gave GPs the option to refer patients to a MDT team of specialists offering support for home visits. The 2 other services included community rehab units that were carer-led, to offer extra support by GPs, pharmacists and therapists. If the support required was more complicated, there was also a GP-led community unit, with nursing support at Rochdale Infirmary.

“Prior to that, the patients locally had a long length of stay on Acute beds. It now has one of the lowest in the country. The end result was having a service that had quite a dramatic impact on the local health and social economy. By bringing all these people together, all the old barriers broke down and everyone started to work together really well. We saw big success straight away.”

Key results of the new collaborative care service in Rochdale
  • 2-hour turn around rapid response in all cases
  • Length of stay dramatically dropped - one of the lowest in the country
  • Positive patient experience - “If you intervene early enough most patients don't want to be in hospital, they want to be at home and we helped rebuild independence very quickly.”

From a GP point of view, there is a greater opportunity for many GPs to become portfolio GPs. It has been overwhelmingly seen as a very positive experience. It enables GPs to identify medical complexity and fragility but also to address it.

It’s a service that is a success as a result of working at scale together with multiple organisations and, from the outcome, there have been a couple of spin off initiatives.

1. HEATT Car (Heywood Middleton Rochdale Emergency Assessment & Treatment Team): an ambulance reflection service that pick up referrals from the North West ambulance treating or signposting patients there and then, which reduces pressure on the ambulance services and A&Es.
2. Discharge to assess service: offers a better patient journey, by offering a patient assessment service managed at home, so there is no need for long stay in hospital.

“As the lead GP involved in the initial setup, it’s been a very rewarding experience. The service has done very well, and far better than expected. The teams in Rochdale deserve a lot of kudos from an acute and social services perspective. It has been especially rewarding seeing people from all over the world come to see what we're doing and to see good examples of integrated health and social care.

“This process has also changed my skills, as I have a greater variety of work and a more rewarding week because I see both sides of the journey. A lot of GPs and staff have done remarkable jobs and I can't fault it for personal development. I feel quite privileged.”

The differentiators of the collaborative care service
  1. It’s unique in the fact that all organisations were treated as equals, and it’s quite grounded in community - the two sides compliment each other, they don't compete.
  2. It wasn't specific to one age group. Patients were anywhere from 18 and older with complex medical problems. Most services don’t address patients between 18-65 in a holistic way.
  3. Importance of involvement of the third sector and social services - this can address a lot of health issues and once you break social isolation you see the cycle of over dependence on health care systems reduce.

“At its core, it’s an example of how the power of good leadership, a shared vision and agenda with buy in, can create a sustainable health ecosystem. Once you reach a certain level of success and cross a tipping point, then you will be happily surprised by what people will do when given “permission” to do so.”

Dr Zalam Alam
Primary and Intermediate Care Director


Lisa Vecchio

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