How we are working together (Old Version)

Read our Better Care bulletins and keep up to date with how the programme is progressing.

How we are working together

We are working on a number of projects with the local authority and local provider organisations that offer better care to people in our hospitals, care homes and their own homes. These projects will provide joined-up care around people’s lives, not forcing them to fit their lives around the care they need.


Ambulatory care

Ambulatory care is where a patient receives a consultation, treatment or procedure at a hospital or clinic as a day patient.

Our vision is to deliver seven day services in either people’s homes or as close as possible in the community to reduce the need for patients to go into hospital.

A pilot introducing Locality Hubs in the Goole, Howden and West Wolds area will see GPs, community health care and social care working together to offer care closer to home, providing services in the community.

Patients with multiple long-term conditions will be given rapid access to GPs for advice and visits if they need extra support. They will have a named worker to co-ordinate their care and care plan. If their condition deteriorates patients can contact their named worker who will carry out checks at home to avoid unnecessary admissions to hospital.

Our aim is to reduce the number of inappropriate admissions to hospital, help to reduce the length of stay for patients who do need hospital care as well as empower patients to manage their condition.

Single point of contact

We are developing a Single Point of Contact (SPoC) making it easier to access health and social care services.

The future will see patients, social care workers and clinicians having to ring just one number for information, advice, assessment and access to all services.

Prevention and self-care

We want people to manage their own physical and mental health where it is safe and appropriate to do so.

We want to encourage people to make positive lifestyle choices that keep them healthy and reduce the likelihood of becoming ill.

Our aim is for people to get a greater understanding of their condition, become empowered to self-manage which improves their health and increases their independence.

We are developing a number of schemes aimed at getting people involved and taking an active part in their local community. This helps to increase their independence, improve their health and well-being whilst reducing isolation and loneliness.

Living Well – A project in Hornsea managed by the Hornsea United Reform Church.  It offers older, more isolated adults the opportunity to get together for lunch and take part in activities on a regular basis.

Befriending service – A telephone support networked manned by 23 volunteers who make around 40 phone calls a week to over 70 older people living alone.

Let’s get moving – A sport, play and arts mobile service that visits groups and villages offering fun and informal activity sessions for adults aged 50+ with a disability.

Re-ablement beds – A service offered to patients who have been in hospital a long time and are nervous of returning home and having to be independent. Wold Haven centre in Pocklingon and the Applegarth extra care housing scheme have beds where patients can stay for a short while to regain their confidence and learn to live independently.

Bereavement services – Befrienders work with people who may be left alone and depressed by the loss of a loved one, to help tackle their loneliness and isolation. End of life support is also offered for those wishing to die at home.

Community based diagnostic services – Key diagnostic services are being developed in the community so people can have tests carried out at home or in their local area rather than at hospital.

Lifeline – A service offering a range of alarms and sensors in a person’s home to detect risks. If a risk is detected an alert is sent to a monitoring centre summoning help. It helps users to live safely and independently in their own home, providing peace of mind for both users and carers.

Personal care plan – Offers patients the opportunity to develop a plan with their clinician and carer that details what should happen in the event of them needing any treatment or care services. The plan is available for all health and care workers involved in the patient’s care so everyone has a history of the patient’s health and knows what treatment is required.

Live well – A one-to-one weight management service for adults with a body mass index of 45+. Patients are referred by their GP and supported through a programme of behaviour change, dealing with exercise, nutrition, healthy eating and motivation. The aim is to encourage and empower people to make long-term healthy lifestyles changes.

Connect to support – A website that offers people who have a personal budget to fund their care needs, online information, help and support. It allows them to choose goods or services from a broad range of suppliers. Visit and click on East Riding.

Our Plan for Better Care (including Easy Read)
We have been working closely with patients, carers, members of the public and health and social care professionals to develop our plan (vision) to get the best health and social care services for people in the East Riding.  In September 2014 our Better Care Plan was assessed by NHS England and placed in the ‘Approved with support’ category. This recognises the excellent working being done in partnership to enhance local services and improve the lives of people in our community.

Our Plan looks at 4 main things:

  • People to have more power and control over their own health and care - Health and social care services will support this work.  They will help people to think about their health and care needs and offer support and services to help people know how to stay well.
  • Services to be run in the local community - More health and social care services will be run in the local community.  We will set up Hubs to help this happen.  A Hub might be a building where health and social care services are based or lots of buildings where health and social care services work closely together.
  • Health and social care services to work closely together locally through a Hub so they know what people need - Local Hubs will break down barriers so that people get the service they need at the time they need it, not just when they are in crisis.
  • Hospital services with expert help to work alongside community services - Only people who have complex health and care needs or ill patients who need expert help and advice will use hospital services. 

Organisations involved

  • East Riding of Yorkshire Council
  • East Riding of Yorkshire Clinical Commissioning Group
  • Vale of York Clinical Commissioning Group
  • Humber NHS Foundation Trust
  • Hull and East Yorkshire Hospitals NHS Trust
  • GP Federations
  • Primary Care Practitioners
  • Healthwatch East Riding