Complete Happy Healthy at Home evaluation

The final summative report on the vanguard projects at North East Hampshire and Farnham has been published, giving an overview of the impact of the new ways of working explored over the last three years.

The evaluation underpins our approach to delivering care for local people in an integrated way with our partners, focusing on the needs of local people and not being constrained by organisational boundaries. We are committed to continuing to develop these new ways of working and extend them not only across the localities in the CCG, but also more widely across the systems of Frimley Health and Care Integrated Care System, and the Hampshire and Isle of Wight STP.

The evaluation has been completed by our independent evaluation partner the Academic Health Science Network.

The report highlights the following key findings:

  • 50,000 patient contacts and interventions in 23 new services
  • 3,300 patient reported outcomes demonstrated significant improvements in how they feel about their health status, confidence and wellbeing
  • 530 staff reported outcomes from the new care model teams and primary care, demonstrated statistically significant improvements
  • From the second year of the programme there was a significant reduction in the trend of emergency admissions.
  • Qualitative interviews and case studies found positive benefits for patients, staff and the system

The evaluation highlighted the importance of allowing time to establish new teams and ways of workingGP engagement was a key ingredient in successful delivery. 

For a snapshot of the overall programme's impact, click on the image (above right).

To view the complete evaluation report, click here.


The Farnham Integrated Care Team

Clinicians, practitioners and other professionals from health and social care working together as a single team for Farnham patients with highly complex needs who require support from different agencies and organisations.

By working more closely together the team ensures that all aspects of a patient's care can be covered and all their needs met in a comprehensive and efficient way and that cross-agency solutions can be used to provide a better overall service.

The joint approach also prevents patients from 'slipping through the gaps' between organisations.

For some of the key achievements click on the image on the right.

To read the full evaluation report, click here.


Farnham Integrated Care Centre

A service established to support three of Farnham's GP practices by providing urgent same-day GP appointments to a population of 30,000 patients.

The centre was created in an unused part of Farnham Hospital and Centre for Health with funding through the Happy Healthy at Home programme to convert the area into a custom-built facility.

Staff are provided by Farnham Integrated Care Services, the local GP federation.

For further information, performance figures and patient feedback, click on the image on the left.

For the full evaluation report, click here.


Farnham Referral Management Service (RMS)

This service has been put into practice by Farnham GPs to review all non-urgent routine medical and surgical referrals to hospital.

The aim of improving the overall quality of referrals, reducing the numbers of avoidable planned referrals and making the service more efficient by ensuring that all referrals go to the right place first time.

To see some of the key achievements of this work, click on the image on the right.

For the full report, click here.


Yateley Urgent Care Centre

Established at Yateley Medical Centre in early 2017, the Yateley Urgent Care Centre works in a similar way to its younger Farnham relative.

The centre provides same-day (urgent) appointments for patients of Oakley Health Group (spanning three Yateley surgery sites) who might otherwise have attended A&E.

Patients call their surgery in the same way as they normally would and, if they need an urgent appointment one can be made for them.

The service also links with Frimley Health NHS Foundation Trust to see if there are Yateley patients attending A&E for medical needs that could have been met by the Urgent Care Centre.

The centre is staffed by Oakley Health staff on a rotating basis.

For further information, performance figures and patient feedback, click on the image on the left.

To view the complete report on the Yateley Urgent Care Centre, click here.


The Yateley Integrated Care Team

As with the Farnham team above, the Yateley Integrated Care Team brings together a range of different professionals to provide a joint solution to the problems faced by Yateley residents with complex and chronic health needs.

They discuss patients' conditions and combine their expertise and organisational capabilities to make the patient's experience of health and care services as smooth and positive as possible, with better outcomes.

Click on the image on the right for a summary of some of the team's successes.

For a copy of the full evaluation report, click here.


North East Hampshire and Farnham Recovery College

Happy, Healthy, at Home has placed great emphasis on the benefits of preventative measures i.e. supporting people to be able to live healthier lives to reduce their risks of illness and injury, and if they do have an illness, injury or medical condition, to provide the necessary help and support to enable them to manage it better themselves.

The North East Hampshire and Farnham Recovery College runs educational courses and workshops to help people with a range of psychological, mental and physical health conditions.

For a summary of the Recovery College's achievements, click on the image on the left.

To download a copy of the full evaluation report, click here.


The (Aldershot) Safe Haven

Established in 2014 as an out-of-hourse mental health alternative to A&E, to support people experiencing, or on the verge of, a mental health crisis.

The Safe Haven is groundbreaking, in that it marks a shift away from conventional clinical support models.

It is based in a non-clinical town centre setting, it offers a range of support, from providing a safe place for people to sit quietly, to read, to play games, to have conversations with other service users, to discuss their situation with, and receive advice and guidance from, mental health support workers and, if necessary, to receive clinical support.

The model reflects the expressed wishes of mental health crisis service users for whom previous mental health crisis services were proving unhelpful.

Its success has led to the creation of similar services across Surrey, as well as the Young Persons' Safe Haven, in Aldershot, and The Oasis, in Farnborough.

To read the full evaluation report on the Safe Haven, click here.


The Aldershot Integrated Care Team

Providing support to residents of the Aldershot area with the greatest health needs, working as one team for a joined-up, complementary approach.

The team not only caters to the individual person's needs, ensuring they receive the right treatment at the right time, but also supports them to live as independently as possible.

This evaluation covers 44,000 patients registered at Aldershot's five GP practices. (Since this work was carried out, two practices - Southlea Group Practice and Victoria Practice - have merged to create The Cambridge Practice.)

For some of the headline facts and figures of the team's performance, click on the image on the left.

To view the full evaluation report, click here.


The Farnborough Integrated Care Team

Supporting 60,000 people across seven GP practices - working with those local people with the most complex and chronic needs.

Made up of clinicians and care professionals working as a single multidisciplinary team, providing joined-up care.

Improving outcomes for patients in their health, their confidence around their health, their personal wellbeing and their overall experience of health services.

For the headline facts and figures, click on the image on the right.

For the full evaluation report, click here.


111 GP Triage service

This service was set up to support colleagues in acute services by reducing the number of non-urgent referrals to A&E from the 111 service by offering callers an alternative - in the shape of a call with a GP within 15 minutes of their original call.

With growing numbers of people calling 999 or attending A&E unnecessarily, attention was focused on ways to reduce the demand while ensuring that patients received treatment that met their health needs.

The service is only designed to catch those callers who do not need to visit A&E. If the GP on duty feels the patient needs to attend A&E then they will advise them to do so.

For more information and performance figures, click on the image on the left.

To view the full evaluation report on the service, click here.


The Enhanced Recovery at Home Service

The best bed is your own bed and getting patients home is a key aim to all of those involved in their care, particularly in their rehabilitation and recovery following a stay in hospital.

Staying in hospital any longer than necessary can be detrimental to somebody's recovery and it also reduces the hospital's ability to treat other patients. Therefore the Enhanced Recovery at Home Service was set up, not only to enable more patients to benefit from timely hospital discharges but also to help avoid admission for those who can be supported to remain at home.

The team is made up of a range of health and social care professionals, all working together and assisted by their local Integrated Care Team (see other flashcards and reports), to support adults, particularly those with multiple medical conditions.

To see the headline facts and figures from the service, click on the image on the right.


Fleet Integrated Care Team

Supporting a population of 45,000 patients registered with four GP practices.

As with counterparts in Aldershot, Farnham, Farnborough and Yateley, the Fleet integrated care service brings together clinicians and care professionals from different disciplines to work as a team to focus on the most vulnerable and complex local patients.

All outcomes after the intervention of the vanguard (health status, health confidence, personal wellbeing, experience) were improved, compared with before.

For the headline facts and figures on the Fleet Integrated Care service, click on the image on the right.

To download a copy of the full evaluation report, click here.


Making Connections

Making Connections is a 'social prescribing' service - i.e. a service that provides non-clinical solutions that can help people to maintain or resume active, social and fulfilling lives, reducing the risks of people's health and wellbeing declining through social isolation.

The service is delivered by a voluntary sector partnership - to people who are referred to the service, primarily by GPs and Integrated Care Teams.

For the headline facts and figures click on the image on the right.

To download a copy of the full evaluation report, click here.


You can find further analysis on other areas of Happy, Healthy, at Home work programmes by clicking on the links below:


Aldershot Rapid Home Visiting Service report Emergency Severity Index evaluation report
Farnborough Rapid Home Visiting Service evaluation report Mission Test Clinic evaluation report
Farnham Referral Management Service evaluation revisit Pre-Diabetic Education Programme
Fleet Rapid Home Visiting Service evaluation report

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