Borth Integrated Health and Care

Hywel Dda University Health Board

Dr Sue Fish, GP Partner Borth Surgery and Chair Cambrian Primary Care GP Federation

Jacqui Jones Browne, Project Manager

Claire Bryant, Clinical Coordinator


The COVID 19 pandemic has led to waiting times for planned care, increased health and care needs of the population and recruitment challenges across the health and care sector. Consequently, there is an increased demand in general practice which has reduced the availability of primary care clinicians to manage complex health and care needs for their patients in the community resulting in an escalation of referrals to secondary care and the local authority. Through improving the coordination of care between the different organisations who provide individual patient support in the community there will be less duplication and the care will be more patient centred.  This will make better use of resources and improve the health and wellbeing of the population.


The project intends to transform the way that general practice, community pharmacy, community health services, local authority services and the third sector work together to provide integrated patient centred care. Through enabling the local community (including statutory partners in health and care) to deliver more effectively the resilience, health and wellbeing will be improved for all residents and visitors and their families in the locality.

How will this be achieved?

A clinical health and care coordinator based in general practice will case manage integrated multi-disciplinary team working between primary care, Hywel Dda University Health Board, Ceredigion County Council and the third sector. Through shared decision making with the patient anticipatory care will improve the health and wellbeing of the population reducing both unscheduled and planned referrals to secondary care and social services. This will also ensure improved patient health and wellbeing whilst on long waiting lists and establish an effective community led discharge planning process.

Expected Benefits

The reduction in demand in general practice will enable clinical staff to manage more complex patients in the community. Improved discharge planning will increase bed capacity in hospital enabling more patients to be treated who are currently on waiting lists.