Together we’re better – Issue 1

Read the first newsletter to find out about Joined Up Care Derbyshire and

  • Meet the organisations which are working for you and with you to make a difference
  • Our top five priorities
  • How people are getting involved in the conversation
  • How connecting care services is already having an impact

Across the country services have never been in such great demand. In Derbyshire more than 20% of the population is aged 65 or over. As life expectancy increases, so do the ailments of old age and there are now more people than ever living with chronic illness like heart failure and arthritis. We often see patients with a range of these complicated conditions, but we can treat them with new drugs and treatments that weren’t available in the past. Advances in medicine are rightly helping people to live longer, but place new pressures on our already stretched services.

Financially in Derbyshire our health and care services are under huge pressure, just as they are everywhere in the county. The financial challenge means we’ll have an estimated funding gap of £240m in our health system and £136m in our local authority over the next three years if we don’t change the way we work.

So, we’ve come together to face the challenge ‘head-on’. There are big opportunities to improve care by making practical changes to how we all work. If we can improve what really matters to local people, like making it easier to see a GP, speeding up a cancer diagnosis, making sure people with mental ill health get help quickly and supporting people to get home from hospital to aid a better recovery, we’ll make a real difference.

Across England, the NHS and many local councils have come together to set out their ideas for improving health and care provision. These 44 new collaborations- led by the NHS – are known as sustainability and transformation partnerships and are developing future plans for the health and social care they provide by making sure they make the best use of limited money and resources.

In Derbyshire our partnership connects the 12 organisations that provide care across the county. You can read more about them on page 2. The partnership has come together to make sure how it looks after people meets the needs of modern day life. We’ve called our alliance ‘Joined Up Care Derbyshire’ and we’re calling on our patients, the public and staff to work with us to support people to stay healthy and live longer using the resources we have in the most efficient way. Our newsletter will help to keep you up-to-date with the latest developments and will tell you more about how you can get involved and have your say.

Joined Up Care Derbyshire Steps Up

By combining our skills and expertise, the 12 organisations that either buy (commission) or provide health and social care are taking steps to create a new way of working that will make sure people in Derby and Derbyshire receive the right care in the right place to support them to stay well. It’s a real challenge to change things that might have worked in the same way for many, many years – but it’s the right thing to do.

The Joined Up Care partnership want its residents to lead happier, healthier lives, to be well supported when they do need care and for that care to be provided in their own communities. We’ve pledged to work together for your benefit, with more co-ordination and less duplication. That way, you’ll notice more of what’s good about the care you get and less about what’s frustrating. It won’t be an overnight fix, but all 12 organisations want their joint approach to succeed.

Working for you and with to make a difference are:

Organisations that commission health services for you

  • NHS Erewash Clinical Commissioning Group
  • NHS Hardwick Clinical Commissioning Group
  • NHS North Derbyshire Clinical Commissioning Group
  • NHS Southern Derbyshire Clinical Commissioning Group

Over the past decade, the role of commissioning has become increasingly important. Commissioners plan, agree, contract for and monitor services on behalf of their local populations. They make sure local people have access to care and services that meet national standards and quality measures.

Organisations that provide your health care services:

  • Chesterfield Royal Hospital
  • Derbyshire Community Health Care Services
  • Derbyshire Healthcare
  • Derbyshire Healthcare United
  • Derby Teaching Hospitals
  • East Midlands Ambulance Service

From responding to a 999 call, caring for you on a hospital ward or in an outpatient clinic, through to out-of- hours GP services, mental health care working and helping you to rehabilitate in your own home, these organisations make sure you get the right care when you need it.

Organisations that provide your public services and social care:

  • Derby City Council
  • Derbyshire County Council

Local authorities are the councils that are responsible for providing a range of public services in your area including social care. As a democratically elected local government they also represent their local communities, voicing local concerns and responding to local needs.

What’s the plan?

Talking to patients, staff and local residents it’s clear that people understand why services have to change and they’re clear about what frustrates them about how we work now.

Our alliance brings together a wealth of information, views and opinions – and we used this to support setting out our five priorities. We’ll be using these priorities as a starting point for all our plans and proposals. We’ll be turning to you again when we start to develop new ideas, to see how you feel about them and to get your thoughts about what would make them work effectively and efficiently for you.

Our priorities:

Priority one:

Preventing physical and mental ill health and helping people to make better lifestyle choices is important to you.
If we all work together to get to grips with issues affecting people – before they become bigger problems – they’ll be able to lead happier and healthier lives.

Priority two:

Make sure services are tailored and targeted to people and their communities.
Health and social care needs to make sense for people and where they live and not concentrate on what’s easiest for organisations. We want to work together to come up with solutions that put patients, not organisations first.

Priority three:

Make it easy for people to get the right care, when they need it, in the right place for them.
Make sure local people are cared for in the best place for them – as close to home as possible and in hospital only when absolutely necessary. This will help to make sure anyone with serious or life-threatening injuries, accidents and illnesses can get the immediate and critical care they need.

Priority four:

Health and social care need to work seamlessly together.
We all try to work together but very often organisations work separately, which often causes people problems and issues when they’re trying to access the care they need. We should integrate and co-ordinate more effectively, to avoid gaps in care or duplication – and make all our services a consistent high-quality.

Priority five:

Become as efficient as possible.
We’re spending public money and people want to make sure we get the best value for every ‘public pound’ we use. Our partnership needs to use the limited health and social care resources we have to become more efficient, in order to support local people effectively.

Join up care – yes we can!

Work has been taking place for some time to across the county to coordinate the way we all work together and look at ways to improve the way we help support people to stay well.

But saying we are joining together and looking at how we can better support people and deliver the best care for people in the most efficient way is a lot easier to say than do. Changing the way we work will not happen overnight and sometimes we won’t get it right first time.

All of us are committed to delivering the best possible care for people in Derbyshire and that will continue to drive us all on to make the changes we need.

There is already great work taking place across the county, where organisations have come together to find solutions or put in place ideas that have worked elsewhere that have transformed the way we support people to stay well. Over the coming months we will be sharing examples of teams who are working together and putting in place new ways of working.

If you have a great example no matter how big or small about how you and your teams are working together to transform the way we support people to stay well, please get in touch. We would love to share your stories. Get in touch.

Let’s get you home…

There was a time when coming in to hospital meant at least a week’s stay – if not much longer. But, thanks to advances in treatment and medicine and a better understanding of what a hospital stay can do that’s no longer the case.

There’s no better demonstration of how successful joined up care can be than one example of collaborative working in the system between Chesterfield Royal Hospital, Derbyshire Community Health Services and Derbyshire County Council. By pooling expertise and resources they’ve successfully put a nationally recognised way of working in place that’s getting people back home – or to a residential nursing home – when they’re medically fit to leave.

Is hospital really the best place to be?

Nationally, around one third of patients admitted to hospital in a medical emergency are over 80 years old and for this group in particular a prolonged stay in hospital runs the risk of reduced mobility, loss of muscle strength, lack of independence and risk of infection. In fact, all patients, whatever their age, can quickly become reliant on a hospital environment – even if they say they want to get home again as soon as possible. A ward can soon feel like ‘home’ and ‘the best place for me’.

So, at Chesterfield Royal Hospital as soon as a patient is admitted to a ward the staff start planning for them to go home again, which is the best place to recuperate and reduces the number of days they have to stay in hospital unnecessarily. There’s nothing like your own kitchen when you want a cup of tea or a snack, nothing like your own bathroom for privacy and definitely nothing like your own bed for comfort in the peace and quiet of your own room.

What happens when someone is medically well enough to be discharged from hospital?

Planning for someone’s discharge from hospital can be challenging and requires lots of people from different organisations working together in the best interest of every individual patient. Just how easy is it to arrange?

In the NHS and social care world we call this planning ‘Discharge to Assess’. What it means in practice is bringing lots of services together to get a patient home, keep them safe and make sure they’re supported while they continue to recover.

The ‘discharge part’ takes place in hospital. Each day a multitude of staff – doctors, nurses, therapists, social workers and others – review patients to work out what support they’ll need to go home. That means understanding their home circumstances, what equipment they might need to help them at home and if they’ll need carers to support them.

This mass of information gathering means that by the time a patient is well enough to leave hospital everyone’s on-board and understands what needs to be achieved. Once that date is agreed, the discharge team at Chesterfield Royal work in partnership with a team of people from Derbyshire Community Health Services and the ‘assess’ part of the pathway begins.

What happens at home?

Once a patient is home, community health services carry out a home assessment. Unlike assessments that traditionally used to be undertaken in hospital, this gives a much more honest picture of how someone can manage key tasks like washing, dressing, cooking and making a drink. It’s the patients’ home environment and it’s a more realistic ‘check-up’ than watching someone make a drink in a hospital ward kitchen.

Not only does Discharge to Assess determine how independent a patient is at home, it gives the team a clearer picture of what additional support someone needs. The community teams have an opportunity to make sure they have appropriate, coordinated support from a range of professionals in place right from the word ‘go’. Care and care packages are reviewed regularly – to make sure people have exactly what they need for the longer term.

Matron, Warren Hutson comments:

“Discharge to Assess is exactly what a joined up approach to care should be about. It’s the best thing for our patients and works around them, not around the needs of our organisations. It’s making sure that elderly frail people in particular, and patients with complex health needs, stay out of hospital unless they absolutely need to be there. By working smarter, in partnership with health and social care colleagues, we are giving our patients a better experience because they get exactly the right support, at the right time.”

Changing hearts and minds

While most patients put going home at the top of their wish list when they’re in hospital, it’s an anxious time for family members and the thought of them coming home, and worrying how they’ll cope, can be difficult. Changing traditional views about hospital being the best place for someone is a challenge.

Mr A’s mother is 79 and had been in hospital with a respiratory illness. He was worried about her coming home and wondered if she would cope. He knew with work and family commitments he couldn’t always call and the town house he lived would be difficult for her to manage in. He comments:

“When the consultant said Mum was well enough to go home I was concerned that she was being ‘pushed out’. I was worried she wouldn’t cope at home and I knew I couldn’t always be there. However, the discharge team assured me that the home assessment would be thorough and it was. Mum has carers going in three times a day for the next couple of weeks and to be honest once she was back in her own environment she was much more positive about her recovery. In hospital she was a bit down about it all and had to be coaxed out of bed. We had a couple of hiccups with the arrangements, but on the whole it’s made me think differently about where people get the best care. For Mum, being at home after a short hospital spell has worked. I think if she’d have been in hospital for a longer period her general health and well-being would have suffered.”

Get involved int he conversation

We hope that reading about Joined Up Care Derbyshire and how it’s connecting care services, will encourage you to get involved and join in the conversation about the future of health and social care. There are lots of ways to get involved in the conversation. You can send us an email with your thoughts, answer our questionnaire or attend an event. If you have any meetings you would like us to attend please get in touch and we will do our best to come along.

When Joined Up Care Derbyshire puts forward specific plans and proposals we need local people from across the county to get involved and have their say. We’ll have lots of ways to help you engage and participate – from surveys through to public meetings -to make sure we are involving communities every step of the way.

We’ve already started the conversation and been out and about with Healthwatch Derby and Healthwatch Derbyshire to talk to people across our communities. You might have even spoken to us about our partnership and what it could mean for you and your family. All the views we have gathered so far will help to inform our plans and we’ll be reporting back what you have told us so far by the end of the year.

Keep checking our website for more information and see how you can get involved in Joined Up Care Derbyshire!

You can also download this update as a PDF.

Written By Joined Up Care Derbyshire