The programme

Team Up Derbyshire is an ambitious programme in Derby and Derbyshire that aims to create one team across health and social care who see all housebound patients in a neighbourhood.

A housebound patient is someone unable to leave their home due to physical or mental illness. It includes people living in their own home or a care home. These patients tend to have complex health and social care needs. Being housebound can be a permanent or temporary situation.

This team will provide anticipatory (also known as ‘proactive’), planned and urgent care. If someone is housebound and needs a service, this team will deliver it. 

This team is not a new or ‘add on’ service – it is a teaming up of existing services – with general practice, community, mental healthcare, adult social care and the voluntary and community sector all working together.

The overall aim is to keep people safe at home and provide the best, most seamless, care, keeping people out of hospital wherever possible. Team Up Derbyshire aims to ensure that person-centred care services are provided at the right time, in the right place, by the right person. As a result, people should be able to live well, for longer.

Team Up Derbyshire (including Ageing Well) is being advanced locally by the primary care networks across Derby and Derbyshire – with the support of local place alliances and all health and care organisations.

The need to improve care for older people

People in England can now expect to live for longer than ever before – but these extra years of life are not always spent in good health, with many people developing conditions that reduce their independence and quality of life. The health and care sector has a key role to play in helping older people manage these long-term conditions, making sure they receive the right kind of support to help them live as well as possible. The NHS Long Term Plan (January 2019) set out a vision to give people greater control over the care they receive, with more care and support being offered in or close to people’s homes, rather than in hospital.

The national Ageing Well programme is a requirement of the NHS Long Term Plan and concerns how the population is looked after in the community. There is no age criteria although the vast majority of community resources are used to care for and support the moderate and severely frail population, of which there are approximately 30,000 in Derbyshire. The moderately and severely frail population in Derbyshire had 96,605 hospital bed days (in 2019-20) – the equivalent of about 10 wards. This figure is only predicted to increase in the future.

Programme objectives

Team Up Derbyshire’s objectives are to:

  • Promote a multi-disciplinary team approach where professionals from the NHS and social care work with their communities in an integrated way, to provide tailored support that helps people live well and independently at home for longer 
  • Ensure that the care and support people receive is based on their wishes, preferences and aspirations, particularly towards the end of their lives 
  • Offer more support for people who look after family members, partners or friends because of their illness, frailty or disability 
  • Develop more rapid community response teams, to support older people with health issues before they need hospital treatment and help those leaving hospital to return and recover at home 
  • Offer more NHS support in care homes, including making sure there are strong links between care homes, local general practices and community services.

Team Up Derbyshire includes a new approach to providing a home visiting service for patients, reducing the need for emergency admissions, and relieving GP workload. It brings together step-up support (when an individual’s care needs escalate) and discharge pathways (ensuring that there are suitable options in place to allow people to leave hospital when appropriate to do so).

Team Up Derbyshire also incorporates three key initiatives of the national Ageing Well programme. These are: community urgent response (providing crisis response and reablement care), enhancing health in care homes (providing comprehensive support to care homes and their residents), and anticipatory care (working proactively with patients to maintain or improve health and wellbeing).

Acute home visiting service

An acute home visiting service is a responsive and effective home visiting service for patients, providing person-centred care, timely assessment and support for vulnerable patients. As well as being designed to help prevent hospital admissions, the acute home visiting service is set to improve the patient experience and lead to a better use of resources.

Housebound patients (in residential care or their own homes) are at higher risk of deteriorating health and hospital admissions. For GPs, home visits have to be fitted in around other surgery commitments, and smaller GP practices, in particular, can struggle to meet on-the-day peaks in demand for home visits. This has previously meant that patients unable to attend their surgery could experience a delayed holistic assessment of their needs.

Responsibility for providing the service will be across a larger footprint than a single GP practice. New approaches are now being explored in areas such as Erewash, Derby and Chesterfield. In the city and county, the aim is to provide an acute home visiting service which makes better use of the workforce, with visits being provided by a range of different professionals according to patient need. This will increasingly see nurses, therapists, paramedics or social care practitioners carry out home visits. 

While GPs will still visit people at home under this approach, their role will increasingly be one of overseeing patient care, supporting other members of the team. In this way, a range of professionals will provide the care that is most appropriate, working together as a team.

Urgent community response (Ageing Well)

The urgent community response service aims to support people with complex needs to live safely in their communities, through co-ordinated and responsive care, reducing the need for unnecessary admissions to hospital and long-term care.

The urgent community response service is set to provide crisis response care within two hours of referral and reablement care within two days of referral. 

A crisis response service is a community-based service, typically provided by a multi-skilled team to people in their home with an urgent care need. Reablement care is a community-based service, typically provided by a multi-skilled team to maximise independence, and involves an assessment and intervention(s) to achieve goals set with the person. This is the active process of an individual regaining the skills, confidence and independence to enable them to do things for themselves, rather than having things done for them. 

The current response to people in their own home who have an urgent need is largely via the ambulance service or general practice. This approach is flawed because it is delivered by a single clinician who can feel time-pressured and unsupported or that they are alone in problem solving. This can also result in reliance on hospitals as a place of safety rather than reserving them for specialist provision of healthcare. It is proposed to develop community multi-disciplinary teams to be the default first line urgent community response. This will see a response not only to the presenting issue and the need to ‘make safe’ but also with an explicit remit to identify and address underlying issues.

Enhanced health in care homes (Ageing Well)

People living in care homes should expect the same level of support as if they were living in their own home. This can only be achieved through collaborative working between health, social care, the voluntary and community sector and care home partners.

The NHS Long Term Plan contained a commitment, as part of Ageing Well, to roll out enhanced health in care homes across England by 2024. This reflects an ambition to strengthen support for the people who live and work in and around care homes, including how urgent community response is accessible to people living in a care home.

Enhanced health in care homes should see GP practices aligned to care homes, the development of multi-disciplinary, weekly home rounds to care homes and personalised health and care plans put in place for residents. For the purposes of this programme, a care home is defined as a Care Quality Commission-registered care home service, with or without nursing. 

There are seven components of the care homes framework:

  1. Enhanced primary care and community support
  2. Multi-disciplinary support
  3. Falls prevention, reablement and rehabilitation
  4. High quality end-of-life
  5. Mental health and dementia care
  6. Joined up commissioning and collaboration
  7. Workforce development
  8. Data, IT and technology.

Anticipatory care (Ageing Well)

Older people living with frailty are the highest users of services across health and social care and have the highest levels of emergency admissions to hospital. Yet with greater use of anticipatory care (also known as proactive care), we can identify patients at risk of hospital admission in future, and support them before things go wrong. Anticipatory care will help people to live well and independently for longer through proactive care. For anticipatory care to succeed, we need to understand the housebound population better and use those insights to provide more personalised approaches.

Anticipatory care would be provided by teams of professionals such as community matrons, nurses, physiotherapists, occupational therapists, pharmacists and social workers working together, ensuring the right support at the right time. The programme is at an early stage in Derbyshire, with initial discussions and plans being progressed.

Step up

Step up care describes a pathway for people who are tipping into or have tipped into a care crisis and who have a care need that cannot be managed within their own home or they cannot be left safely at home. At this time they may benefit from being stepped up into care such as a community reablement bed or a care home bed. 

It is commonly recognised that many patients end up in hospital because they are not able to access the appropriate wrapround support in the community. This part of the programme will enable multi-disciplinary teams, involving professionals such as nurses and therapists, to quickly provide more support, often temporarily, tailored to the patient’s individual needs.

Discharge pathways

This programme mirrors ‘step up’ but sees services put in place in the community to receive patients from hospital. Patients who are clinically stable and do not require an acute hospital bed, but may still require care services, are provided with short term, funded support to be discharged to their own home (where appropriate) or another community setting. 

In Derby and Derbyshire, there are three discharge to assess pathways with pathway one being a transfer to home for further assessment to determine a person’s ongoing care needs. As well as an assessment in the home, there may be a period of rehabilitation provided by the community health and social care teams.

Team Up Derbyshire - an introduction

Team Up Derbyshire has produced this flyer to provide an introduction to the work of Team Up and the Ageing Well programme. It sets out the national and local context in which this work is happening, the key priorities and the service areas where improvements are being progressed.

Team Up Derbyshire - visit our blog

In 2021 we set up a blog site where we could post news, views and updates. The site is being added to all the time so please take a look and see what our latest post is all about. The blog hosts videos, Q&As and other content we think is of interest. If there's something you'd like to see on the site, just let us know.

Visit the Team Up Derbyshire blog site

Engagement with public and patients

We are carrying out extensive engagement with local people to understand their views on how services are developed. As part of this, we have produced a survey which was promoted through social media, the Joined Up Care Derbyshire Citizens’ Panel, and patient participation groups. We have also held two ‘virtual’ engagement events on Microsoft Teams and invited local residents to join us and discuss ideas. The events were well attended and built on the responses received from the online survey. A feedback report has been produced based on this engagement.

Providing care closer to home

A number of community support beds have been established in two care homes in north east Derbyshire. These beds are for patients who are medically well enough to leave hospital but are not quite ready to return home or to the place they will call home. Support services wrapped around the patient provide rehabilitation and reablement enabling the individuals to return home, generally after a period of around two to three weeks.