Linda turned up at A&E twice a day. A dedicated team now stops that

In a desperate effort to get relief for excruciating pain caused by osteoarthritis, curvature of the spine, and abdominal discomfort following surgery, Linda Douglas went to A&E twice a day.

The chronically ill 48-year-old, who lives near Sunderland, was “at the end of [her] rope” because of the constant pain and frequent hospital visits, and felt life “was not worth living”. That was until a new team of health and social care professionals took over her case and improved her quality of life from “six to 99%” in early 2016.

The team comprising her GP, consultant, community matron, social worker and paramedic worked together to come up with a care plan tailored to her needs. Now, she can largely avoid hospital and live a much more normal life, mainly because John, her husband and carer, has been trained to administer her daily medication. She says: “My life was driven by fear. I was terrified of being unwell and not being able to get the care I needed to control my pain. I don’t need to worry any more. It’s like a weight has been lifted.”

Douglas was helped thanks to the All Together Better partnership, part of NHS England’s Vanguard programme that was ushered in last year via chief executive, Simon Stevens’s Five Year Forward View blueprint policy. This same programme, which was expected to champion ways of providing better, more efficient care for heavy users of NHS services, has not been given as much money as originally hoped. According to Kerry McQuade, head of vanguard delivery in Sunderland, the £4.8m the partnership received in 2016/17 did not match the initial bid, although it received more than similar projects in other parts of the country.

Sunderland is one of the most deprived cities in England. On average, people born there start having health problems more than 10 years before those born in wealthier parts of the country, and die more than six years sooner.

The NHS is a big part of many lives there, but a small minority of long term sick, vulnerable or frail elderly locals account for a large proportion of health and social care resources. Six per cent of the population – those with long-term, multiple illnesses – are responsible for half of the city’s health spend. With the pressure on from NHS England to reduce costs by nearly £1bn by 2021 in the Northumberland, Tyne and Wear region as central funding is squeezed, the focus on the most needy patients makes sense.

Local GP Dr Fadi Khalil describes Sunderland’s scheme – one of 14 across England – as “massive” in scale. Covering nearly 300,000 patients at 50 GP practices across the city, it is focused on reducing hospital admissions via a series of initiatives designed to offer care that aim to keep patients well and cared for where they live.

In the past, despite the “best intentions in the world”, the most needy patients weren’t getting the best care because of a disjointed and fragmented set of services, says Khalil. Patients had to undergo repeat visits to A&E, repeat crisis admissions to hospital, and had to repeat their stories to a string of frontline primary, community, acute and social care staff.

This was not only bad for them but a tremendous waste of precious resources. Finally, under the vanguard programme, local authority and health commissioners and providers are being encouraged to work together with patients.

“In the past when someone [got] a chest infection, they would end up in hospital. Now we’ve got things in place that keep them at home where they’re safer and more familiar with their environment,” Khalil says. Such patients, who have been identified by their GPs as at risk of rapid onset of health problems, have access to their GP, and a nurse or paramedic out of hours who can visit them at home, and who make regular check-ups to prevent urgent, unplanned visits to hospital.

Five teams, created late last year, are at the core of Sunderland’s scheme, with community matrons, district nurses and social workers all were moved into the same office.

It was a shock to the system at first and “initially quite daunting”, according to adult social care team manager Rachel Daurat, particularly to the social workers who had to move out of their dedicated offices at Sunderland city council.

She says health and social care have traditionally worked to entirely different agendas. However, working together on a patient case has meant they have been able to learn from each other’s perspectives and ensure different providers are working in harmony to improve circumstances for those receiving their care.

Sue Hughes, a district nurse taking part in the initiative agrees: “We are just a team now,” she says. “We understand the pressures we each face day to day and we support each other. It’s hard to ever imagine us going back – and I don’t think it could work.”

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Linda turned up at A&E twice a day. A dedicated team now stops that