Joining up care in Derby and Derbyshire - a case study for the NHS England Integrated Care Bulletin - a fortnightly update on integrating health and care across the country.
A forward-thinking integrated care programme in Derby and Derbyshire is creating the conditions in which primary care networks (PCNs) and local place alliances are able to introduce innovative new roles in the community.
Team Up Derbyshire is an ambitious programme seeking to establish one team across health and social care that sees all housebound patients in a neighbourhood. The team covers urgent, planned and preventative care. It is not a new or ‘add on’ service, but a ‘teaming up’ of existing resources.
Team Up integrates general practice with community providers, mental healthcare providers, adult social care and the voluntary sector. It brings together home visiting, urgent community response, enhanced health in care homes, and anticipatory care (all aspects of the national Ageing Well programme).
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. Team Up is an integral part of Joined Up Care Derbyshire, the local integrated care system (ICS).
There are 15 PCNs in Derby and Derbyshire, covering all 112 General Practices, and they are being encouraged to explore tailor-made local solutions to the challenges of delivering the most appropriate and effective care for their housebound population.
The new roles being implemented by PCNs within Team Up include:
Getting on the front foot in providing proactive care – Arch PCN
Arch PCN (covering Alfreton, Ripley, Crich and Heanor) has appointed an elderly care liaison officer, Cheryl Stanley, to visit people in their own homes to take a more holistic assessment of an individual’s health and care needs. Cheryl, a former healthcare assistant, began her visits in May 2022 and is taking referrals from across the nine GP practices in the three neighbourhood areas, in an attempt to work with patients before they have a crisis.
Cheryl says: “GPs and nurses simply do not have the time sometimes to spend with people to listen and understand all of their health and wellbeing needs. I am in a privileged position to be able to sit down with someone in their own home and build up a rapport with them. The time needed varies – from about half-an-hour to more than two hours on one occasion – so I can fully understand what a person needs to help them feel safe and as independent as possible.”
Arch PCN is currently revising how Cheryl identifies and works with her caseload of referrals. Initially, by using an elderly frailty index, she was being referred to GP practice patients who were known to, and already in receipt of, a number of health and care services. However, the aim is to link her up with individuals who might not be on the radar of so many services, so that an intervention, or interventions, can take place before the presenting situation escalates further. In this way, Cheryl can work with individuals to better understand their specific needs and address them, through a variety of ways including completing respect forms, organising support equipment, linking up with befriending or respite services or referrals to other services.
Offering GPs a different way of working – Derby City PCNs and Chesterfield and Dronfield PCN
PCNs across Derby and Derbyshire are promoting the opportunities and benefits of becoming a community general practitioner (GP). The innovative role provides the chance for GPs to develop flexible, portfolio careers working alongside their health and social care colleagues in multi-disciplinary teams in the community.
A number of individuals have already begun working as community GPs in PCNs in areas such as Chesterfield and Derby, and within Derbyshire Community Health Services, but there are vacancies for more to join, with the opportunity of selecting sessions to fit in with other career commitments. A community GP oversees a team of community-based professionals who provide personalised care to the housebound, carrying out some visits themselves and supervising the visits of their colleagues. It is both a clinical and team leadership/supervisory role.
Dr Amy Lampard, a community GP with Chesterfield and Dronfield PCN, said: “This model of working allows the community GP and team members to take a more holistic view of the person they are caring for and allows for greater continuity of care. The care provided tends to be more joined up between disciplines, where you can really get to know the patient, and often by doing so, we can anticipate the individual’s care needs before any concerns escalate.”
A new video featuring community GPs in Derby and Derbyshire discussing the benefits of the role is now on YouTube.
Bringing new skills into primary care – Derbyshire Dales PCN
PCNs across Derby and Derbyshire are currently advancing their home visiting services – in Derbyshire Dales the service is being led by a community GP with the support of a number of different professional roles including paramedics.
A comprehensive induction programme was prepared for the four paramedics joining the team to support their transition from the ambulance service to primary care.
Alex Guevara, operations lead for Team Up Derbyshire Dales, who has worked as a paramedic and clinical practitioner, says: “Paramedics are an obvious choice to play a key role as they are already very capable of providing a high standard of care to those in their own home. Our new service allows them to spend more time with patients in order to identify needs other than the more obvious medical care.”
All members of the multi-disciplinary team providing the home visiting service have been brought together at a hub at Whitworth Hospital, Matlock, with local care partners such as local authority social care and Derbyshire Community Health Services which already provide some of the Team Up services.
Alex adds: “This allows us to bring everyone together under one roof. The different members of the team will be able to talk about the care that the patient requires and refer to different services. This is linked into the holistic perspective of the service where someone can take the time to sit down with a person and identify all the areas in which they might need support.”
Feedback on the new approaches
Initial feedback on the home visiting service has been very good. In Derby City, 98% of people receiving the service said they would recommend to friends and family. Erewash carried out a patient questionnaire in 2021. Of the 21 respondents, over 95% rated ‘I always felt my views were being considered when planning my care’ - as either agree or strongly agree. 95% rated ‘I trust the people supporting me’ - as either agree or strongly agree. A survey of local health and professionals in Alfreton, Ripley, Crich and Heanor found 100% of staff rated the Team Up home visiting service as positive (with 85% saying it was very or extremely useful).
Dr Ian Lawrence, clinical lead for Ageing Well and Team Up Derbyshire, said: “The thing I am most proud of with Team Up Derbyshire is that we have created the conditions for local teams to figure things out for themselves and to learn from each other. It hasn’t always been comfortable, but these innovations are testament to the power of this approach. We haven’t always got what we expected, but that is usually because a local team has come up with something better than we could have planned.”
Next steps
Following the success of initial Team Up implementation, there are plans to expand the remit of the programme, making better use of strengths-based approaches, changing not only the delivery of services but the culture and mindset involved. This is likely to include areas such as personalisation of care, having ‘quality conversations’ and social prescribing. Team Up aims to bring in more aspects of population health management, an area which will greatly support plans for prevention and anticipatory (proactive) care. In addition, there is the possibility of developing frailty virtual wards and a frailty front door approach.
Further information
For further information about Team Up Derbyshire and Ageing Well, please contact:
Helen Baxter, Deputy Ageing Well Programme Manager, helen.baxter@nhs.net
