Team Up Derbyshire has had a helpful head-start in certain parts of the city and county which already had services running which aligned very well to the aims of the national Ageing Well programme.
In Derby City, there has been a home visiting service in place since 2018 (as opposed to the usual GP practice-delivered home visiting service) supported by a culture of strong partnership working between health and social care.
The city has 28 GP practices, serving a population of 390,000, and five Primary Care Networks (PCNs) in the city which have come together as one to further develop services; a period of closer working enhanced by the need for an effective and co-ordinated response to Covid-19.
Currently based in Derby’s Cardinal Square, the leadership team and multi-disciplinary colleagues are looking for new accommodation from which to further develop services and co-locate with the wider system team. The team is led by Dr Riten Ruparelia, a GP at Hollybrook Medical Centre in Littleover, as strategic medical director, and Janine Patton, as strategic management lead, along with five dedicated clinical leads for the Ageing Well programme.
Janine Patton, Strategic Management Lead for Ageing Well in Derby City, says: “We are fortunate in Derby that we have been providing services in a way that aligns to Team Up for several years and we are aided by the economies of scale that the backing of five PCNs brings. This provides greater flexibility in creating and filling specific roles and has brought greater recognition from partners; they are more willing to talk to us and work with us. We also have a ‘get on and do it’ culture which means we can make changes and develop new services quickly. Sometimes we are doing so much that we tend to under-estimate the achievements being made.”
Of the many initiatives in place, the focus below is on two key services provided by the team – home visiting and the complex needs service.
Home visiting
When Team Up Derbyshire was launched, the home visiting service was already being delivered across a footprint that covered 170,000 of the city’s population. This has since expanded to provide coverage across a population of 390,000.
The home visiting service runs five-days-a-week, 8am-6.30pm, and covers all people in a neighbourhood who are currently unable to leave home without support. These tend to be individuals, living at home or in care homes, with complex health and care needs. They are cared for by a multi-disciplinary team which includes GPs, community enhanced practitioners, advanced nurse practitioners, and paramedics. Following triage, the person is visited by the appropriate professional for their needs. A holistic assessment is carried out which seeks to identify and address all of their care needs.
Home visiting – patient case study
Avoiding the need for a hospital admission through dedicated patient care
An 85-year-old woman, unable to leave her home without support, had been discharged from hospital and referred into the home visiting service. The person had just had a terrible night with a very upset stomach, nausea and vomiting. The triaging GP asked an advanced nursing practitioner (ANP) to visit the patient who was an insulin-dependent diabetic and had very low blood sugar levels but did not want to go to hospital. The ANP stayed with her for 90 minutes, offered support, checked her blood sugar levels every 15 minutes and gave the patient something to eat until she felt better. The ANP gave her some medication to relieve the nausea and vomiting. The ANP advised other services that the patient’s insulin dose should be halved due to low blood sugar levels and a reduced appetite. She also asked the district nurses to check the patient’s blood sugar levels in the afternoon and evening of that day. The ANP spent 1.5 hours with the patient providing support, both clinically and socially, preventing a hospital admission and then contacting the patient the following morning to check that she felt better.
Complex needs service
The home visiting service is able to refer people into the complex needs service which seeks to take an anticipatory care approach – putting in place support to prevent or minimise care needs escalating. This service brings together areas such as primary and community care, mental health care, ambulance service, social care, housing, and the voluntary and community sector, led by a whole-time equivalent community GP.
The process for support from the city’s complex needs service is that:
1. The person is referred to the service and consent is obtained
2. The case is assessed by the community GP and specific aims of intervention identified
3. The case is brought to the city’s multi-disciplinary team’s meeting for review and update
4. The person is seen by the appropriate professional/service and referred on if necessary
5. The multi-disciplinary team reviews achievement, care provided and referrals and all other information including medication changes is communicated back to the GP practice.
The complex needs service links in with other services in the city including local area co-ordinators and the Livewell service. Local area co-ordinators are able to consider a person’s whole needs which may be beyond the immediate health and social care sector and include housing, transport and financial advice. The PCNs, through Team Up, have been able to fund three additional local area co-ordinators, employed through social care, to expand on good practice elsewhere in the city.
The Livewell service considers a person’s health and wellbeing needs, and has a public health dimension that includes areas such as support for giving up smoking or support with weight management. Funding, via Team Up, has been secured for one-day-a-week support from Livewell. In addition, via Community Action Derby, two social prescribers have been recruited to work within the complex needs service, identifying non-medical interventions, for example, helping people access befriending groups, to help with lifestyle and wellbeing needs.
Complex needs service – patient case study
An 82-year-old man, who was receiving frequent visits from carers, district nurses, a physiotherapist and an occupational therapy team and was known to constantly call their GP, 111 and DHU, was referred into the complex needs service. He was visited by a community GP, who recognised an unmet need of loneliness and isolation. The patient was discussed at the multi-disciplinary team meeting, with the agreement to explore social prescribing. The social prescriber arranged for a befriending service to see this patient. Now linked in with the befriending service, the patient is happier and has had a reduction in calls – see chart below.
Reduction in East Midlands Ambulance Service (EMAS) calls
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