Making health and social care better – together

Blackburn with Darwen Council, Blackburn with Darwen Clinical Commissioning Group and representatives from the local community and voluntary sector heard the plans at a meeting of the Blackburn with Darwen Health and Wellbeing Board last night (12 March).

Under the new arrangements – described as ‘integrated care’ – GPs and practice nurses, social workers, mental health workers, community nursing teams and other health professionals like pharmacists will plan people’s care together, making it easier for people to get the help they need in one place.

They will work together in four local areas – east, west, north and Darwen – which have been established based on the boundaries covered by groups of GP practices.

The new arrangement will benefit people with a mix of health and social care needs who have previously had to deal with two or more organisations, such as older people with long term conditions, children and young people with mental health or other complex needs and people under 65 with substance misuse or other complex needs.

The aim is to reduce unnecessary hospital and residential care admissions and prevent delays to people being transferred from health services into social care by ensuring the right support is in place in the community where they live.

It is part of a national drive by the government to encourage local health and care organisations to work more closely together. Councils and GP-led clinical commissioning groups across the country have been asked to put some of their budgets into a single pot called the Better Care Fund to pay for the new way of working.

In Blackburn with Darwen, the Council and Clinical Commissioning Group are investing £12.2m in the Better Care Fund. The money is being spent on rolling out a project which has already been successfully trialled in four GP practices in the east local area.

The scheme involved health and social workers working together to give people with long-term conditions extra support to reduce their risk of being admitted to hospital or into long-term residential care, with a single, named health or social care professional to oversee all their care. There has also been a big emphasis on helping people to understand how they can take better care of themselves and manage their own health conditions, with the support of family and friends.

The joint working arrangements will initially be extended across the rest of the east area – covering Shadsworth, Queen’s Park, Higher Croft, Audley, Guide and Intack – from April. It is expected to roll out across the remaining three areas by September.

The Council’s Executive Member for Health and Adult Social Care, Cllr Mohammed Khan, said: “This is all about making sure that support is tailored to what individual people need, in other words it’s about the person rather than the service or organisation.

“We know people do better when they can be treated and supported at home and in their local community rather than in hospital or residential care. By having one person co-ordinating people’s health and social care and helping them, with the support of family and friends, to take better of themselves, they have continuity of care and can enjoy a better quality of life.”

Clinical Chief Officer of Blackburn with Darwen Clinical Commissioning Group, Dr Chris Clayton, said: “We have been working closely with Blackburn with Darwen Borough Council to support joint working as part of our commitment to making sure that health and social care are more joined up and easier to access for people who need them.

“These localities will allow services to come together in geographical neighbourhoods in order to coordinate their patients’ care and decide which services should be delivered to meet their needs. As a result patients will benefit enormously from this more personalised approach.

“Thanks to our strong relationship with the Council a lot of work has been done on this and we look forward to these localities becoming operational once details are finalised.”

CASE STUDY

How joined up health and social works

Robert (not his real name), 62, from Blackburn, was one of the first patients to benefit from the trial health and social scheme in the east of the borough that is now being extended.

He suffered a number of long-term conditions including diabetes, heart failure and chronic obstructive pulmonary disease (COPD), but also struggled living alone and was lonely. He had visited or been admitted to hospital 17 times in the previous 12 months and made multiple GP call-outs.
Robert needed support with medication and monitoring of his various conditions, as well as social care needs such as equipment to reduce the risk of him having a fall and practical help with shopping and managing finances.

Social workers, district nurses, a community matron, mental health lead and the manager of his assisted living accommodation met with Robert and his family to plan his care together last autumn.

Regular visits by community matrons and district nurses were put in place, as well as a late night care visit to support Robert at night, when he got anxious about his health. Family members agreed to look after his budget and shopping and fall prevention equipment was provided.
During the six months that he has been receiving the additional support, Robert has had just two hospital visits and reports feeling more supported.

Find out more about how joined up health and social care works by watching the King’s Fund animation Sam’s Story at http://www.kingsfund.org.uk/audio-video/joined-care-sams-story