Real integration? A new way of supporting older people in Doncaster

“We could to that.” I whispered.

I was sat next to Dr Rod Kersh, Consultant for older people, at the Microsystems Festival in Sweden in March. We were listening to Göran Henriks talking about a mobile geriatric team and the difference it had made to keeping people older out of hospital and GP surgeries.


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“We could do that, and add in Community Circles, so that it covered health and social care. What if we used the Buurtzorg approach too?”

I was excited about the potential of a pro-active team, who worked with older people who were the two percent of people who were regular visitors to a GP’s surgery and often in hospital, to support them to stay well at home.

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Fast forward to May, and we are a few steps closer to making this happen in Doncaster, where Rod works. We are putting together a mobile team to support older people living in Doncaster, in a particular neighbourhood around a GP practice. We want to bring together three key elements:

1) Proactive health support


An advanced community clinical support service provided through advanced nurse practitioner reviews, providing support and assessment in collaboration with general practitioners and consultant geriatricians. This will examine:

  •      Falls
  •      Pain
  •      Cognition
  •      Continence
  •      Polypharmacy, drug effectiveness and interactions
  •      Advance care plans
  •      End of life plans
  •      Mobility

2) Enhanced, flexible support at home, using the Buurtzorg model

We are setting up a subsidiary of an established home care provider, Caring Hands, to deliver whatever support the person needs, use a range of person-centred practices and operating as a self-directed team. The staff would be ‘Wellbeing Workers’, salaried at above the living wage, as part of a social enterprise.

3) Co-ordinated community support

We are working in partnership with Community Circles and Age UK Doncaster to place a Community Circles Connector as part of the mobile team. This person will be the link to the community groups and resources in the area, and can organise a Community Circle for the person, bringing together friends, family, neighbours to meet informally to support the person. They will also encompass a community navigator role.

Can we go further and have a social worker as part of the team?

We want to explore this as well. Having a social worker as part of the team would enable us to move quickly if the person was eligible for a personal budget, to complete an assessment with the person and allocate an indicative budget to meet the person’s outcomes. This could also be an opportunity to demonstrate what Individual Service Funds could look like in this context, where the funding is held by the provider, and the service designed with the person. This means moving away from set 30 minute visits to create a flexible service that delivers outcomes within the person’s budget and community resources.

Outcomes

The main outcome we would hope to achieve from this collaboration would be improved experience and quality of care for older people living in Doncaster.

This could result in:

  • Reduced admission to long-term care
  • Reduced hospital attendance and admission
  • Reduced outpatient visits
  • Reduced hospital readmissions
  • Reduced length of stay in hospital, secondary or community care
  • Reduction in falls – reduction in hip fractures
  • Reduction in GP visits
  • Increased likelihood of dying in preferred place of death
  • Reduced deaths in hospital care
  • Staff satisfaction
  • Staff retention
  • Decreased staff sickness

Does it sound too good to be true? There is evidence from the team delivering this in Sweden and from the evaluation of Buurtzorg that this is possible, we have just not seen it here in the UK, and in the context of personal budgets and The Care Act. We will share our journey – highs, lows, mistakes, detours and stories as we move forward, both here, and on Rod’s blog too.

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