What does joined-up health and social care look like?
In this video Gordon Duvall shares his experience of how joined-up care enables him to look after his wife May in their own home.
Anthony Farnsworth, Chief Executive at Torbay Care Trust, talks about how joined-up care works in practice.
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Video transcript
Gordon Duvall says:
"Well, May was diagnosed with Alzheimer's disease about four years ago, when we were on holiday in Australia. She went in hospital because she developed some bowel problem and they took her in. They didn't think that she would be coming out. But she recovered and they sent her home and she has been here now, being looked after by the local district nursing.
"The doctor rings me up occasionally because he called in shortly after she came out of hospital to see her and he has been several times, but now he calls us up to see if we've got any problems or if we need any more help. So we're getting good attention from him as well. The district nurses have been very helpful really. They've been fairly consistent with the advice that they have given us and the help they've given us. It has been a lot easier dealing with them.
"At the moment, we are getting two carers four times a day, to dress her, to change her clothing if necessary, to change her bedding if necessary, and to turn her to make sure that she is not lying too long in one position. The district nurses are in contact with the doctor, yes. If I speak to him, he generally knows exactly what is happening.
"I'm very happy with what we are getting now. We're getting a lot of attention. If something goes wrong, I've only got to ring up the district nurses and something happens almost immediately. The crisis unit, they'll turn out and have turned out, whenever we have needed any extra help."
Anthony Farnsworth, Chief Executive, Torbay Care Trust, says:
"The thinking starts around Mrs Smith who is basically a patient, largely elderly, with complex needs. And we've been addressing the puzzle of how do we make the services for Mrs Smith better, how do we get them to her more quickly, how are they more integrated and how do we cut out steps in the process of helping her to get her needs met.
"And in the formation of the Care Trust, there was a very strong pressure from frontline staff saying to the council and to the NHS, that we could do this better if we were running a single system together, an integrated management structure and put the two budgets together, so that we weren't all the time thinking about what was Mrs Smith's health need and what was Mrs Smith's social care need, we were just looking at meeting her needs, whichever, whatever they were.
"And the number of steps that a GP, or a hospital, or a patient or their family, the number of steps that people have to take to get what they want, has been much reduced. We've got a system of co-ordinating that work through health and social care co-ordinators which is a role that we have developed here, which has worked very, very well - it won an HSJ award in 2008, and we're really proud that - it's a pivotal part of how we actually co-ordinate care arrangements for Mrs Smith."
Gordon Duvall, says:
"I was offered the possibility of May staying in hospital or having her care in the home. And I much preferred having her care taking place in our home, where it saves me having to go to the hospital every day. I can sit with her all day. I can spend more time with her. I can see exactly what's happening when the carers arrive. And this makes it easier for me to accept where we are and where we are heading."
