>>Janice James : We have such a huge problem now we have to move from what I call this
episodic care into this long term lifelong care - and actually you cannot do that alone.
>>Michelle Airey : Those residents that used to be in hospital are now in nursing homes,
and those residents that used to be in nursing homes are now in residential homes, but the
skillset hasn't changed
>>Lesley Bainbridge : We've got a health and care system that's set up to look after people
with single system diseases and we're trying to squash people with very complex needs into
single system disease boxes and it just won't work.
>>Janice James: I always want to create legacy. To leave something better than we actually
came into.
>>William Roberts : I think people can really see the differences this is making. I think
especially for clinicians and managers it's really tangible and real.
>>Rachel Binks: I've been in nursing for over 30 years and I think this is the biggest innovation,
but the most simple innovation actually,
>>William Roberts: It doesn't feel like something where you're writing a plan, or sitting in
a meeting, it actually feels like real change happening on the ground.
>>Janice James: I really feel we're making a difference
>>Lesley Bainbridge: At last, more people than us the specialists are interested, and
everybody's getting to know this is everybody's business
>>William Roberts: We know people are living older and we also know there are challenges
in terms of the aging population needing car for longer, but we also see that there are
some challenges for the providers being able to live within the funding they receive, and
also in terms of families no longer live with people as long as they used to, so we need
to think about different ways of society supporting people to live healthy long lives.
>>William: There are six vanguards. They've been working together to identify what are
the things we're going to do to improve the health of people in care homes. We've identified
seven things you need to do in your local area to improve that health.
>>William: One of those key elements is enhancing primary care - and you do that by joining
up all the people who deliver care.
>>Sarah Stacey: Here in Sutton our vanguard is focusing on joined up care. What we're
trying to achieve is that the resident is at the centre of everything that we do and
we all work together as a team to improve the life of that resident in our nursing home.
>>Sarah Stacey: It may not be that we all sit together in a meeting discussing that
resident but it's all about communication and sharing information.
>>Physiotherapist: So I just wondered about this gentleman, what pain relief he's on
>>Care Coordinator: This gentleman is on Paracetamol
>>Sarah Stacey: The care coordinator is a really important role. Their role is really
sort of pulling everything together.
>>Care Coordinator: How's he doing
>>Physiotherapist: He's doing well
>>Sarah Stacey: It's about spending more time with the residents. It's about spending more
time with the residents' families. And it's having that extra time off the floor to dedicate
to that role.
>>Care Coordinator: Still in pain!
We also have link GPs dedicated to the residents at this home. He comes in on a weekly basis.
The care coordinators prepare for his round. We discuss with him, the families have got
access to him. It's a longer round. It's much more valued time now. He's reviewing more
residents as well.
>>Sarah Stacey: To me one of the great successes of this vanguard is the red bag. It's as simple
as a red bag. But what's really important is the pathway and the paperwork that goes
along with the red bag.
>>Sarah Stacey: It was born at Crossways out of a meeting we held with the hospital. What
was going wrong I think people were going to hospital from care homes, their information
wasn't been transferred
>>Carer: We need to sort out what you're taking
>>Sarah Stacey: We put people's belongings, we put a change of clothing, primarily for
when they're discharged because before, I'm sure everybody's seen it, patients being discharged
in gowns, We put their personal belongings in it but most importantly we put the paperwork.
So what the resident is normally like, we also put in a social history. These things
are really important.
>>Carer: Everything packed up there.
>>Sarah Stacey: So everything's handed over to the ambulance service. They then take it
to the hospital. That's handed over to the hospital. If somebody's admitted that's handed
over to the ward. It's literally about this red bag following with the patient the whole
way through the journey.
>>Jacqui O'Connor: When I have a sepsis attack, I really don't know anything about it. All
I know is the red bag has travelled with me in the ambulance. The red bag gives my family
the security of knowing that all the information that is in the red bag will have helped me
>>Jacqui O'Connor: Right from the beginning of the vanguard meeting, I attended and have
always been involved from then on. If there's only the voice of the manager, they don't
hear the voice of the people.
>>Sarah Stacey: I'm really proud of the relationships we have with the multi-disciplinary team,
but most of all I'm proud that the residents' life is improving in the nursing home.
>>William Roberts: It's really important to get people working together and build strong
relationships between staff delivering care, but on top of that we also need to break down
barriers to help organisations work together if we really want to make this work.
>>Lesley Bainbridge: What we've done in Newcastle and Gateshead is to bring together all the
organisations, and importantly all the disciplines - that's the people who our patients and their
families would meet on their care home journey. And the reason that we've done that is that's
the best way, the very best way to make sure they get the best care.
>>Lesley Bainbridge: Moving on to the main part of the session - we're going to review
our end of life work plan.
>>Lesley Bainbridge: So we've got nine organisations representing eight disciplines that come together
as a Pathway of Care Team. What's great about it is having all of that expertise - all of
that knowledge, all of that understanding in a room in one go.
>>Nurse: We're going to try and offer two monthly palliative care meetings with the
older person's nurse in the homes
>>William Roberts: We know that if you're going into a care home you're likely to be
in the last years of your life. Therefore it's really important to bring all the different
people together to support you to get your end-of-life care wishes met. The vanguards
have worked really hard to do this and see it at the centre of their local care model.
>>Lesley Bainbridge: Every week we have a Pathway of Care Meeting and we focus on a
different element of work.
>>Care home manager: Until I started coming to the meetings I didn't even know you were
out there in Gateshead.
>>Lesley Bainbridge: It's conversational leadership - that's what it is. Its everybody coming
together, learning from one another and going out and being a frontline leader. Because
we need leadership at every level.
>>Lesley Bainbridge: We could take that patient story that you've shared - if we could use
that as a base to maybe think about what the pathway needs to be
>>Lesley Bainbridge: The workforce is much better equipped because of the learning. So
their knowledge and skills are greater. And it's joined up.
>>GP: I couldn't really understand why but they seemed a bit reluctant to have her back.
>>Lesley Bainbridge: The relationships are better -because we don't just need relationships
with our patients and their families on an individual basis. We need the whole system
to have relationships. And that's what we get through all of us coming together.
>>Lesley Bainbridge: There are definitely less people going into hospital, there are
less people in A&E departments, and there's more care being provided in the community
that would have traditionally once have only been provided by secondary care.
>>Lesley Bainbridge: Anyone can do what we've done. Anybody. All you need is for organisations
to know their best people. Know their people, their best people to field.
>>William Roberts: One of the key things we can do is to keep people in the community
for longer, to support them to stay at home through re-ablement and rehabilitation. But
once they go into those care homes, allowing them to have opportunities for the community
to come in and work with them. To bring in the community to wrap around to be part of
the care home
>>Janice James: One in 25 people move un-necessarily into a care home when they could have been
supported in a more independent setting. That's absolutely what Wakefield care homes vanguard
is about - maximising people's independence for as long as possible.
>>Janice James: The asset-based approach. Working with our community, working with our
volunteers, really helps that sort of mental wellness, which obviously impacts if it's
not right negatively on the physical health.
>>Janice James: We have organisations called Community Anchors. So Community Anchors are
physical buildings located right in the heart of the community. And they put stuff on - for
people in the community.
>>Lesley Wagstaff: Being part of the vanguard means we go into a local independent living
scheme. We have a team of volunteers who deliver lots of different activities.
>>Volunteer: She gets a lot of reward just by mixing and coming out of her house.
>>Lesley Wagstaff: So it just helps to combat some of the social isolation that some of
these people sometimes feel.
>>Volunteer: There's a lunch club on a Tuesday that Jean could come to.
>>Marjorie Smith: I'm Marjorie - and I've been living here nearly two years. And I'm
90 years of age.
>>Marjorie Smith: Somebody told me, when my husband died, if anybody asks you to go out,
anywhere go - because they won't ask you again. So I do that.
>>Marjorie Smith: We do get encouragement. Yes. Lots of people come from the NHS and
we get clothes parties, and jewelry parties, all sorts of things.
>>Lesley Wagstaff: The volunteers are actually becoming a part of these people's lives. And
it's a very important part of a holistic, well-being approach.
>>Janice James: We're seeing the multidisciplinary clinical teams really understanding and valuing
what our community groups can offer.
>>William Roberts: Technology is really important to you and I, but it's also really important
if we want to deliver better care in care homes. It allows us to take care into the
care homes from elsewhere in the NHS but it also allows us to join up information to make
better decisions about the care we provide.
>>Rachel Binks: Since 2011, we have run this 24/7 clinical hub, which means care homes
and nursing homes can access us 24 hours a day, 7 days a week, 365 days a year - and
they get a clinical response to any kind of worry that they have, any question that they
have.
>>Call taker: Hello - I'm Louise, how can I help today?
>>Carer: This is Eric Pickles,
>>Call taker: Hi Eric
>>Eric: Hello thre
>>Carer: Eric's been quite withdrawn over the last 24 hours.
>>Rachel Binks: The staff that are answering the calls are a mixture really of different
specialities. All registered practitioners
>>Carer: His diet and fluid intake has been in decline slightly.
>>Call taker: Eric can you tell me a little bit about how you've been feeling today.
>>Eric: I was a bit lethargic
>>Rachel Binks: The care home staff in terms of benefits can get a call answered immediately.
If they've got a worry and they're not sure whether they need to get the GP of a district
nurse, or they can deal with it themselves, then we can give them the answer to that and
we can actually give them support to deal with that issue too.
>>Call taker: What I want is the staff to start monitoring your input. How much you're
drinking and how much you're eating throughout the day.
>>Rachel Binks: In terms of the benefits for the residents, mainly it's the fact that they
don't have to travel anywhere, so we actually take the care to them.
>>Dr Sheila Jackson: For the carers, they have the confidence of immediate access to
competent advice, they don't have to wait hours for a GP or an out of hours doctor.
For us, there's a huge reduction in workload because we're avoiding visits, and it's benefitting
our other patients too because we don't have to rush out in the middle of surgery to see
a poorly patient in a care home.
>>Carer: Do we need to inform the GP?
>>Call taker: At this point no - just continue to observe and obviously if there is any change
at any point then by all means get straight back in touch
>>Rachel Binks: I've been in nursing for over 30 years, and I think this is the biggest
innovation, yet the most simply innovation actually, and what it's all about is all of
us all doing what we do really well, but doing it much better more efficient way using the
technology that's out there.
>>William Roberts: The people who deliver our care at the staff - and
if we don't get their training and development right, they're not going to be able to deliver
great care. We have some brilliant staff in social care, and the work of the vanguards
is looking at how we can make them even better and deliver high quality care to the residents.
>>Michelle Airey: East and North Hertfordshire are up-skilling residential care practitioners
so that they can better care for residents with complex needs and prevent them from being
admitted to hospital or using urgent care services and keeping them in their homes.
>>Michelle Airey: If we can make the staff who are currently in the homes feel more appreciated
and more empowered, they want to stay in those jobs.
>>Michelle Airey: On the ground we do lots of training around particular subject areas
because we feel that you should have a 'go to' person in your home - for example dementia.
You have your dementia champion in your home. That person can mentor you, that person can
coach you if you have something you want to talk through or they can train.
>>William Roberts: High quality dementia care really matters in care homes. Nearly 80 per
cent of all residents will have a dementia diagnosis. And we know you can make a really
big improvement to people's care by being able to deliver high quality dementia specific
care to them. The care homes work has really started to look at how we do that systematically
across health and social care.
>>Kelly Crawley: It's nice to give us more knowledge and more power so we can spread
that out to the care team.
>>Michelle Airey: The benefits that we really see already is how confident the staff feel.
You give them that extra competence and all of a sudden they feel that they can talk to
GPs about their residents and GPs believe they understand what they're talking about.
Their confidence and competence levels have sky rocketed and it's really benefitting the
residents.
>>William Roberts: So you can do all sorts of things, you can improve care, you can get
people to work together, you can bring organisations together - but if you don't get the people
who have the money to come together and work together it isn't going to last. It's really
important that we work with our providers and bring together the commissioners, so that
when we make decisions, those decisions will have the money in the right place to deliver
the care that we need to the right people at the right time, at the right price.
>>Jane Godden: Back in 2012 we had a care home closure that happened very suddenly,
very quickly, with a significant number of residents having to be moved out of a home
over a weekend. It was made even more complex by that fact that we had two separate contracts.
Two lots of quality monitoring information and data - and it was the main motivation
for us to look at how we could do things differently moving forward.
>>Steve Oakley: The City Council was already doing its process to re-procure the services
for care homes and it was then a thought that actually if we're going to do this together,
let's do it together as a joint contract.
>>Jane Godden: Here in Nottingham I think we were really fortunate because we have a
long history of partnership working. And because we had that really senior management commitment
and support to make it happen, we were really keen and I think we all had that can do attitude
right from the very beginning to make it work
>>Steve Oakley: The benefits of undertaking this is we've got the one process, one contract,
one specification that we can use. It really helps us to improve quality of care by working
together. In the past we didn't have that, we were working in silos, we had our own performance
management approaches and we didn't see benefits across the whole city and it really has changed.
>>Jane Godden: It's brought care homes much more into the limelight than they were previously.
They were probably seen as a bit of a Cinderella service operating slightly to one side of
the NHS. They're just as important as hospital beds. It's where all our most vulnerable residents
are obviously going to spend, potentially, the rest of their lives. We want to ensure
they've receiving good quality care while they're in those homes.
>>William Roberts: I think if we don't spread this, we don't get wider adoption we miss
a huge opportunity to really make a difference.
To deliver better care for people in home care settings. To miss that opportunity would
be a real shame.