It’s two years since All Together Better was launched in Sunderland – a programme bringing together health and social care, designed to improve the lives of people in Sunderland who need it most.

The programme – which aims to get some of the frailest people in the area back on their feet as quickly as possible and to promote independent living – puts GPs at the heart of patient care, working as part of five locality teams to provide community-based support to people with the greatest health and social care needs.

We speak to Houghton-le-Spring based GP Dr Jane Halpin, to find out the difference that All Together Better is making to the lives of people in her locality. 

Dr Jane Halpin is a busy GP based at Herrington Medical Centre.  Working as part of the Community Integrated Team in the Coalfields, Jane has seen a huge difference to the quality of care she is able to offer to older people in the area, thanks to All Together Better.

She said: “Ask the majority of 85, 90 year olds, do they want to go to hospital if they become unwell and most would look at you in horror.  That question wasn’t being asked three or four years ago.  And that’s what the vanguard gives us the time and space to do.  To follow through with patient wishes and be able to deliver what they want – and it’s priceless.”

Jane also works with the care homes in the local area, supporting them with weekly visits, where care professionals can highlight any concerns to Jane, who is able to carry out an immediate assessment and ensure the person gets the right support to get them back to their best again.

Jane comments: “Before All Together Better, care was disjointed and there was no real continuity of care.  Now, issues can be saved up for when I visit care homes once a week and we can make better informed choices for patients.”

All Together Better was designed to provide new and innovative ways of improving care while easing pressures on the NHS and social care services.  The additional support that is being afforded to care homes, where many of the city’s most unwell people live, includes additional technology known as NEWS, which allows professionals to build a clear picture of someone’s condition and seek appropriate help if the person’s health deteriorates.  They also benefit from weekly visits from care home nurses, to offer additional medical support and have introduced care plans, which ensure that a patient’s wants and needs are respected during times of crisis.

Lisa Reed, senior carer at Springfield Care Home, which is aligned to Dr Halpin’s surgery, said: “Most of our residents now have an emergency health care plan with details in of what their – and their family’s – views are on going to hospital or staying at the home if they become really unwell.  This saves residents going to hospital and having to wait in A&E for hours before they’re seen.  Instead, we call Recovery at Home if someone needs urgent support and we try to keep them at the home and provide support there if that is what the person wants.”

Knowing Dr Jane will be visiting once a week means Springfield Care Home works in a more efficient and streamlined way.

“It helps that we are run with the Coaflelds and that Dr Halpin comes in weekly to check patients – that’s really good.  She’ll check whoever we need her to each week, so it is better for us as a care home, as we don’t need to keep calling doctors out, and it means residents don’t have to leave the home to be seen,” Lisa adds.

Funded by NHS England, All Together Better is one of 50 national NHS vanguards and consists of three main parts; Recovery at Home, Community Integrated Teams (CIT) and Enhanced Primary Care.

The programme is making a huge difference to the lives of people in the city, as well as their families.  Helen Gray, communications manager at All Together Better, is one such family member, who witnessed first-hand how GP alignment helped make her mother Rita’s move to a new care home easier and more comfortable.

Helen said: “My mam has advanced Alzheimer’s disease, and with all of the family working and her needing special care, a care home made a lot of sense. Having mam in a home put all of our minds at ease knowing she had someone there 24/7,” explains Helen

“It’s hard making the decision to move  a relative into a care home, and while I had knowledge of what was planned and what was in place because of my work on All Together Better, it was interesting to observe the processes from the other side.”

Through the move, Helen saw how All Together Better is working for those who need extra care.  Helen and her sister, Sharon, were directly involved in the process of drafting Rita’s Care Plan; this enabled them to discuss how Rita would be cared for in an emergency, with her best interests put first.

“It was really important for me to know there would be full support out of hospital as, even with planned appointments, my mam can get very distressed and anxious when she is outside the home. Having regular visits by her GP, a major community based health, social and mental service available through the community integrated team and properly trained and supported staff in the care home means a lot.

“Mam is so settled and well cared for – it is such a relief.”

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