Project Description

Although colleagues across health and social care organisations are often supporting the same groups of people, they don’t always work effectively together.

Teams providing health and social care in Weymouth were working in silos, with very little joint working, and multiple hand-offs. Staff were working to the needs of their teams/services, rather than the needs of local people.

IT systems didn’t link to each other and care was often duplicated, or people fell between the gap between services, leading to unnecessary crisis and hospital admission.

We set out to address this and involved primary care, community physical and mental health services, secondary care, social care, the ambulance service, the voluntary sector and local people. Everyone played their part from the outset, with teamwork and collaboration getting us to opening day in November 2016.

Duty workers and admin coordinators are based together in Westhaven Community Hospital to make sure care is joined up.

The hub has one point of access to help avoid hospital admission and support discharge, with three health and social care co-ordinators taking calls seven days a week.

We have input from social care, community nursing, community therapy, the ambulance service, the consultant geriatrician, local GPs, community psychiatric nurse, community matrons and the voluntary sector.

There take a ‘virtual ward’ approach and do a daily ward round and there is access to step-up beds via the hub where needed, though we aim for ‘home first’ as much as possible.

With access to all IT systems for all teams and a strong belief that this is everyone’s hub, we’ve developed a can-do attitude and an ethos of no hand-offs.

For local teams it’s a central point of coordination for the locality where they can easily access information, care resources and support.The locality’s twenty nursing and residential care homes also have direct access to the hub.

Since November 2016, the hub team have been undertaking a Wessex frailty fellowship – developing a toolkit for proactive identification and management of frailty.

Transformation of services has been achieved using existing resources, by focussing on the needs of the local population and providing better care for people who are frail or have complex needs.

Over 2000 people received input from the hub in the first 12 months – the majority had Rockwood Scores of very frail and severely frail and over 90% were able to stay at home.

There’s been a four per cent reduction in acute bed days a nine per cent reduction in emergency department attendances.

GP comments included: ‘One call and everything is sorted’ and ‘We wouldn’t accept going back to how things were’.

Crucially, the hub model has resulted in excellent patient and carer satisfaction and is being seen as an exemplar. This is illustrated in a short film by NHS England called ‘Now we have help’:

Key features

• Shaping services to suit the patient not the organisation
• Co-locating to work more closely with partner organisations
• Using technology to provide one view of the patient
• Involving everyone early on and all the way through.