From helpless to helper – patient’s remarkable recovery thanks to Integrated Care



A health initiative for patients in the Bradford district has proved to be a life saver – for patient Carol, 52, from Bradford. She has recovered from debilitating depression and is now working as a volunteer in a community centre – and it’s thanks to the care and support she has received from several organisations working together on the Integrated Care for Adults programme.

The programme is run by local providers of health and social care, including Bradford Teaching Hospitals NHS Foundation Trust, Voluntary Services, Bradford Council, Bradford District Care Trust and the new clinical commissioning groups (CCGs). It aims to foster co-working and communication between the different organisations that provide support to Bradford residents in order to provide a joined-up, holistic approach to care within communities and prevent the need for stays in hospital.

“Working in an integrated, or joined-up way helps organisations to support people as whole individuals, rather than focusing on only one part of the person at a time, such as their heart, their feet or their home care needs,” says NHS programme manager Walter O’Neill.

“This is the key to ending the cycle of dependency and hospital admission that some people find themselves in. Carol’s case is a perfect example of how the input of different organisations has helped her to overcome her health problems in the community, without the need for hospital care.”

Carol recalls: “I went to the doctor with depression and suicidal thoughts. I was basically going downhill and something needed to be done about it.” She had become socially isolated and also suffers from a number of physical problems, including long-term conditions and lower back and ankle problems. Carol was referred to Health on the Streets (HOTS) – a multi disciplinary team providing a range of services and support, including signposting to local groups and activities.

She was given a number of counselling sessions, adapted to her particular needs, and she also received a home visit from a HOTS worker who helped Carol identify which groups and activities could offer her the support she needed. One of those was the Young at Heart group that Carol now attends at the Rockwell Centre in Thorpe Edge. The group is a social support network for people over 50. “It’s been a life saver. I’ve gone from not having a network to having a network,” says Carol.

At the same centre Carol also became involved in the Live@Home ‘Good Neighbours’ project – a vulnerable people’s support service. As part of the project, Carol receives regular telephone calls from winter support coordinator Jacqueline Howcutt, which have been an important contributing factor to Carol’s recovery. “It’s having a network of people who care and they do, especially Jackie – I get a telephone call from her most mornings, checking if I’m alright and asking if I need anything.”

As part of the project, Carol’s driveway was cleared during snowy weather. “It was brilliant because the night before they did it, I’d actually slipped and realised how important it was to have it done because, even now, my back still isn’t right after that slip. It made think that if they hadn’t cleared the drive, I would have been slipping continuously, and I don’t think I’d be walking now if I had,” she says.

“It’s extremely rewarding to see Carol’s progress thanks to our input on the Good Neighbours project,” says John Sheen, community development manager at the Rockwell Centre. “Carol is one of over 40 isolated or vulnerable people we have helped. We have been able to offer daily phone calls, snow clearing, hot meals delivery, odd jobs, transport to appointments and home support visits.

“We have been able to respond to all referrals from the Integrated Health and Social Care team. The uptake has been very good and the service has been very well received by the users, who have given excellent feedback. A big thank you to the NHS and Bradford Council for all their support which has made this project possible.”

Carol is still on medication and dealing with her depression but she is no longer suicidal, and she is re-building her confidence, so much so that she now volunteers at another community centre. “I’ve started to facilitate regular coffee mornings. So basically I chat with people to find out what they want in the area.”

She is no longer socially isolated and is thankful for the help she has received. “I now know there’s all that support I can have, and that inclusion I can have. It’s supportive, it’s reactive and it’s value for money. I could have ended up in hospital, ended up taking a bed. I could have gone downhill and ended up on more medication than I’m currently on. And I’m sure if you add it all up, the cost of the care I’ve had will be less than a bed in hospital or other health facilities.

“It has helped me a lot. It has helped me to realise that there are people who care and are concerned. It’s what should be happening to vulnerable people who are socially isolated and need support and help.”

Walter O’Neill says: “Integrated care involves identifying people like Carol – with the most complex and high risk needs – and helping them to remedy issues before they become urgent and lead to unplanned hospital or care home admissions. This is a popular approach because, not only does it enable people to continue living at home, with all the things that are important to them within easy reach, it keeps hospital beds free for genuine emergencies.

“Integrated care has a strong focus on helping people to have clear plans to help themselves, as for every hour a person might spend with a health or social care professional, they will spend many more with their own families or by themselves. This approach makes good use of the variety of voluntary organisations that are present in every community, and helps to build friendships and relationships that reduce dependency on public services.”

The teams responsible for aiding Carol’s recovery are just one of numerous initiatives in the district that aim to provide care within communities and prevent avoidable stays in hospitals. Groups of GP practices have come together to work with community nurses, social services and voluntary groups to help coordinate better locally based care across organisations. Other initiatives include:

The HALE Project (Health Action Local Engagement) in Shipley has been conducting outreach work to help manage and prevent diabetes and cardiovascular conditions in the Manningham and Frizinghall areas. Using their Mobile Outreach Venue (MOV), workers have gone into the community to provide in-depth information about diabetes; what it is, how it affects health, how to prevent it, etc, as well as signposting to appropriate services and local groups.

Great Places to Grow Old is a programme lead by Bradford Council. It aims to combine a range of housing options with social care, health and community support to enable older people to stay independent and well, thus avoiding the need for residential or nursing home admissions. The programme will also improve care and support for people with dementia. The programme wants Bradford’s older people to make great lives in great places, whatever challenges life brings.

Bradford Teaching Hospitals are running a Virtual Ward pilot scheme to support elderly patients and those with some long term conditions. The patient’s home becomes the ‘virtual ward’, where they are visited and treated by hospital staff (nurses, physiotherapy and occupational therapy, and consultants) in order to support their discharge from hospital, or avoid being re-admitted or admitted in the first place.