Making a difference: our stories of integrated care in action
As we build on the good work that is taking place across Lancashire and South Cumbria, it is becoming more important for us to share the stories of how our partnership working is having a positive impact on local people. Below you will see some examples of how our partners are working together to improve services and outcomes for our local communities.
COVID virtual wards (focus on Pennine)
East Lancashire Hospitals Trust, East Lancashire CCG, Blackburn with Darwen CCG and Primary Care worked together to provide an at-home monitoring service for people vulnerable people with a positive COVID-19 test result or clinical suspicion of having COVID-19 illness. Patients are identified as being clinically vulnerable to developing low blood oxygen levels due to age, a pre-existing condition or other significant risk factors.
To avoid patients being admitted into hospital, they are given a pulse oximeter and patient diary at home to monitor their oxygen levels in their blood. They are in daily contact with health care professionals, either by phone, video consultation (or a home visit if required) who provide physical and psychological support. This provides a reassurance to the patient which includes emotional and practical support whilst they are unwell.
Diabetes Community Clinic (Fylde Coast)
Primary Care, Blackpool Teaching Hospitals and Lancashire and South Cumbria Foundation Trust staff have come together to provide a ‘one stop shop’ for diabetes patients to speak to a range of health professionals to get advice about how to manage their diabetes.
Referrals are made for diabetes patients to access the community clinic who can then choose which health professionals they would like to speak to, including a diabetes consultant, diabetes nurse, GP with special interest, dietitian and podiatrist.
This joined up approach means that patients can get help and advice quicker and are not signposted to a number of different services over time.
Winter Ready (West Lancashire)
A West Lancashire partnership, including West Lancashire Borough Council, West Lancashire CCG, West Lancashire CVS and Primary Care worked together over the winter months to help mobilise and support the local communities to be prepared for winter.
Patients were identified using a data analysis tool called Nexus as being high risk of severe complications if they got COVID-19. GPs wrote to those identified with a recommendation to contact the Winter Ready team to help them to improve their overall health and reduce risks of serious illness. A communications campaign ran alongside this to encourage all members of the population to utilise the service.
Virtual outpatient appointments
At the beginning of the COVID-19 pandemic, it was necessary for the hospitals across Lancashire and South Cumbria to deliver virtual clinics. The four Trusts, Blackpool Teaching Hospitals, East Lancashire Hospitals Trust, Lancashire Teaching Hospitals & University Hospitals of Morecambe Bay worked collaboratively to quickly put new digital systems in place.
The joined up approach to using video consultations for scheduled clinic appointments was a key milestone as part of the response to COVID-19 and received great feedback from staff and patients.
More than 14,800 virtual clinics were delivered between April and June 2020, totalling more than 6,000 hours, to make sure local patients got the best possible advice and support from their homes at an unprecedented time.
Homelessness partnership working (Morecambe Bay)
A collaborative partnership between Bay Integrated Care Community (ICC), Lancaster and District Homeless Action Service (LDHAS), Lancaster City Council (LCC) and Hope Church Lancaster enabled the co-ordination and delivery of services to rough sleepers and homeless people, ensuring they had access to health care during the COVID-19 pandemic.
LDHAS identified people who needed support, LCC identified temporary accommodation and the Bay ICC team identified practices that could support homeless people placed in temporary accommodation. This included establishing a COVID-19 testing pathway for people placed or living in a multi-occupancy facility.
Most homeless people are not registered with a GP, so this support meant that some of the most vulnerable people in the community had access to services that they wouldn’t have previously been able to access, with potential to end their rough sleeping. The testing also reduced the risk of community transmission of COVID-19 amongst a vulnerable population.
Central Allocation Team for Care and Health (Central Lancashire)
Primary Care and Lancashire Teaching Hospitals work together to provide a community-based single point of access for health and social care intermediate care services. Central Allocation Team for Care and Health (CATCH) is a multi-disciplinary team who manage demand and oversee capacity within intermediate care.
Referrals can be made into the service every day between 8am-8pm by GPs, the Integrated Discharge Service, Integrated Care Teams and Social Workers and this helps to avoiding hospital admissions where they are not needed.
Myplace Ecotherapy Project
Lancashire Wildlife Trust has been working in partnership with Lancashire and South Cumbria NHS Foundation Trust since 2016 to deliver an ecotherapy project that helps people reconnect with nature in a gentle, participant-led way. The project was first launched five years ago after a successful bid for National Lottery funding to work with children and young people and following further successful bids and funding support, the initiative has since expanded to benefit adults now too.
During lockdown, Myplace continued to run online sessions and phone calls along with resources for people at home. The project won a prestigious HSJ Award for 'Mental Health Innovation of the Year' in March 2021 in recognition of the incredible work of Myplace, particularly over the last 12 months. Read more about the award >>
People living in Lancashire can refer themselves to the project or they may be referred by their GP or mental health team. The initiative provides non-clinical support for mental health and helps to reduce social isolation. Research has shown that the types of activities run by Myplace can reduce stress, anxiety and many low level mental health conditions whilst also improving physical fitness, health and wellbeing.
Orange Button scheme
A partnership of NHS and voluntary, community, faith and social enterprise groups in Lancashire and South Cumbria worked together on a community scheme to help people struggling with their mental health.
The orange button is worn by people in Lancashire and South Cumbria who have undergone extensive suicide prevention training, and while they are not able to counsel people, they can provide comprehensive signposting to relevant services. People who are having thoughts of suicide, or who are worried about a friend or family member, can ask for information and support from anyone wearing the orange button.
The Orange Button is an instantly recognisable symbol and offers an easy way to ask for help. Anyone in the community with training in suicide awareness can help people struggling with mental health to access immediate help and support.
Single maternity record system
NHS Trusts across Lancashire and South Cumbria have worked together to establish a single maternity record to enable pregnancy notes to be shared between hospitals and health services.
Software is rolled out to the four hospital Trusts across Lancashire and South Cumbria so that data can be shared across all organisations, wherever the pregnant woman is.
This means that mums-to-be will only be asked for information once and will no longer need to carry their paper record with them at all times and time is saved for staff.
LSCFT Resilience Hub
Lancashire and South Cumbria Foundation Trust (LSCFT) offers a support resource for all public sector workers and volunteers who have worked through the COVID-19 pandemic.
Anyone working in the NHS, local authorities and councils, ambulance service staff, care home workers, those working in social care and community workers can call a number or email the team to receive psychological support.
The resource is there to support everyone who has felt the psychological strain of COVID-19 and give support to those in need of extra help and guidance on their wellness, people who need urgent psychological help and also support people who aren’t sure what they might need.
Lancashire and South Cumbria Vaccination Programme
Partners across Lancashire and South Cumbria have worked together since December 2020 to deliver the largest vaccination programme in the history of the NHS. The NHS locally, regionally and nationally is leading the work with significant support from local councils, hospital trusts, Primary Care Networks, pharmacies, volunteer organisations, the military, police and many more.
By working together, these partners have been able to deliver the biggest and most highly anticipated immunisation campaign in history with Covid-19 vaccinations taking place at large-scale vaccination centres, hospital hubs, local GP-run vaccination services and local pharmacy-run vaccination services.
Vaccine hesitancy in ethnic minority communities
Early in February 2021, a number of anecdotal reports were shared with the Lancashire Resilience Forum (LRF) BAME cell that ethnic minority communities in Lancashire and South Cumbria were Covid-19 vaccine hesitant, and this was impacting on vaccine uptake in those communities. Some of the challenges included reports of false information being shared in communities, low levels of trust in official information sources, and a lack of information in community languages.
Following this, measures were put in place to increase understanding and confidence in the vaccine which included local community leaders being filmed having their Covid-19 vaccinations, vaccination clinics in mosques in areas of low vaccine uptake, increased engagement with systematically marginalised communities e.g. Gypsy, Romany and Irish Travellers, Black Afro-Caribbean, Chinese, refugee and asylum seeker communities, and a three-month independent research project looking at the factors behind vaccine hesitancy in ethnic minority communities.