A more joined up approach to your care
- We want services to come together, locally, to match support to people’s needs. At present, people are often referred to a number of services.
- We want to use local information to help identify needs sooner, to improve people’s health and wellbeing. At present, people often access services too late.
- We want to focus on what matters to people when we organise support and communication for them. At present, people often feel that their care is not co-ordinated and services repeat the same questions.
Why we need to change
At the moment our community health and social care services are not joined up enough. We need to work with people earlier to promote their wellbeing and independence for longer.
How can we change?
We propose to change the way health and social care services work together locally.
Our teams have already been trying new ways of working. They started by looking at the needs of frail older people.
To make sure they offered the right support, staff focused on understanding people’s goals better and improved how they work together across different areas. These simple changes have led to quicker and better care. We have found that this has helped people to stay at home for longer. Check out Mary’s story on this page.
We now want to build on this great work by our teams and introduce this right across Fife.
We propose setting up seven Community Health and Wellbeing Hubs, based on this way of working. There will be one for each local area:
These hub teams may see you in a local community centre or in a local hospital. This means that we’ll bring more services to your local area and local teams will arrange your appointments together all in one place, where possible.
For the South West and North East Fife areas, we would respond to the rural and local needs in a different way. Our hub teams would travel around to work from different places on different days. As we develop this way of working we will spread out to support a wider range of needs, for example for younger people with long term conditions.
How our teams could work differently to benefit you
Importantly, we will discuss and agree all your care needs with you to ensure we focus on what matters to you. To help us do this, professionals in each local area will get together to jointly agree what the best clinical or social care options are for you. These meetings, known as huddles. Huddles are frequent but short briefings for teams so that they can keep up to date, review work, make plans, and move ahead.
These could include local health and social care professionals such as Nurses, Social Workers, GPs, Mental Health staff or Occupational Therapists.
The team will consider what support is available to you locally, including in the voluntary and independent sectors.
If you have more complex needs
If you have complex health and/or social care need or there are a number of professionals involved in your care, one of the team will agree to act as your Care Co-ordinator. They’ll work with you to focus on the things that matter to you, for example being able to walk to the local shop for your paper after an illness which had made you unsteady on your feet.
By introducing this new approach, we’re confident we can:
- Identify and support people earlier.
- Put services in place that can respond day and night so you don’t always need to go to hospital.
- Help local professionals share appropriate information more easily and safely.
- Make the best use of local skills, knowledge and experience.
- Link people with local support networks and services such as befrienders.
- Reduce waiting times, frustration, and duplication.
How do we know this approach could work?
We asked our teams to try it. Charlie Chung, Rehabilitation Manager at Queen Margaret Hospital talks about what this has meant for patients and for staff:
Listen to *Mary’s story, which is based on a real patient experience:
*not her real name