NHS scheme where 'joined-up' health and care is stopping unnecessary hospitalisation

A community-based health and social care team in Thanet has succeeded in reducing ‘bed-blocking’ in the district’s busy hospitals, by integrating care workers, GPs, doctors, nurses, therapists and volunteers into a single team for the first time.

The Thanet Acute Response Team (ART) has been so successful the project is being rolled out to care homes as well.

The ART, which is based at Queen Elizabeth the Queen Mother Hospital (QEQM) and Westbrook House in East Kent, supports people who have fallen ill and are at risk of being admitted to hospital. Instead, the team treats and cares for the patient in their own home or in a community facility.

The ART has its own direct telephone number for care workers, NHS health professionals and families who may be concerned if a patient, client or loved one is becoming frail or has worsening dementia and is at risk of unnecessary hospital admission.

It has been estimated that the ART resulted in 200 avoided hospital admissions at QEQM over the winter of 2017.

‘Lack of short-term care’ leading to ‘unnecessary’ hospitalisation

The primary aim of the ART service has been to enhance the level of integration of a range of services including Primary Care, Rapid Response, Intermediate Care Team (ICT), South East Coast Ambulance Service, Age UK Thanet, Kent Enablement at Home, Pharmacy and the Integrated Discharge Team.

Dr Ash Peshen, a local GP and clinical lead for the ART, says: “Too often people are admitted to hospital because there has been no home-based service to give them the short-term care they need to recover from a period of illness or injury. That’s what we are providing with ART.”

The scheme was born out of Thanet Health Network’s frustration that patients were not always seen by the most appropriate practitioner in the most appropriate place.

It found that some patients were taken to hospital by ambulance because there was no other option and some patients were being admitted to hospital who could have been cared for in their own home.

One of the care providers, Age UK, has been commissioned for 12 hours per week to participate in the ART since its inception in November 2016. The charity has been able to provide a range of support to help people to remain at or return home.

Age UK visited one patient at home who said she was upset because the people who normally supported her were unavailable. Also, her daughter was seriously ill and unable to help her.

The patient requested information about day centres as she felt she would benefit by mixing with others. She informed Age UK that she didn’t have any food in the house.

Age UK helped her compile a shopping list and went shopping for her. The patient was referred to the Support at Home scheme and was given information regarding day centres and outreach.

Better integration between the primary community and secondary care

Mr Timson, who is a local care lead at NHS Thanet Clinical Commissioning Group and the originator of the scheme, says: “The ART was borne out of the concept of the Primary Care Home, soon to become Primary Care Networks, for Margate, Ramsgate and Broadstairs and some smaller rural areas tending to some 30,000 to 50,000 patients.”

The primary care homes model, which brings together health and social care professionals, triggered ideas about how to better integrate health and social care services on a larger scale across Thanet.

Mr Timson says one of the primary aims for the development of the ART was "to facilitate better integration between health and social care, and in terms of the health element to facilitate better integration between the primary community and secondary care".

The core ART team developed from the existing rapid response service which enabled the team to be involved in the development of the service. Financial support from the CCG was essential as was the engagement and support from other service providers.

One family member was impressed with how the local ambulance interacted with the scheme. He said: “The doctor actually phoned for an ambulance and the ambulance people, when they came out said, ‘This might be the ideal candidate for the ART team coming out’.”

‘Health and social care the norm by 2018’

In 2013 the Government announced that it would like integrated health and social care to be the norm by 2018.

Since then there has been a lot of speculation about how healthcare and adult social care services can become more ‘joined-up’, but the journey to date has been slow.

The Department of Health added social care to its title, rebranding itself as the DHSC, in January 2018. Then, one year later, under the helm of new health secretary Matt Hancock, the Department announced its long-term plan for integrating the two previously separate entities.

However, Thanet Health Network were already ahead of the curve with the ART, which was developed in November 2016, piloted until March 2017 and has gone from strength to strength in a relatively short space of time.

It was shortlisted for the 2017 NHS England Healthcare Innovation Awards and a finalist in the coveted Improving Outcomes and Reducing Variation category. The majority of feedback from the scheme has been positive from carers, clients and families.

For example, one family carer in a recent survey service valuation report said: “My husband actually went down to the GP surgery and said: ‘We’ve been told about the emergency response team, we need somebody out now to help us”.

Another person needed a personal care intervention, and although it was only slight, it has helped that person remain more independent.

The respondent said: “All I asked them to do is just mainly fill up my two kettles with water because I’m non-weight bearing on my foot and I can’t do this, because I’m on crutches...and they emptied my commode every day and they do my washing up for me and that’s all I needed really'."

However, another person said they felt the ART discouraged independence. She objected to meals being microwaved for her mother, rather than her mother being encouraged to do this for herself, saying, 'I don’t think that they should be there to do things for the person if they are able'."