dedicated outreach/patient tracking

There is a gap in provision.  Overall joined up service between health and Social Services fails to respond at individual patient level, until there is an emergency.  Individuals working from GP practices, along the lines of Community Nurses/Practitioners/Matrons, could pick up on problems before they become acute. They could provide a familiar face, build relationships, and make referrals to other agencies where necessary could pick up on problems before they become acute.  The position should carry professional clout so that they can make things happen.  Some people suffering from chronic conditions become effectively housebound.  This compounds problems  - isolation worsens depression for example.  The healthcare system relies on patients as initiator, making appointments to see their GP for only 10 minutes. This typically leads to further hospital referrals in cases of any complexity. If hospital appointments are missed, patients are eventually referred back to their GP.  There's no tracking of the patient, so if the patient does not or cannot visit their GP they simply slip through the net.  Mental health patients are at particular risk. The next time the system registers them may well be when they present at A&E.  This cycle often repeats.  Social Services are not always notified and may not be unless the patient's family are articulate and aware.  Low estimations of Social Services response (beyond estimating needs) are often justified, and others struggle to provide the practical help the patient needs. In my experience (a patient with epilepsy, COPD and depression) the local hospital (N&N) has the best practice, and works sensitively, effectively and efficiently in patient outreach care.  Patient out reach care is not a core function for a hospital - but a CCG should regard it as one of their first. Social Services cannot be trusted to deliver this kind of service.  They appear to prefer strategic and oversight roles to functional service provision. At first sight, Social Servies seem the obvious choice for the lead agency in patient outreach, but their record in effective provision only makes them the obvious choice of budget for it.  

Why the contribution is important

The healthcare system relies on patients as initiators, making appointments to see their GP for only 10 minutes. This typically leads to further hospital referrals in cases of any complexity. If hospital appointments are missed, patients are eventually referred back to their GP.  There's no tracking of the patient, so if the patient does not or cannot visit their GP they simply slip through the net.  Mental health patients are at particular risk. The next time the system registers them may well be when they present at A&E.  This cycle often repeats.  There is a gap in provision.  Overall joined up service between health and Social Services fails to respond at individual patient level, until there is an emergency..Some people suffering from chronic conditions become effectively housebound.  This compounds problems  - isolation worsens depression for example.  Mental health patients are at particular risk. The next time the system registers them may well be when they present at A&E.  This cycle often repeats.  Social Services are not always notified and may not be unless the patient's family are articulate and aware.  Low estimations of Social Services response (beyond estimating needs) are often justified, and other agencies struggle to provide the practical help the patient needs.  This is problematic; a lack of expertise often compounds existing problems

by beanbetter on July 26, 2019 at 04:47PM

Current Rating

4.5
Average score : 4.5
Based on : 2 votes

Comments

  • Posted by ChairWNCCG July 30, 2019 at 11:55

    What you are describing is very similar to something we are pioneering in West Norfolk.
    Population Health Management is a system where some software called NHS pathways monitors a wide variety of data sources within the health and social care system to identify those people with issues that are not currently causing a problem but which may well do so in the next few months. By identifying these and intervening before the deterioration we benefit the patient and the local haelth system.
  • Posted by Sall August 27, 2019 at 11:04

    I agree with beanbetter ad my daughter had mental health problems and has been completely failed and lives in a dangerous situation and alone and where she could have committed suicide at any time!
    Police abuse , mental health support non existent ( odd phone call checking if alive and a nurse one a fortnight or three weeks for an hour , no holiday cover)and the whole system is dangerous.
    Social services are that slow it can take over a year or more for assessment and appear to not understand mental health.
    The agency’s don’t work together and when person is unable to leave house for meds they stop taking them .
    No educational for the people at the coal face or the patients leaves everything very precarious!
    Loneliness and no help or groups locally had broken my daughter and we live in a different county and I have been ignored many times by people who should know better and are paid to help us .
  • Posted by Sall August 27, 2019 at 11:12

    I don’t believe anything will change in areas like Cromer as
    The area had nothing to offer the mentally ill.
    Should you think your health is failing may I suggest you move county quickly, talking from our own experience.
    Don’t wait for change as it won’t happen any time soon and when it does it will be a sticking plaster.
  • Posted by Sall August 27, 2019 at 11:16

    I note that mental health is still not mentioned as long term serious condition on your list , the same goes for the benefits system!
    Just because a person looks ok dosent mean that they aren’t completely disabled underneath!
    You need to work with agencies and learn about bipola etc and not discriminate through lack of knowledge!
    It is shameful that these people are neglected so badly in Norfolk which leads to suicide neglect loneliness and serious physical and mental deterioration!
Log in or register to add comments and rate ideas