News

Doncaster Place Plan refresh – working together to improve outcomes and experience for patients and members of the public

Over the last few years, much has changed across the national health and care landscape. Rising demand, fewer resources and an ageing population means that we need to work much more closely together.

In line with the NHS Long Term Plan, Doncaster health and care services are moving towards a focus on people as opposed to services. This means that instead of looking at where care is delivered, we are now thinking about local communities and their needs.

Doncaster’s first Place Plan was published in December 2016, highlighting how health and care services would develop and change over the next five years. The time has now come to update the plan and change the way we work and think to address the issue of rising demand and fewer resources to work with, but at the same time, improve and future proof our services so people can lead healthy lives.

The refreshed Place Plan has the same vision and partnership working commitments at its core. It highlights how services will continue to work together to ensure seamless, coordinated services for the people of Doncaster.

To support delivery of the Place Plan, Doncaster’s first ever joint health and social care commissioning strategy was published earlier this year. Aligned with the NHS Long Term Plan, it sets the direction of travel for priorities up until 2021, reducing duplication and making best use of local resources. It also highlights how we will change the way we work and think in the future.

The Place Plan refresh is based on a four layered model, focusing on:

• Supporting communities to thrive, working much more closely with the voluntary, community and faith sector, investing in social prescribing to improve health and emotional wellbeing
• Developing a ‘front door system’, where there is no wrong door to access health and care services. This will help get people to the right place, first time
• Joining up care and support at home. We know many people can recover quickly and easily if they are supported at home
• All of this will help ensure our specialist services can be used more appropriately, across all three life stages – reducing the demand and need for hospital and emergency care.

What does this mean for me?

Over the last 12 months, staff across health and care organisations in Doncaster have been testing new ways of working to make better use of our time and resources, for the benefit of our patients and members of the public.

Dawn Lawrence, Early Help Pathway Manager at Doncaster Council has been leading a project to look at how wrapping health and care services around individuals, families and carers can improve outcomes and experiences for Doncaster residents.

Dawn said: “The work we have been undertaking to look at how services can be delivered and joined up in local communities in Doncaster is an important step in addressing demand and future need.

“A key outcome we have seen is a huge will to work together, across health and care services. As an example, a family who moved into Doncaster that had no money or basic everyday items would have had to wait three days for a screening assessment, followed by a further 45 days for their case to potentially be addressed and picked up by the relevant health and social care teams.

“A new approach, resulting in a team around the family means that from the initial ask for help, the family had received support, been provided with basic items and had their benefit application assessed and approved. In addition, the local health team also supported mum-to-be who was pregnant.

“Without this support, the family could have been waiting much longer, resulting in further intervention and support required in the days and weeks ahead. This could also have resulted in the possibility of a need for additional health and care services due to the effect on their health and wellbeing.”

A frailty programme is also developing at pace to help keep older people as healthy, happy and independent as they possibly can be.

Rachael Webb, Clinical Leadership Fellow at Doncaster and Bassetlaw Teaching Hospitals, specialising in the Integration of Elderly Care Services is leading this important programme.

Rachael said: “People living with frailty and their family carers often experience deteriorating physical and mental health, often with one or more long-term conditions, sometimes including dementia.

“Individuals with frailty are likely to be coming towards, or in the last stage of their lives and can often experience crises in their physical and mental health, resulting in frequent attendance at the Emergency Department or in unplanned, emergency admissions to hospital.

“Recovery after a crisis can often be poor and leads to a deterioration in the health and independence, leading to further crises. There can be a wide range of professionals, family carers and services involved in their care and support.

“The frailty programme is working to develop a model of tight, one-team integrated working, focusing on the needs of older people or that need help and support to prevent or respond to a predicted crisis in their independence, health and wellbeing.

“In Thorne, we have been coordinating a single, holistic assessment based on what is important to the person and their strengths.

“A jointly created care plan means that we can identify and address actual and potential issues that can be anticipated. This could be anything from the risk of falling, mobility, pain control, problems with activities of daily living, managing anxiety and depression.

“There is still some way to go, but I am optimistic that this new way of working will not only benefit patients, their families and carers, it should also help reduce unplanned hospital admissions, supporting older people in their local communities where recovery can in many cases be quicker and more effective.”

A commitment to making better use of technology

Also included in the Place Plan refresh is a commitment to making better use of technology to further join health and social care services together.

A brand new health and care Digital Strategy will follow in the coming months to maximise use of the Integrated Doncaster Care Record, increasing the number of health and care professionals that will have access to multi organisational patient records at their fingertips.

How can you help?

As you can see, this new way of working and approach is being led by staff, for staff – joining the dots together, reducing duplication and the time it takes for applications or processes to be followed.

However, there is much more we can do and we need your help. We know you all have bright ideas and thoughts as to how we can work together more closely together, in similar ways to the ideas already generated by the frailty and local solutions programmes that are taking place.

A dedicated team of experts from all organisations meet regularly to look at how we can integrate our work and processes; there are always opportunities to share your thoughts, views and ideas.

Please let us have your thoughts – speak to your line manager or email your organisation lead.

DCCG Place Plan Refresh 2019-2022