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Take a ride around Maggie Bell’s patch to see how healthcare is changing in Wiltshire

Maggie Bell at Ramsbury SurgeryMaggie Bell at Ramsbury SurgeryFor evidence that healthcare in Wiltshire is changing all you need is an introduction to Maggie Bell.  She’s one of the Wiltshire Clinical Commissioning Group’s (CCG) new Care Coordinators – there are 29 working across the county at a cost of £1.3 million a year.

She was the first to start work.  Since September she’s been based at Ramsbury Surgery and has responsibility for patients registered with the GPs’ surgeries at Ramsbury, Marlborough and Great Bedwyn.

She reports to a manager at Ramsbury surgery and to the leader of the community nursing team based at Savernake Hospital. She is employed by GWH and paid by them with funding from the CCG.

She has a list of 22 people she visits: “But it’s growing all the time.”  If there’s an obvious medical problem she will visit with the community matron from Savernake Hospital: “If someone has a social need but they also have a medical need, it’s better we both go on a single visit – people don’t like lots of people coming into their home.”

The CCG’s flagship policy is its Community Transformation plan which aims to bring health care closer to people’s homes, keep them out of hospital for longer and make sure they are safe when they leave hospital.  It is aimed particularly at the elderly, most vulnerable patients.

Maggie Bell is not a nurse.  Her training and experience has been in social care.  And her role is preventative – to keep people healthy and help them avoid issues like isolation and stress that can lead to illness especially in the elderly.

One of her many jobs is to monitor people once they have left hospital.  She has access to the GWH data base that tells her who has been discharged and she will then contact or visit those who are likely to be at risk to make sure they are doing well.

This is a sure way to prevent the all too frequent occurrence of quick re-admissions to hospital – especially of the elderly.
“The GPs love it – to be honest they think it’s an absolutely brilliant scheme.”

The now defunct Wiltshire Primary Care Trust established the county’s ground-breaking neighbourhood teams of nurses and physios. When the PCT was no longer allowed to provide services, the teams were transferred under contract to Great Western Hospital and will be run by them until April 2016.

In their Community Transformation Plan the CCG are taking the neighbourhood team idea to a whole new level – and are working closely with Wiltshire Council to develop this new way of working at community level. Across the county, they’re designing local care for 23 clusters each of about 20,000 people.

In this they are ahead of the field:  the government has ordered that from April 2015 a slice off the CCGs’ funding will go towards a £3.8 billion pooled budget for CCGs and councils to join up health and social care services in England – the much-talked about ‘integration’ of care.

This fund was called the Integration Transformation Fund – a descriptive title.  But the politicians have got at it and it is now called the Better Care Fund – an aspirational title.

Maggie Bell and her fellow care coordinators are the first part of the CCG’s Community Transformation Plan.  Among other initiatives still to come is a ‘rapid response’ service that will bring health and social care within one hour to support people in time of crisis and prevent ‘unnecessary’ hospital admissions.

Maggie worked for two years as team leader for the Marlborough area’s Leonard Cheshire Disability’s Help to Live at Home team – a Wiltshire Council scheme. Now she really feels she’s making a difference: “I have the added advantage of knowing the area, the social services and community health team.”

“I’m stopping people being unhappy – to be frank. It helps people keep healthy when they know someone cares – especially people who come out of hospital. It’s good for them to know someone’s there.”

Margaret RendleMargaret RendleMaggie took me with her to visit Margaret Rendle who’s over 80 and lives in Marlborough. He husband died very recently and suddenly. Her GP asked Maggie to see her because she was afraid Margaret was very isolated, had all the problems of coping with the bereavement and needed to get out of her house more.

And frankly, Margaret’s not at all happy.  She’s still in shock and not feeling too good in herself.

Maggie filling in that formMaggie filling in that formShe’s got bad arthritis in her hands, so Maggie fills in the huge Council form – “It’s as big as a book” – to get her council tax changed.  And Maggie takes a look at the carers’ log to make sure they’re coming as they should.

Margaret is desperate to keep out of hospital – worried what would happen to her partially disabled son.

Maggie Bell is going to phone her bank to ask about her husband’s will. She’s going to talk to her GP as Margaret wants to know why her husband died in hospital so suddenly.

And there’s a large bill for the carers her husband needed that’s making Margaret anxious and must be sorted out. Margaret is very relieved and grateful that Maggie is on her case.

Maggie & her essential carMaggie & her essential carAlthough they are such a new addition to the NHS’ armoury, the Care Coordinators are settling in well and getting on with their important job.  As Maggie puts it: “Things are going very well with all the coordinators – the commissioners are very pleased – like the GPs.”

Every month all the 29 Care Coordinators meet together for a forum – exchanging information about support charities and care agencies and go through a case study to see how they can do things even better.  And they probably moan a little about the mileage allowance!

They do a great deal of driving – especially in the most rural areas like Maggie’s.  Quite who picks up the carbon footprint for all that driving must remain another mystery of the complex restructuring of the NHS.

As other parts of the Community Transformation scheme come on line, the Care Coordinators jobs will change as they have more local elements to fit in with.   The aim is that by the end of 2015 the CCG’s new community system will be looking after many more of the vulnerable – who are most often the elderly – in their homes and keeping them out of hospital.

Care Coordinators are a first step in the plan. And Maggie's enthusiastic about what they can do: "I love my job."

[With thanks to Margaret Rendle and Maggie Bell.]

 

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