An innovative project is helping Luton’s health and care professionals work even better together to look after elderly patients in their own homes. Since October 2018, local NHS, care organisations and GP practices have collaborated to bring proactive care (from medical home visits to Age Concern services) to more than 800 of Luton’s older residents. This approach has improved patient care, helped more of individuals to manage their conditions at or close to home, and supported 228 fewer unplanned admissions to hospital than the previous year.

The project has succeeded by bringing together Luton’s community nurses, mental health professionals, social workers, paramedics, GPs and hospital doctors, and more, for regular “huddles” and multi-disciplinary meetings to discuss patients and organise care. These meetings have allowed healthcare professionals to access the most appropriate services for patients more quickly, to learn from each other, and to co-ordinate the variety of services supporting each patient.

The most important measure of success has been positive patient experience. Chris, a patient who has recently benefitted from this joined-up approach to care, said “The community matron and his team are great, because they ask you what you want, and contact whoever would be appropriate and pulls it all together. When different agencies work together, it makes a lot of difference - things move forward.” It’s not just Chris who was pleased - 92% of patients and families surveyed said they would recommend this approach based on their experience.

This proactive approach will now be expanded to become business as usual, building on the At Home First model, which Luton Community Services use to co-ordinate adults’ care for some time. This will help health and social care services to better serve a larger number of Luton’s frail elderly patients, and further support Luton Clinical Commissioning Group’s ambition to ensure person centred care.

Commending the improvements made to date, Matthew Winn, Chief Executive, Cambridgeshire Community Services NHS Trust (which delivers community health services across Luton) said: “By collaborating with multiple organisations to support patients before they need urgent hospital admission, Luton’s health and care professionals are developing a preventative approach to care and building a sustainable model for the future.  They are also putting themselves at the forefront of approaches highlighted by the NHS Long Term Plan, which will be a crucial part of helping the health system meet the challenges of an ageing population.”

Maud O’Leary, Head of Adult Social Care at Luton Council, added: “We’re very excited to be part of this programme. It’s about focussing everything around the individual, looking at what’s important for that person, for their family, and making sure we work in a way that’s integrated, and that we’re all working together for the same purpose.”

“We’re aiming to work collaboratively … to provide much more integrated care for the patients”, said Dr Haydn Williams, GP and Chair of Hatters Health Primary Care Network. “It’s a more proactive model of care so that we identify patients that may have needs, and we go to the patient, looking at their home support, environment, perhaps what level of social support they have, and how that impacts on their medical problem at the time.”

Helen Standen, Dementia Nurse Specialist, East London NHS Foundation Trust (which delivers mental health services in Luton), commented: “This project has been a really good opportunity for services to overlap and work together. A brilliant example is the work the falls team has been doing with this project, which has allowed us to get them out to see a gentleman, and that’s prevented hospital admission. We got a hospital bed, sliding sheets, the family has given really positive feedback, and that’s been very useful. People these days do lots of things via email to faceless people, whereas now these are real people, real professionals, working together to coordinate a huge service.” 

“At the meetings we have every week, there are valuable contributions being made by all disciplines around the table. You really feel at the end of the meeting you know the patient, their social surroundings, their families, and that’s how we can come together and make a decision that we feel is in the best interest of the patient. It’s definitely a very good basis for a service in the future”, added Dr Peter Albert, Consultant Geriatrician at the Luton and Dunstable University Hospital.