Doncaster Place Plan refresh: more joined up care, closer to home

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.

Doncaster’s 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.

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, focussing 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.

To support health and social care integration in Doncaster, various activities have been taking place over the last 12 months.

A team of health and care professionals have been working together to test new ways of working to see how working much more closely together can improve outcomes for patients and members of the public and also improve the experience of service users at the same time.

Dawn Lawrence is an Early Help Pathway Manager at Doncaster Council who 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 is a Clinical Leadership Fellow at Doncaster and Bassetlaw Teaching Hospitals, specialising in the Integration of Elderly Care Services.

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 difficult and can lead to a deterioration in the health and independence, sometimes 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, focussing 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.”

Another example of how Doncaster health and care services are working much more closely is the Rapid Response service. Shortlisted as a national example of innovative practice at this year’s HSJ Value Awards, the service aims to reduce hospital admissions, as a result of a fall at home, and care for people in their local community.

Mel Gibbons, Community Nursing Rapid Team Service Manager at Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH), said: “Staff at RDaSH are proud to play a part in Doncaster’s Place Plan, working together with partners across the borough to deliver the best care possible to residents.

“The Rapid Response Team works hard to support residents after a fall, helping to keep them out of hospital. This means they can recover fully supported by health and social care staff who deliver excellent care while surrounded by family and friends at home.”

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.

Jackie Pederson, Chief Officer at NHS Doncaster CCG said: “The launch of the Place Plan refresh in Doncaster is another step in the right direction to improve health and care service delivery people in Doncaster.

“The plan brings key health and social care organisations in Doncaster together from Doncaster Council, through to acute and community trusts, as well as St Ledger Homes Doncaster to ensure we continue to work together to provide the best possible outcomes and care for our local communities.

“A key chapter in the NHS Long Term Plan is harnessing the use of technology to help more people take control of their own care. The digital strategy will ensure that all Doncaster IT systems will connect and talk to each other, as well as ensuring our staff have the tools they need to do their job quickly and effectively.

“The possibilities are endless and we will continue to work with and for local people, ensuring they remain at the heart of everything we do.”

A series of delivery plans will be available in the next few months and will highlight how the Place Plan will be delivered and by when. Patients, members of the public, their families and carers will help shape and evaluate how services are provided.