An extraordinary first year for community services contract

Community services teams across North East Hampshire and Farnham and Surrey Heath mark their first year of working together this month following an extraordinary first year.

The contract for integrated community services led by ourselves and Frimley Health Foundation Trust began in April 2020 as the worldwide pandemic response took hold.

Community services played a critical role in ensuring patients were able to transfer quickly from acute hospital services into either intermediate care or going back home, thereby freeing up beds to ensure there was capacity to deal with the pandemic.

There has been an average of 5,500 contacts a month between patients and the community services teams in their first year, compared with an average of just under 5,000 in the previous year, due to the impact of the pandemic.

This has meant more patients getting the health and care support they need in their own homes and in many cases preventing the need to admit patients to hospital care, supporting up to 1,000 patients who otherwise would have gone to hospital. More patients coming towards the end of their lives also get their wish of being kept comfortable at home.

Staff were also able to use their specialist skills to support patients with Covid, either on wards or as outpatients giving nursing and therapeutic support to help them in their recovery. For instance, the Intermediate Care Team were able to give rehabilitation and recovery support, with 3,500 patient contacts a month on average over the year.

While dealing with the immediacy of the pandemic response, the teams also worked together to further integrate services, joint training and education sessions, shared home visits to patients and working together to support patients with complex needs.

Other achievements by the service include:

  • A new night nursing service which means patients can be supported overnight at home rather than in hospital. These are predominantly patients at the end of their life who want to spend their last days at home.
  • Integrated ways of working for the in-reach and intermediate services from Frimley Health and Virgin Care which reduces duplication, supporting timely decision making and care delivery appropriate to patient need.
  • A new community matron role supporting patients with long-term conditions. This role promotes proactive disease management and enables patients to manage their own condition in a supported way.
  • Integration enabling the piloting of a new Hospital@Home Service led by the frailty team and consultant geriatrician with the support of community colleagues.
  • A shared electronic patient record which supports the ethos of patients only needing to tell their story once.
  • Collaboration between specialist services, hospital clinicians, general practice and community services teams to develop care pathways for diabetes, Parkinson’s and respiratory patients so they have end to end care, from hospital to home.
  • Stronger social care, voluntary sector, mental health and general practice links.

Fran Campbell, Head of Community Services at Frimley Health, said: “Our community services colleagues have responded magnificently to the challenges this year, not only adapting to and developing new ways of working, but also the unprecedented challenge presented by the pandemic response.

“These achievements have all underlined the importance of teamwork and keeping the patient in focus to ensure that what we do is providing the best possible care for any patient, whatever the circumstances of their care needs.

“We will continue to collaborate, develop and grow our services to ensure patients in our communities get the best possible care in the right place.”

Susan Joyce, our Director of Community Services in Surrey said, “It’s been incredible to see both teams come together effortlessly to provide such a wonderful service, and one which will benefit so many.

“I’m extremely proud of all the teams working together to make this a reality, and I am proud of what has been accomplished by the two organisations in such a short time – a great accolade for the future just shows what can be achieved through integration and collaboration.”

Nicola Airey, NHS Frimley CCG Executive Place Managing Director (Surrey Heath), said: “We’re delighted with how this unique partnership between Virgin Care and Frimley Health NHS Foundation Trust has been delivered over the past year.

“When we first considered commissioning this service, we wanted to ensure we had the best-in-class care for our local population and from the feedback we’ve received since from our patients and staff, this certainly has been the case.

“It is remarkable to see such great teamwork and togetherness during a challenging 12 months.

“The contract has strengthened relationships and other service providers, including those which support holistic care across physical and mental health, in the NHS and with local authority partners.

“I’m sure this contract will continue to strengthen both our reputation for selecting the best quality care locally and for striving to place local people at the heart of what we do.”