In Blackburn with Darwen, health and social care professionals jointly plan and co-ordinate the care they provide for local residents – a way of working known as 'integrated care'.
This work is being delivered by Blackburn with Darwen Council, NHS organisations that plan and deliver health services in the borough – Blackburn with Darwen Clinical Commissioning Group and Lancashire Care Foundation Trust – and local voluntary organisations, including Age UK.
Our vision is to deliver effective, efficient, high quality and safe integrated care so that the residents of Blackburn with Darwen can live longer and live better.
You said: You only want to tell your story once, instead of saying the same thing to lots of different professionals. Information should be passed effectively and efficiently between the different professionals in the NHS, social services, the council and the voluntary sector who are responsible for your care.
We have: Introduced four integrated care teams across the borough to jointly plan care for residents with multiple health and social care needs. Those residents will have one care plan and a single professional – which could either be a health or social care worker – who knows everything about their care and talks to the other professionals involved – more details below.
Joint health and social care is already changing people's lives. Early evaluation shows it reduces emergency hospital attendances and admissions and improves people's quality of life.
People who have already benefited from integrated care say it has helped them to overcome barriers and make important changes to their lives that improved their wellbeing.
Scroll down to find out more about what is happening in Blackburn with Darwen – or you can watch our video here.
Integrated care is happening all over the country. You can watch Sam's Story, a short animation here, to learn more about how it benefits residents and patients.
Integrated health and care teams
Teams made up of GPs and practice nurses, social workers, mental health workers, community nursing teams and other health professionals like pharmacists plan people's care together.
They work closely with each other in four local areas – east, west, north and Darwen – which have been established based on groups of GP practices.
They meet weekly to develop joint care plans for people with increasing or additional health and care support needs and those who are most at risk of unplanned hospital admissions, particularly:
- Older people with long term conditions
- Children and young people with mental health or other complex needs
- People under 65 with mental health, substance misuse issues or other complex needs.
The four localities and the GP practices in each locality
What this means for you
Bringing health and social care together makes it easier for people with multiple needs to get the help they need, closer to home and all in one place.
Services are co-ordinated around individual needs and because teams are talking to each other, services and support aren't duplicated.
There is more emphasis on supporting people to feel confident to better manage their own conditions, with the help of family and friends.
People are assessed once and the information shared with other agencies who are involved in their care. This prevents the need to repeat information to different professionals and avoids delays.
The people who benefit from joint health and social care have one care plan, rather than several drawn up by the different agencies they have contact with, and they are involved in decisions made about their care.
For more information about integrated health and social care where you live, speak to your GP.
Programme Manager Paul Hegarty describes what integrated health and social care means for residents:
"People who will benefit most from joined up health and social care are identified either by a care professional or through using GP and/or hospital data.
"Each person has a designated lead GP and the sharing of information and its benefits are explained to them in detail, although that only begins once they understand what is happening and have given their consent.
"This is a less reactive and more planned way of working and people will notice that they will only have one care plan, rather than several, each drawn up by the different agencies they have contact with, so straight away the system is simplified.
"A matron may well draw up an assessment and a social worker may only need to follow up with a few additional questions, rather than go through the whole process again.
"Professionals will sit down and discuss a patient rather than putting requests for information from each other into the system and being frustrated by weeks of delay in receiving it. So, for example, a matron can find out instantly that a patient has a social worker or that they are having work done to the their home.
And what it means for health and social care professionals:
"Joint working breaks down barriers and is more efficient. For instance, a social worker and therapist may do a visit together rather than going separately and then being unable to liaise over the best course of action.
"It gives professionals more freedom and the ability to make decisions and work better. The aim is to give pride in a job well done and less stress as well as giving staff more resources and knowledge. We want to deliver a system that makes people want to go to work and makes them proud to work in Blackburn with Darwen."