Community trusts have an opportunity to embed their services firmly into their communities, developing close relationships across health, education, social care, justice and the third sector. Cambridgeshire Community Services NHS Trust has successfully integrated contraception and sexual health services (iCaSH) to meet the needs of local people, often in hard to reach communities. Innovation and service redesign have resulted in standardised, cost effective, high quality services. These include a 'one stop shop' where people with symptoms can have an initial appointment, diagnosis and treatment in one visit. There is also quick and easy STI and HIV testing for people with no symptoms, using an online and postal service without the need to visit a clinic.
Integrated community services in Wigan have shown how a range of community based providers can collaborate to help people live independently, taking into account all aspects of their daily lives at home, and so helping to prevent hospital admissions. In one example, they worked with a woman who was admitted to hospital six times with suspected sepsis from leg ulcers. The team at Bridgewater Community Healthcare NHS Foundation Trust developed a plan for her needs to be jointly assessed by a community matron and social worker. Under a management plan linked to her GP, she was re-housed, and given weight management support and physiotherapy. Since then she has not been admitted to hospital.
In the Hospital@Home service run by Sussex Community NHS Foundation Trust (SCFT) in partnership with Brighton and Sussex University Hospital, community nurses and therapists look after patients with complex needs at home. Patient feedback is positive and the scheme is popular with staff who have the opportunity to develop and practice skills that would normally be used in an acute setting. The pilot launched in 2016/17 to 60 patients per month, and the scheme has now been extended to more than 500 people. SCFT say the scheme is delivering financial benefits as well, with the cost of a patient cared for by Hospital@Home 27% less than if they were looked after in an acute setting over the same period.
Rehabilitation services delivered by community providers help people return home from hospital more quickly, re-establishing independent living and, where appropriate, a return to work or education. Neuro rehabilitation provided by South West Yorkshire Partnership NHS Foundation Trust supports patients with traumatic brain or spinal cord injury and stroke. New and established interventions are used to deliver efficient and effective rehabilitation, seven days a week. The trust’s activities exemplify the key contribution community services play across a range of priorities including public health, prevention and palliative care. They include stop smoking services with the highest proportion of stop smoking quitters in England. In addition, mental health nurses further work within the multidisciplinary care home support team in Wakefield. The team is made up of a range of specialist staff who provide personally tailored care plans to help residents stay well.
Community based teams working to support discharge from hospital are able to make a clear judgement about which patients are fit to leave and the support they will need back in their place of residence. The work carried out by the supported discharge service at Harrogate and District NHS Foundation Trust shows how, with the right support, patients often make a quicker recovery than if they remained in hospital. During the team’s first 32 weeks of operation, the service discharged home 394 patients, resulting in an estimated 975 patient bed days saved.