Published on: 20 December 2023
Patients in South Tyneside are among the first to benefit from a new care programme for people who are frail or have complex health conditions.
The scheme – being tested by North East and North Cumbria Integrated Care Board and South Tyneside Council – identifies frail and elderly patients who are at high risk of hospital admission and invites them to meet with doctors, social prescribers, physios and other specialists all in one appointment.
These 'Living Well' clinics offer the chance to meet with a range of health and care professionals at one time, meaning better care and less need for appointments in different places.
The project team then agrees a personal plan with the patient, to help them stay healthy and independent at home for as long as possible.
Caroline Sykes, practice nurse lead for long term conditions at North East and North Cumbria Integrated Care Board, said:
"The idea is simple: instead of the patient seeing lots of separate services for different needs, we can focus on the person as a whole and think about all their needs in a holistic way.
"We're working with geriatricians, social prescribers, community matrons, physios, pharmacists and social care professionals so that people can get the advice and support they need in one place."
One aim of the clinics is to give patients the confidence and knowhow to manage their own conditions more effectively.
Rose Issacks, 74, of South Shields, was among the first to use the new service:
"Before having my hip done, as soon as I woke up, I would be in agony and all I wanted was sit down and shut myself away. I did try to go out, but I wasn’t able to do the things I really enjoy."
"Coming to the clinic, I have had physical support from the physio, and the reassurance I needed to start getting out there and doing things like yoga and swimming, which I haven’t been able to enjoy properly for two years.
"After speaking to the physio and social prescriber I feel more confident to try those things again. I didn’t realise that I was holding back until I spoke to them.
"I got a lot more out of it than I expected, and I feel so much better for it. The team have helped me a lot."
The team will target the most vulnerable patients in our community, with local primary care networks (groups of GP practices) inviting those who can benefit most to the clinics.
Vicky Gilmore, a social prescriber at First Contact Clinical, said:
"I chat with every patient beforehand to find out what matters to them, and meet them in reception before introducing them to the team.
"It's a great opportunity to speak to as many professionals as they wish, with a friend or family member coming along if they prefer."
The team works with patients to create a personal support plan, setting out what services they need and who will provide them. Proactive care reduces the risk of long-term health conditions worsening and leading to a hospital stay.
Edd Nowicki, a geriatrician at South Tyneside and Sunderland NHS Foundation Trust, said:
"We hope that the clinic will improve patients' clinical, social, financial, and spiritual care, helping them to stay well and in society without the need for emergency hospital admissions.
"It’s a chance to take control and to make sure that the health and social care system helps them through every day."
Councillor Ruth Berkley, Lead Member for Adults, Health and Independence, said:
"The Living Well clinics are showing early promise in helping our older residents to live healthy and independent lives.
"By taking a holistic and person-centred approach, we are aiming to keep more of our residents out of hospital and improve relationships between people and their GPs. It’s a win-win all round."
If the scheme is successful, it may later be extended to other areas across the North East and North Cumbria.
