Primary Care through a community lens Archives - Bradford District and Craven Health and Care Partnership

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Abdul’s story

The Proactive Care Team (PACT) supported Abdul’s father in his last stages of life. This is his story.

“My dad was living at home with my two brothers when he became ill. At this time I had contracted COVID and was unable to visit dad. My brothers took him to hospital where he was referred to a virtual ward but after an assessment he was discharged with no after care.

“Dad returned home but he was not very mobile and needed help with climbing the stairs and moving around the house. The hospital arranged for a bath lift to be fitted at my brother’s home but this alone was not enough. We were stuck as a family; we didn’t know where to turn.

“Working for the NHS in Bradford, I had heard of the Proactive Care Team (PACT), so got in touch with them to see if they could help, and they did. Catherine from the PACT team came to visit us and asses my father. She was honest and open, she told us where we were at and that was what we needed at that time.

“Catherine liaised with the hospital and pulled out all the stops to get us what we needed to make sure my dad was as comfortable as he could be. Every week she’d come and visit without fail. She was always there at the end of the phone.

“A couple of months later, dad took a turn for the worse. It was clear he needed a specialist profiling bed and the PACT team sorted this in 3 hours. I was shocked, amazed, and so thankful for their support.

“On Catherine’s last visit, she had an emotional conversation with us that now was the time. She sorted out the right equipment and nursing visits and a few days later, my dad passed away.

“I have so much gratitude for everyone in the PACT team, who went above and beyond for my dad and our family in the last few months of his life, especially Catherine, she was a godsend and all the things a nurse should be. She’s a credit to the team.

“If it wasn’t for the PACT team, we wouldn’t have known what to do as a family, we would have really struggled. I don’t know where we’d be without PACT.”

Thank you, Abdul, for sharing your story. You can learn more about the PACT team on the Bradford District Care NHS Foundation Trust website.

What this means to OUR PLACE - Diabetes

There are around 45,000 people living with diabetes in Bradford District and Craven. The diabetes transformation programme exists to better support all these people and those at risk of developing type 2 diabetes in the future.

We know there are significant inequalities linked to deprivation, with some areas having twice the diabetes prevalence of others. We are working with communities to understand the impact of diabetes and design more accessible services.

How this demonstrates OUR PARTNERSHIP - Diabetes

The diabetes transformation programme is a clinically led partnership. Our Clinical Forum involves fourteen different healthcare professions who are involved in diabetes care and can advise on models of care, evidence-based practice and better integration of diabetes prevention and care.

Across Bradford District and Craven we work in partnership with Bradford Teaching Hospitals NHS Foundation Trust, Airedale NHS Foundation Trust, Bradford District Care Trust, 12 Primary Care Networks, 13 Community Partnerships and a range of voluntary sector organisations. And our long-term partnership with Diabetes UK is invaluable to our programme.

How we support OUR PEOPLE - Diabetes

We act as one in trying to prevent type 2 diabetes and trying to prevent the complications of all types of diabetes.

The prevalence of type 2 diabetes is increasing, and it can be preventable. Obesity is a major risk factor. Preventing people who are at risk of type 2 diabetes from going on to develop the condition is a key strand of our work.

How this demonstrates OUR PARTNERSHIP - Access to Health & Care

This has been a service developed in partnership across health and care bringing together our collective resources and knowledge to create a new and innovative pilot with the potential to change the way people can access care and support for a range of needs. We will undertake a robust evaluation in partnership across the range of VCS provision which will ensure the voices of those the service reach is heard and acted upon.

What this means to OUR PLACE - Access to Health & Care

Our first step in this process is setting up Wellbeing Hubs with the voluntary sector where people can seek wide ranging support beyond just their physical and mental health needs. These are based in, and run by, local community organisations primarily in areas of high deprivation and will open from early until late recognising we can’t all access care 9am-5pm. We have listened to our workforce who want the ability to do one single referral and be reassured that people’s holistic health and care needs can be addressed by the hubs.

How we support OUR PEOPLE - Access to Health & Care

Within the Access to Care programme we recognise that our system is complicated to navigate and often people end up in the wrong place not deliberately but because they don’t know who is best placed to deliver their care or they can’t get into the service they need. In some cases, people don’t end up seeking help at all. We are working with the Inequalities Alliance to better understand the reasons for this so we can develop more accessible services with our health and care partners.

How this demonstrates OUR PARTNERSHIP - Children and young people's wellbeing

The mental health and emotional wellbeing of children and young people is everyone’s business, we are committed as a partnership across health, social care, public health, education and the voluntary sector to driving forward our priorities. Building strong and trusted relationships with schools and communities is a key goal, promoting good mental wellbeing and emotional resilience, supporting prevention and early intervention. We have established and are developing Mental Health Support Teams across many schools. Our Healthy Minds Young Apprentices are delivering their Kindness, Compassion and Understanding campaign within schools and colleges with excellent feedback from pupils and teachers alike.

What this means to OUR PLACE - Children and young people's wellbeing

Supporting one of the youngest populations in the UK to thrive and achieve their potential is our focus. Working closely with Born in Bradford and Age of Wonder research partners to take a place based approach to understanding and responding to the needs of our children and young people. Supporting our young population to prevent mental health problems arising wherever possible and providing appropriate and timely support for their mental wellbeing whenever needed. Our Healthy Minds Young Apprentices work in schools and communities to understand issues affecting the mental wellbeing of children and young people in our place.

How we support OUR PEOPLE - Children and young people's wellbeing

Our programme is focused on improving the mental health and emotional wellbeing of children and young people across Bradford District and Craven. Children, young people, parents and carers have told us that it can be difficult to understand what services are available locally and how to access them, they would like more early intervention and prevention support, more support in schools and local communities. Our programme is focused on responding to the needs of our local population. Children and young people have told us what matters to them the most and what will make the biggest difference to their lives.

How we support OUR PEOPLE - Ageing Well

We have been working closely with Living Well and the Race Equality Network to empower our people to stay active (especially during the pandemic) and reduce the risk of deconditioning. Small ABCD grants have been allocated to community groups for them to implement activities such as gardening, chair yoga and wellbeing walks. AHPs across our place have developed a Keeping Well at Home flyer with tips and advice on staying active, eating healthy and staying connected. The flyers and short videos highlighting key messages are available in different languages. Look out for our Community Recognition event in 2022 where we’ll be celebrating the great work that has taken place through the ABCD grants.

What this means to OUR PLACE - Ageing Well

Bradford District and Craven can become a place where people ‘age well’. They feel connected and part of their local community and are supported to remain independent for as long as possible.

How this demonstrates OUR PARTNERSHIP - Ageing Well

Many people with long term conditions such as frailty and dementia require wrap-around care from multi-disciplinary teams. Through our priority work-streams we are focussed on integrated working between organisations across our system so people receive the right care, at the right time in the right place.

How this demonstrates OUR PARTNERSHIP - Respiratory

Working as part of a partnership, we will coordinate care on a wider footprint, seeking economies of scale and sharing the workload. This will result in quality outcomes being delivered across our partnership but with flexibility for local implementation.

What this means to OUR PLACE - Respiratory

Acting as One means our teams work together planning and transforming pathways, sharing knowledge and skills and resulting in a stronger collaboration.

How we support OUR PEOPLE - Respiratory

offering tailored, accessible care based on population health management data, ensuring every contact counts.

How we support OUR PEOPLE - Better Births

We recently held 2 community engagement events in Bradford and Keighley in partnership with BD&C Maternity Voices Partnership. These were well attended by a diverse mix of service users, providing the opportunity for seldom reached groups to meet with local organisations and maternity service providers and share their voices. Feedback from these events will help to shape future projects within the Better Births programme, ensuring that the voice of the families in our communities are at the heart of everything we do.

What this means to OUR PLACE - Better Births

The Better Births programme has initiated a place-based approach for several important pieces of work including the Ockenden report response, training and development, venues for community maternity care and the current staffing crisis.

In September, we held a ‘Maternity Safety Event’ which was well attended by over 100 registrants and received excellent feedback. This success was followed by our ‘Reducing Inequalities in Maternity’event in March.

How this demonstrates OUR PARTNERSHIP - Better Births

Each of the Better Births workstreams has representation from across all sectors and organisations. The recent events we have held demonstrate this in practice. Another example is the at-a-glance perinatal mental health referral pathway and services directory which was designed in collaboration with our partner organisations and has been distributed among professionals in all sectors. We have also developed a resource for service-users which we promoted during maternal mental health awareness week. The information collated for this has also been made available online on the Healthy Minds website. With maternal suicide being to leading cause of death in the 1st year following birth, this topic is high on our agenda.

How this demonstrates OUR PARTNERSHIP - Healthy heart

All our work can only be achieved through supporting all stakeholders at place. Working with communities and addressing their needs, means that partnerships of the VSC, Primary and Secondary Care can deliver a collaborative innovative approach to improving access to health care and outcomes.

Working together in community settings our partnerships deliver to the community in a meaningful way. Partnerships provide a holistic approach to the individual and collective, to ensure that people receive the right care, at the right time, from the right person.

What this means to OUR PLACE - Healthy heart

For our place it means those who experience the greatest inequalities in health will be levelled up to the standard that improves outcomes, in a meaningful way.

Addressing local need and working with a community based approach, means that services can be delivered close to home reducing the travel and cost implication that can form barriers.

Providing services locally means the environment is known and non- intimidating. The ultimate goal for the place is to see a reduction in the number of people experiencing a cardiac event across our place.

How we support OUR PEOPLE - Healthy heart

Healthy Hearts Act as one programme is supporting our people by engaging with national agendas and local level targets aimed at reducing health inequalities.

Through collaborations with people who are experiencing cardiovascular disease we are hearing their barriers, want and needs in relation to managing their health. Through working with VCS Primary and secondary care we can address these issues through placed based approach.

To reduce inequalities in health through making accessing services easier and signposting to other services at place who can support and improve their wellbeing.

Primary Care through a community lens

A stronger voice for general practice: reflections from our community of practice

Progress is possible: reflections from our community of practice

Evolution doesn’t stop revolution

Seeing things from both sides – the human element of communications

How can the voluntary sector help with the challenges facing our health system?

Bridging the gap between best practice and consistency in healthcare

The pain of change is well worth it!

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