Working Together Programmes
A trailblazing Working Together programme in Leighton Buzzard that wraps health and social care around the needs of individual patients has now expanded to support people in Dunstable. Clinical lead Helen Mills, from Bedfordshire Community Health Services (BCHS), talks about her role and how the new approach is making a difference to the two communities.
“Working Together is a partnership approach, led by BCHS and Central Bedfordshire Council, to better connect health and social care needs for individual patients, particularly those with complex needs. Health and social care professionals discuss the needs of individuals and ensure all relevant services are linked together and providing the support that people need.
Its aim is to help people who need support from more than one agency get all of the help they need, to help them stay out of hospital and to strengthen how different services communicate and provide joined-up care.
We mainly help people with complex needs by listening to their needs and considering any additional support they might need from health or social care partners. This might be through identifying needs following a spell in hospital or a home visit and the professional then contacting other services, or through our multi-disciplinary team (MDT) team meetings where we discuss what other needs an individual has and who can provide that help.
It is a programme that connects Bedfordshire Community Health Services (BCHS) teams, mental health colleagues, children’s services, social care professionals, Primary Care Networks (PCNs), the fire service, social prescribers, housing support staff and a range of other health and wellbeing partners.
Working Together was launched in Leighton Buzzard in November 2021 and has now expanded to Dunstable. Our hope is to eventually extend across Central Bedfordshire and Bedford Borough.
The change in tone from people we help is one of the most rewarding things. One mum we supported was frustrated and didn’t know how to access help for her daughter. Working Together connected with social services, organised Occupational Therapy (OT) support, liaised with her daughter’s school, showed them where to go for disability assessments and we also linked them with a nutritionist.
Case study
‘Dave’, 40, from Dunstable
This patient had an open wound on his hip, poor bloods, weight loss and was suffering from poor mental health through lack of social activity.
The Working Together team liaised with his GP, the Tissue Viability Nurse (TVN) and dietitian to help improve his blood results and close the wound so he was fit enough to receive surgery and prevent the need for further treatment. ‘Dave’ was also connected with the psychology team to improve his mental wellbeing.
