Rob’s story

Rob has been supporting his dad since he was discharged from hospital after an operation following a serious heart attack. He phoned the numbers he’d been given to try and set up home care for his dad and equipment to help him stay at home. He describes his experience:

“I’ve been calling in to see dad every day since he came home and have spent hours on the phone to social services trying to get him some regular help.  I can’t be with him during the day as I have to work and I’ve taken so much time off since he has been ill. 

“Dad isn’t very good on his feet and he gets confused - he also forgets to eat and take his medication.  They said he would need regular visits to his home to help him wash, dress and prepare meals but the process is so slow and I’m still waiting to find out what support they can provide.

“I finally managed to get a walking frame and special toilet seat organised for him.  I wasn’t there when they brought it round and he told them he didn’t need them and sent them away.  He’s a proud man and I understand that, but it had taken me weeks to organise the equipment he needs.

“Now I have to start all over again with more phone calls.  It takes forever to get through to the person you need - the last time they couldn’t find any information on the system about my dad!  I’m worried for the future – he’s lonely now he can’t get out and about like he used to but there’s only so much I can do.  I don’t want to see him fade away and go into a home but I need to work for my family.”

Integrating health and social care

Social care link workers now make up a crucial part of the multi-disciplinary teams in the City’s eight Care Delivery Groups (CDG). They work alongside GPs, community nurses and therapists and contribute to case reviews and care planning meetings.  This integrated health and social care approach is improving professional practice and speeding up referrals and access to care for citizens. The team manager describes their role:

“The social care link workers provide vital insight and expertise to look at a patient’s immediate and ongoing social care needs.  This enables the CDG team to take a ‘whole person’ approach, rather than simply addressing medical and health needs.

“They provide a social care perspective on discussions about patients who may have several long-term conditions and a variety of care needs, sometimes spanning physical health, mental health and social care.

“The link workers undertake social care assessments in conjunction with community nursing teams for patients who need support at home, including those recently discharged from hospital.  Communication between agencies has been vastly improved - previously health teams may not have known about some of the social care support available and whether patients were eligible for referral to a service.  Integrating social care link workers into the CDG teams means that people get the right support much more quickly as we have more knowledge to support care planning.

“Social care link workers can also provide advice on services in the community which are free to access, such as friendship and activity groups, lunch clubs and voluntary organisations who can help with food shopping and odd jobs around the home.

“Working in this new joined up way reduces the amount of time that GPs and district nurses spend on the phone or on email trying to source appropriate support - they can discuss with the social care worker there and then to progress things straight away.”