Our new integrated care system (ICS) in south east London brings together all the organisations responsible for delivering health and care for our communities. Working together in this way means that we can intervene much faster to keep people well and makes it easier and simpler for people using local services. When health, social services and voluntary sector work more closely together, it means more joined up support for people who face significant medical challenges.
The new Hospital@Home for Children and Young People (CYP) team is a really good example of how joined up care is making a real difference to people’s lives. The service was set up in south east London recently to provide a level of medical care and support you would get in hospital, only within your home. The work of the dedicated home nursing team means that people are able to continue to live their lives independently without the disruption of hospital stays. It also means fewer journeys for people to make, and an all-round positive impact on people’s day to day lives; in particular, Daisy.
Daisy is 15 years old and lives in Chislehurst in Bromley with her mum, Rachel; her dad, Rob; and her older sister, Lily. Daisy suffers with recurrent chest infections and intermittent neutropenia and this means she often has to spend weeks at a time in hospital, with her mum alongside her. When she wasn’t in hospital, she had many outpatient visits and emergency trips to A&E, all of which impacted on her life, her friendships, and her family too.
Previously Daisy would spend two week stays in hospital receiving treatment for her chest. Each visit to A&E usually involved having to explain the background to Daisy’s condition, telling her story from scratch each time. Sometimes, after a long wait, when Daisy was much younger, they would be transferred to a hospital out of the area, having to explain Daisy’s condition and treatment again to a new team.
Now, under the Hospital@Home team, Daisy’s life and that of the whole family has radically changed for the better. She still has to manage her serious condition, and all that comes with it, but now Daisy’s nursing team visit her at home. This removes the need for many trips and hospital stays. The dedicated and friendly team already know Daisy and her health needs really well, so she never has to repeat her story. They understand her condition and see the progress she makes each day. Each visit builds trust and rapport with Daisy. She knows she can tell them anything and be honest about how her condition is each day. They, in turn, don’t hesitate to escalate when it’s needed. Daisy’s medical treatment now largely fits round her life and her needs, not the other way round. Being at home also means she can exercise in her own time and own environment, which in turn improves her chest.
A key aim for 15-year-old Daisy was to keep school life and friendships going during her treatment. Previously, she would miss weeks of schoolwork and was unable to catch up, which in turn was stressful. Hospital Wi-Fi meant that connecting to online lessons was almost impossible, and treatment schedules and ward rounds were an added complication. Now with Hospital@Home she can still join her lesson online and just log off for the time when the team visits, minimising the amount of schoolwork she misses.
It also means she can carry on with as much of a normal teenage life as possible, seeing her friends, watching films and being with her family. It’s so much easier for her friends to see her at home rather than having to travel after-school to the, often overwhelming and unfamiliar, setting of a hospital.
For mum Rachel there have also been many positives. The constant trips to hospital and long-term stays meant that Rachel and her husband felt they were constantly fighting fires rather than enjoying life as a family.
Treatment at home means the family have regained valuable time with each other, cooking and eating together.
Regular communication with the Hospital@Home team means everyone knows what should be happening and when. Before, Daisy would attend the ward on Saturday and Sunday evenings for her meds. These days, if a Sunday night check or meds are needed then Daisy can be at home, relaxed and ready. The treatment is quick, and the family have their whole evening back together.
Daisy now enjoys simple day-to-day things like taking the dog out for a walk with her big sister when she’s back from university. Previously it had been hard for Lily over the years when she had to visit Daisy in hospital. She’s grateful for the time she has at home with her now and this has inspired her to go into training for a career in medicine.
The impact of Hospital@Home is much more than the efficiency of providing treatment in someone’s home rather than hospital, it’s the positive impact on the home, wellbeing, social and mental health of the whole family. They feel that it’s given them back time together and can now minimise time in the hospital setting.
"I've definitely noticed that she recovers so much quicker at home and alongside her own wellbeing, mentally, socially, everything else from an actual physical recovery perspective, I would say is huge"
Rachel - Daisy's mum
Rose Café in West Norwood provides community-based care for elderly people living in Lambeth, and aims to improve health and wellbeing at neighbourhood level, with a particular emphasis on strengthening or forging new connections between community and health organisations.