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Devon community teams delivering care closer to home


No Place Like Home: Thumbs Up For New Ways of Working One Year On


Personalised care for people in their own homes by enhanced teams of nurses and therapists, keeping people well at home and out of hospital, has won a vote of confidence from people who have used the re-designed services.

One year on from changes to the way that community hospitals provide services in Exeter, Seaton, Honiton and Okehampton – including the closure of 71 inpatient beds – patients, their carers and GPs have broadly welcomed the way that care services are working together to improve the health and independence of those who would previously have been admitted to, or spent longer in hospital.

Those who have recently received the care services at home are backing them, with all those recently surveyed saying they would recommend them to others.

Latest figures show a significant increase in the number of community nurses – up as much as 50 per cent since 2010 in East and Mid Devon - rising from 170 full time equivalent posts to almost 260 in 2017/18.

Community nurses in these areas now carry out more than 17,000 home visits every month.

Community Conversation events have recently been held in Honiton and Seaton, bringing together a wide range of local representatives, including patients, carers, doctors, nurses and community groups, to discuss how well services are working and how communities can lead further developments for their areas. A drop-in event is planned for Ottery St Mary in June.


Dr Simon Kerr, a GP at Ottery St Mary and Chair of NEW Devon CCG’s
Eastern Locality, told the Seaton event that GPs were working closely with the Royal
Devon and Exeter Hospitals NHS Foundation Trust to “bring the hospital to the

“The RD&E is providing exceptional care for our community,” he said.

“This means not just good care in hospital but getting people home as soon as
possible. This has meant a step change for our community teams.”

Em Wilkinson-Brice, Deputy Chief Executive and Chief Nurse at the RD&E, said:
“We see people who become more frail if they are delayed in hospital once they
have received the acute care they need. We are working to wrap services around
people in their own homes, where we know they get better sooner and can lead a
better life.”

Now the Royal Devon and Exeter NHS Foundation Trust has released a new film,
called Let’s Get You Home, encouraging people to plan ahead when they are in
hospital. It showcases how local people are being expertly supported at home.

The film features TV presenter Angela Rippon, who says: “Getting better faster at
home isn’t just because you have your loved ones and pets around you.

“In familiar surroundings you will find it so much easier to get back to your normal
routine and get active, and being active is the best possible recipe for recovery.”

The film shows how stroke patient Kevin Butler and his wife Maggie are supported
by specialist nurses at home in Devon.

Kevin says: “The stroke team provided nursing care to meet my needs on the day I
arrived home. It was like being in hospital but at home.”

Another patient, Doug, 81, received care at his home in Seaton.

Doug said: “I’ve always been an active and independent person. However, since
1999 I have undergone nine knee replacements and unfortunately it became
necessary to have an above the knee amputation last year which has had a huge
impact on my life.”

Doug spent two weeks on an acute ward before being referred into the care of the
community team. They worked to understand what Doug wanted to achieve and
were able to work together to ensure that the right rehabilitation plan and mobility
equipment was in place. Initially, he had regular visits from community nurses and an
occupational therapist.


Doug can now self-refer to these teams when he feels he needs some extra help or
support to prevent any decline in his condition.

“My ultimate aim is to return to driving and thanks to the continued advice and
support from the RD&E mobility centre and community physiotherapists I know I’ll
get there.

“I cannot praise enough the wonderful care and treatment I have received right
through from the surgical team to the community healthcare professionals. The skills
and attention to detail they have shown is remarkable and it has been a pleasure
having the community team in my home.”

Tailoring care in the home is also greatly valued by families and carers. For example,
June is full-time carer for her husband, David, 70, in Exeter. David was diagnosed
with Dementia with Lewy Bodies, and June was concerned that he was developing
bed sores because of his reduced mobility. Their GP arranged a visit from an RD&E
community nurse who works closely with the practice. The nurse identified that June
and David needed some urgent support to improve conditions for them to stay safe
and well at home.

David can get frustrated and confused in hospital settings so it’s important him and
June to be able to stay at home. June was doing a fantastic job caring for David but
she didn't realise the help that was available to make her life easier and reduce the
pressure she was feeling.

June said: “I don't feel so tired now or so anxious. I was worried about how we were
going to carry on. I do everything so if something happened to me David would
probably end up back in hospital which isn't good for him or where he wants to be. I
didn't know all this help was there, it’s great. Life’s a lot better now.

Roger Trapani, community representative for the Eastern area on Devon Health and
Care Forum, said: “The new model of care is very much a success story.

“Despite people’s initial fears about losing beds in the community hospital, things
have moved on. What we didn’t have before was any plan for when people went
home; now we see services working together to get the best for them and this is
making a big difference.”

The new care model is a system-wide way of working, brought about by closer links
between local health and social care partners who are now collaborating to ensure
that more patients can get the care they need without leaving home.


Specialist nurses at the RD&E now work to prevent admissions where
possible and enable people to return home with packages of care that support them
and prevent readmission.

Modern healthcare means the role of the hospital is changing, so that only the most
seriously ill need to be admitted to hospital and for the shortest possible time. This
not only delivers best value but is known to be better for people – and in line with
their preferences - as they recover more quickly and stay well for longer at home.

This also ensures that vital NHS hospital beds are kept available for those who need
them most, such as emergency patients and those booked for planned surgery.

Lorna Collingwood-Burke, Interim Deputy Chief Officer and Chief Nursing Officer at
NEW Devon Clinical Commissioning Group, said: “It is great to see that we have
more community nurses and other therapists delivering a wide range of high quality,
personalised care that people welcome in their own homes, enabling them to stay as
independent as possible for as long as possible.

“This is a first class service that also helps ensure that hospital beds are used

Added 20th April 2018

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