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SoWhoCaresAnyway E25 So Left Shift Should Be Easy, Right? · SoWhoCaresAnyway

• 0:04
  Hi, I'm Ruth Germaine, and this is, so Who Cares? Anyway, a podcast shaped by my deep curiosity about who cares, what do they care about, what do they do, and why does it matter? My aspiration is to build a community that listens with intention and explores care from every angle, from the North Yorkshire malls to behind clinical doors.
• 0:27
  Each episode invites people to share their stories, their ideas, and talk about what matters to them.
• 0:34
  Together we reimagine what care could be and how we might shape health and wellbeing through the assets, values, and the lived wisdom of our communities.
• 0:44
  And why does it matter? Because for too long, health and care have been treated as things to be delivered, often depleting systems and the people around them.
• 0:54
  And it's time to rewrite the narrative to center everyone as a contributor, not just a recipient, to offer joy, hope, and meaningful belonging to invite each of us to shape the future of health and wellbeing with courage, with creativity, and with care.
• 1:12
  So who cares? Anyway, to find out more about me, head over to my link Tree Dook for Reflective Ruth.
• 1:19
  Here you'll find links to my website, my LinkedIn profile, and in the future, my Facebook page, to now for another episode of So Who Cares? Anyway.
• 1:31
  Hello.
• 1:31
  So welcome to the next episode of So Who Cares.
• 1:34
  Anyway, and today I'm delighted to be joined by two doctors.
• 1:37
  They're both geriatricians, Dan Harmon and Anna Falwell who are joining me because I saw a post from Adam Lent, uh, talking about do with approach.
• 1:46
  Adam often, um, talks about these on LinkedIn and I was particularly interested in the work that Anna and Dan are doing.
• 1:53
  So I'm not gonna talk about it anymore.
• 1:55
  What I'm gonna do is go over and just ask, um, both Anna and Dan to introduce themselves.
• 1:59
  So I'll start with you, Anne, if that's okay.
• 2:01
  And just give a little bit of, um, an introduction as to you who you are and perhaps a little bit about what's driven you to, or how you've got to where you are now, if that's okay.
• 2:09
  Please.
• 2:09
  Yeah.
• 2:10
  So, um, I've been a consultant geriatrician for, uh, 10 years.
• 2:14
  Um, I guess in terms of being inspired to work with older people, I think a lot of that came from, um.
• 2:22
  Uh, having an inspiring granny.
• 2:24
  Um, and I think, you know, that has driven me, uh, through most of my, uh, career and I know it's similar for Dan as well, which is interesting.
• 2:32
  Um, but been working in Helen East riding for 10 years.
• 2:36
  Um, initially, um, was 50% in the hospital.
• 2:40
  I'm 50% in the community.
• 2:42
  And the community sessions were initially mostly around rehabilitation, uh, with some care homework.
• 2:48
  And then about, um, seven years ago, set up a different model of working in the community, uh, which we'll go through in a bit more detail.
• 2:58
  Maybe let Dan introduce himself before we do that.
• 3:00
  Thanks Anna.
• 3:00
  Hi, Ruth.
• 3:01
  I'm Dan Harmon.
• 3:02
  I'm also, hi Dan.
• 3:03
  Also comm, a community consultant, geriatrician.
• 3:06
  I'm slightly older than Anna, so I've been on for a little bit longer.
• 3:10
  Um, but yeah, my passion for, um.
• 3:14
  Caring for older people in a consultant role has been driven a lot by family.
• 3:19
  Uh, for the same reasons as Anna, but also my experiences as an undergraduate and as a postgraduate, as a junior doctor now called resident doctors.
• 3:27
  But as a junior doctor, my experience of of working in a multidisciplinary team and what can be achieved, um, for I think a complex rather than complicated, um, cohort of patients.
• 3:41
  Um.
• 3:42
  Complex in the sense that that's what's fascinating about, um, caring for older people is how many things are happening to an individual that, um, causes sort of cumulative challenges that older people face.
• 3:54
  And I find that really stimulating.
• 3:56
  Uh, and I know Anna does as well.
• 3:58
  So the bit about us moving to the community, I'm sure we'll cover in more detail, but that's the background.
• 4:03
  Thank you.
• 4:04
  That's really, um, nice.
• 4:05
  And it's interesting how both of you, it was your families that.
• 4:08
  That brought you into that and just being aware.
• 4:11
  So immediately I'm thinking about one of the recordings I done called When I Get Old, um, I can't remember the lady's name there, so I should really, but um, I could see a picture, it might come to me later, but it was, uh, really talking about that, you know, when you get old and how people get treated and how they get looked after and what that looks like.
• 4:28
  So I'm sure there's gonna be some comparisons there, but, um, maybe, I think probably at this point it's probably worth us going into what, what it was that you've done or what it is that you're doing differently, um, and how that fits with that do with approach as well.
• 4:42
  Yeah.
• 4:43
  So seven years ago, um, we opened what's called the Gene Bishop Integrated Care Center.
• 4:50
  Um, so it's a bespoke building designed.
• 4:56
  With older people in mind and for older people, um, it's in, uh, a reasonably deprived area of Hull, which at the time that it opened didn't have lots of healthcare facilities.
• 5:09
  Um, and it was driven by, um, I think an acknowledgement from our health and social care leaders that we needed to do something different in the city for older people.
• 5:21
  And there was an opportunity to do that with, um, a new building, um, and the land, uh, that became available from the local authority.
• 5:30
  So, uh, what we've done is kind of gradually build a team, um, centered in the community, trying to deliver care closer to home for people, um, in both a proactive way and then more laterally with more wraparound, urgent and reactive care.
• 5:49
  And, um, the person who inspired a lot of this and who kind of sets the tone for how we deliver this, um, is a lady called Jean Bishop, um, who sadly passed away a couple of years ago, but she was really well known in the city of Hull, um, known as the Bee Lady.
• 6:08
  So she, um, in her seventies made a homemade bee costume, um, and, uh, would wear that, um, throughout the city, particularly in shopping centers, fundraising for a GK.
• 6:21
  So she's raised hundreds of thousands, um, of pounds for that and then received, uh, various different awards and recognition for that.
• 6:29
  So she's a, was a Freeman of the city, um, at British Empire Medal, um, but really epitomized aging well.
• 6:36
  So it was really appropriate that the center that we work in was kind of named after her.
• 6:40
  Um.
• 6:42
  And she was one of the first, uh, people through the doors, uh, that we were able to look after as well, which is really, uh, lovely.
• 6:48
  So, um, we're quite a yellow building, um, and there's lots of pictures of these all over the place, as well as lots of pictures of Jean.
• 6:57
  Um, but I think having her and, you know, inspire us, um, and the whole team has, you know, keeps us focused on what we're, you know, trying to achieve in terms of that vision of, um, helping people kind of stay as independent as possible.
• 7:12
  Age.
• 7:13
  Well really.
• 7:14
  Um, and I think it helps us, uh, maintain standards and quality 'cause we don't want to let her down.
• 7:20
  Just to add to everything that Anna's just described alongside the importance of Jean, I think, um.
• 7:28
  If we roll the clock back to two years before we opened the, there had been some, uh, modeling work of, you know, if we did nothing in our system and our system being at the time two CCGs care commissioning groups.
• 7:39
  So it was whole and east riding.
• 7:41
  Uh, quite different demographics, but covering a population of about 700,000.
• 7:46
  Uh, we have about 220 care homes at the time we did with about six and a half thousand care home residents.
• 7:53
  Um.
• 7:55
  And this sort of 10 year projection of what might happen in our system if we didn't do something different to support older people to, uh, to live as well as possible, close to home was, uh, well pretty damning really.
• 8:08
  And so I think it provided us with an opportunity working collaboratively with system partners.
• 8:17
  Um, you know, particularly from health and local authority, but the voluntary sector as well, ambulance service and uh, mental health services, fire service and so on.
• 8:26
  Um, was to actually redesign a service, uh, bespoke for older people, um, with, uh, health and care professionals right across the spectrum, working together on this, um.
• 8:38
  So I, you know, I think that the, the branding of what we do based around the amazing Gene Bishop is so important.
• 8:45
  The estate is an important part of that.
• 8:48
  It's very rare that you would have an opportunity to design a building around the needs of older people rather than it you perhaps being past a building that.
• 8:55
  It's no longer desired by another specialty, you know, it was quite unique.
• 8:59
  Um, but then the opportunity to plan this service together, to implement it in a, we call about, um, a plan, do study and act process, but really to test this out on a smaller scale and then grow it across Holland and laterally that Easter riding.
• 9:13
  Um, and to make sure we had the data to back up the narrative of what it was that we were trying to achieve.
• 9:19
  So although we're talking as two clinical, uh, leaders within in the team, the bit that can't be understated is the role that so many different people have played to create this opportunity to deliver better care for older people.
• 9:31
  Um, and that all started with a lot of planning right at the beginning, back in 2015 before we opened a couple of years later.
• 9:40
  He said quite a few things there between you and I'm just sort of thinking about, so one of the things, and I think you might have started to touch on this, Dan, that um, Anna was saying earlier on, was around that, um, that it had been acknowledged and recognized by health and social care leaders.
• 9:54
  So I'm quite interested in that piece.
• 9:55
  'cause you're talking about health and social care.
• 9:58
  Yeah.
• 9:58
  Um, and I think where you started to talk about that modeling of what.
• 10:02
  Would happen if you'd done nothing.
• 10:03
  That's really interesting.
• 10:05
  So I wonder if, um, you can describe or sort of talk about some of that and perhaps describe some of that and perhaps give some, a little bit of picture for people of, of what was going on.
• 10:13
  Because I'm sure there were probably things that you were seeing or that you were aware that other people were seeing of, of what was going wrong before we saw that actually start to describe some of the services and what you're doing now, if that's okay, please.
• 10:23
  Well, I think what we were experiencing across the system was, well, first and foremost, older people being labeled.
• 10:30
  So when I say these things, these are not direct criticism of any part or individual within our system.
• 10:36
  As you will know, Ruth, we, you know, we've got amazing people working right across the system, but yeah.
• 10:40
  We, we were almost treating older people as a cohort of frail, elderly, elderly.
• 10:46
  So this sort of label, uh, of a person with a condition and, and that I think what we were seeing was people present in late and often in crisis with, uh, frailty syndrome.
• 10:57
  So something like delirium and acute confusion state, um, a fall or reduced mobility.
• 11:03
  Um, most of these situations are, are preventable and, um, and therefore as a result of those in, um, those presentations being late and in crisis, where we were seeing episodic, disjointed, di disruptive care that was focused around a hospital attendance.
• 11:20
  And what we were trying to shift the dial to was actually seeing the frail elderly as described as actually an older person living with frailty.
• 11:28
  Seeing that as a long term condition and recognizing with evidence that timely interventions can be both preventative, proactive and can support somebody to, um, live independently.
• 11:41
  And we can do that through personalized care planning.
• 11:43
  So there was some limited evidence that the time that the delivery of comprehensive geriatric assessment, CGA, so that's a multidisciplinary team intervention focused around the person's needs, um, could actually be delivered in the community.
• 11:58
  It could be person centered, it could involve all those different organizations that we've just described.
• 12:03
  And actually, if we could do that, invest our time and energy into that and funding, we could move away from what was happening, which was this episodic, disjointed, disruptive care that was described.
• 12:15
  So, um, the, the sort of forward planning was recognizing through data that there was nerve dependency on the emergency department in the hospital.
• 12:23
  And to some degree there still is.
• 12:25
  Uh, but I'm sure we'll talk a bit about the evidence behind our approach later.
• 12:29
  Um.
• 12:29
  That actually due to the, um, expanding older age population that was predicted over the next or 10 to 30 years.
• 12:36
  When I say if we did nothing, we'd be in a, a pretty bad situation.
• 12:40
  It would be, have been a worse situation in terms of dependency and strain on the emergency department and the hospitals.
• 12:46
  Um, so that was really the vision was to try and shift from that older people's care, which was describing the frail elderly to this more proactive approach, which is why it's really pleasing when you see the Darzi report and then the 10 year plan.
• 12:58
  A lot of the things that I think would, will, will describe in this podcast are actually things that we were trying to implement over the last well decade really.
• 13:06
  And, and lots of other teams around the country have too.
• 13:08
  But hopefully it'll give it a bit more teeth.
• 13:10
  I think social care were really engaged as well 'cause they were also seeing a lot of similar problems in terms of, um, you know, strain on, on their services at late presentations and then, you know, emergency requests for care, SSP by et cetera.
• 13:26
  And we're really keen as well to try to move into.
• 13:29
  A more kind of proactive space, you know, really trying to, um, support enablement where appropriate, you know, help more with future planning, um, and predicting change, I suppose, in a different way.
• 13:43
  Thank you.
• 13:43
  That's really helpful.
• 13:44
  And I think that, you know, that description of what's gone on is really helpful and, and what you're trying to move to, which is that sort of doing things with people that proactive your, your episodic disruptive care.
• 13:55
  I think there'd be lots of people out there that have either felt that they've been recipients of that or on the end of that, or actually when we're working and doing things, sometimes we feel that that's what we're doing and it's not what we want to do.
• 14:07
  So that sort of frustration.
• 14:09
  So I wonder if you could talk us through a little bit about the physical building, first of all, and then it would be really nice to hear about actually what's going on.
• 14:16
  It might be that those two relates.
• 14:18
  You might talk about them both together, but yeah.
• 14:20
  Thank you.
• 14:21
  Yeah, so the building, so we're on, um, it was a derelict school site, um, that then got.
• 14:29
  Converted, um, to, um, in part a new.
• 14:34
  Building that we're in.
• 14:35
  So the Dean, bishop integrated care Center, and then the other part of the land, um, uh, was given to, uh, a local housing association for older people.
• 14:44
  So there's, um, a nice neighborhood around, kind of suitable for older people, which, so really lovely part of the community within a reasonably deprived area of the building itself.
• 14:57
  Um.
• 14:58
  We're co-located with the fire service, so they also had building challenges.
• 15:04
  Um, there's an opportunity for them to move in.
• 15:06
  Um, and initially we were quite colo co-located, but there is much more integration between the teams now, which we can go into in a bit more detail, if that's interesting.
• 15:15
  So the building itself, some of the benefits are free parking as opposed to often kind of parking challenges, um, at acute, uh, sites.
• 15:24
  So that definitely seems to help with, um, access, uh, for people when.
• 15:29
  Come in, we've got a kind of nice open reception area and tables for people.
• 15:34
  So we have on any one morning in the core bit where we're delivering proactive care, usually around six new assessments, uh, going on.
• 15:44
  So people have their own little space and there's enough room for, uh, family members.
• 15:49
  There's an onsite cafe run, um, by local, uh, voluntary group who then can provide tea and coffee and warm meals for people.
• 16:01
  'cause they come for an average kind of four or five hours.
• 16:04
  Um, to see the whole MDT can be tiring.
• 16:07
  Obviously, for people who recognize that we need to keep them refreshed.
• 16:11
  The flow of the building was completely designed with older people in mind.
• 16:15
  So lots of.
• 16:17
  Stopping points for people to be able to sit and rest.
• 16:20
  Lots of, uh, disabled access toilets.
• 16:22
  Um, all kind of dotted through the building for easy access.
• 16:26
  And so on the kind of main corridor where people rotate round to see all the different team members.
• 16:33
  Um, we've got.
• 16:35
  Some slightly clinical areas where, uh, people would go.
• 16:39
  First thing to have an initial set of like observations done, height and weight checked.
• 16:44
  ECGs, who can do bladder scans and take some blood tests.
• 16:48
  And then, yeah, people go on kind of carousel, so they'll see doctors or, um, advanced nurse practitioners, pharmacy team, therapy team, social workers.
• 16:58
  We've got carer support.
• 17:00
  We've got, um, a chaplain here if people want any spiritual needs.
• 17:04
  Um, discussing, we've got x-ray on site in the mornings so we can get kind of same day plain film x-rays, which can be helpful for.
• 17:14
  Monitoring or trying to look at any kind of new diagnoses.
• 17:18
  And yeah, so we try to target the, who the person first sees according to what might be the kind of main problem.
• 17:26
  Um, particularly recognizing that people might fatigue, so we get them seeing the, the best person for them first.
• 17:32
  But people are able to see everybody.
• 17:35
  I can't remember if I mentioned social workers.
• 17:37
  I think I might have missed them out, which I'm very sorry for.
• 17:40
  And that was completely accidental.
• 17:42
  Um, so yeah, but people can come get a holistic, uh, review hopefully of all their needs.
• 17:48
  We do call people before they come to go through a questionnaire that we designed with people prior to this and been through various different iterations to try to understand, um, I guess their perspective in terms of where they are from, um, a health and care perspective, what's changed recently or in the last year, and really try to understand, uh, what matters to them.
• 18:14
  Um, and what kind of any gaps, um, might be.
• 18:18
  And so that's how we can decide and try to focus some of the assessments.
• 18:23
  But the principle of what we're trying to deliver is kind of holistic assessment and interventions based on, um, the kind of evidence for how we manage that for pe older people, people living with frailty, which is this comprehensive geriatric assessment.
• 18:38
  And, uh, them all come together in the afternoon for an MDT just to pull everything together, make a plan, have clear goals, clear responsibilities, and that gets shared both with the person and their family and then back to primary care, the hospital, um, systems to try to share that record as much as possible.
• 18:58
  We don't have a seamless integrated, uh, care record yet, uh, locally, so got various different workarounds to try to make sure it's as visible as possible.
• 19:08
  We can go into any of that in a bit more detail.
• 19:10
  Thank you.
• 19:11
  That's really helpful Anna.
• 19:12
  And um, I was just gonna clarify the MDT for those listing is the multidisciplinary teams.
• 19:18
  It's all those people, social workers.
• 19:20
  I say them first this time, all those people that you've spoken about.
• 19:23
  So thank you Dan.
• 19:24
  You look like you were gonna come in and say something, but I just wanted to reiterate that first.
• 19:28
  Yeah, thanks.
• 19:29
  The only thing I'd like to add really is obviously when we started, uh, we're a smaller team than we, we now are, 'cause I'm sure we'll come on to sort of the reactive elements of what we do.
• 19:40
  But, um, with that population size of about 300,000 in, uh, residents in HU and about 700,000 if you include these riding, we knew we had to be quite targeted with our, uh, he would benefit the most from this kind of approach.
• 19:55
  So we used something called, um.
• 19:57
  Risk stratification tool called the Electronic Frailty Index, which was designed by a research team in, in, in West Oxford, Bradford, and Leeds by a chap called Professor Andy Clegg and colleagues.
• 20:09
  And what that, uh, does is it looks through a primary care database and looks for clinical coded information that would define somebody's risk of being frail.
• 20:20
  So you, uh, we will all know that just because you're older doesn't mean that you are frail.
• 20:26
  And when we talk about frailty, we mean, we essentially mean decreased resilience to a stress event.
• 20:31
  A stress event could be a fall or a bereavement or a change in environment.
• 20:35
  But, um, somebody who is living with frailty just doesn't have the physiological reserves to perhaps bounce back as quickly or indeed to the same degree after a stressor event.
• 20:47
  And what the electronic frailty index does is it maps a against coded information in the GPS record, and it's a bit techie this bit, but essentially it tells you if somebody's not at risk of frailty or at risk of mild, moderate, or severe frailty.
• 21:01
  And the importance of that following the evidence is that being at risk of severe frailty does mean that you are at greater risk of dying of attending hospital on frequent unscheduled attendance or, um.
• 21:16
  Transferring to live in a residential or nursing home.
• 21:19
  So if you've got a specialist multidisciplinary team in the way that Anna's described, not everybody needs that, that level of approach at that point, some people would benefit more.
• 21:29
  So we stratified the whole of the population of whole initially and then latter Easter riding, and we identified.
• 21:36
  3,200 residents at risk of moderate to severe frailty.
• 21:40
  So we thought, well, we'll target our, our invitation in to, to those residents first before trying to move sort of further down that pyramid of frailty to the larger group.
• 21:50
  Um, sorry, it was 3,200 residents at risk of severe frailty and 12,000 residents at risk of moderate to severe FRA lt.
• 21:58
  So we started with the severe, moved down to the moderate and severe, and we felt that was the best use of resource.
• 22:03
  Um, and, and so yeah, if people listening wondering, you know, how, how, how did you approach it? It was to use system level data rather than say, we'll go GP practice at a time or street at a time.
• 22:14
  We wanted to try and offer this level of intervention to everyone.
• 22:17
  And the only other thing to add is Anna talks about the importance of having, you know, the voluntary sets of cafe on site and free meal and drink provision for the person that we're assessing.
• 22:27
  But another key factor for us was, um.
• 22:30
  An agreement that we reach with our patient transport service, our ambulance service, so they change their clinical criteria to book patient transport.
• 22:38
  So you'd be familiar, patient transport is available to people who can't get to appointments under their own team.
• 22:44
  So, um, you know, they can ring patient, transport and get either.
• 22:48
  Uh, an ambulance crew or tactic crew.
• 22:50
  So they added frailty to their referral criteria.
• 22:53
  So about 30 to 40% of people that come to the Gene Bishop Center for their appointment actually use patient transport.
• 23:00
  And we have a very low DNA or do not attend rate within the service.
• 23:05
  And I think the combination of the environment, uh, the hot and cold meal provision and drink provision, and the dedicate transport service on our patient level feedback, they're always like positively reported in that sense.
• 23:17
  So I just wanted to get that across.
• 23:19
  And finally, for residents who reside in care homes, we, we actually take the model of care to the care homes, so we don't bring people.
• 23:28
  Um, it logistically can be quite challenging, might cause distress, particularly for people with, um, advanced dementia to move them to, for an outpatient appointment for half a day.
• 23:37
  Um, so our multidisciplinary team go into the homes, uh, to deliver this approach in the homes.
• 23:43
  We don't use the risk stratification 'cause there's a recognition that, you know, everybody pretty much is living with a degree of frailty, um, and residing in a residential or nursing home.
• 23:52
  So we've got a different approach to identifying that.
• 23:54
  The, the, the cohort of patients that would benefit the most.
• 23:58
  They're my extra points.
• 23:59
  No, they're really good.
• 24:00
  And I know we're sort of starting with some of this, like, you know, the data stuff, but it's really important how, how, it's one of my questions, how do you decide who to see and work through that? And you've obviously done a lot of work 'cause there are big numbers that you were talking about Yeah.
• 24:11
  That you needed to see.
• 24:13
  But actually.
• 24:14
  Fact, people can get there.
• 24:15
  They know that there's no problem.
• 24:17
  So all of that bit working with, um, the ambulance service around who, you know, changing their criteria and knowing that you're gonna get there is a comfortable place.
• 24:25
  Yeah, it's a nice place by the sound of it, you know, and, um, I've got pictures of all the, you know, the nice bees and everything else going along.
• 24:33
  Some somewhere to sit down and given a meal.
• 24:35
  And I think quite often when people go to hospital, we go even, you know, people that aren't very frail, but quite often we go when we're unwell and we're rushing about and trying to get there.
• 24:44
  And then when you get there trying to remember everything that you want to say, it sounds like.
• 24:48
  Before you've even started, this is a completely different experience where the person feels comfortable, they're fed or everything sort of attended to.
• 24:56
  So you can then start that assessment.
• 24:58
  So I wonder if we can just move on now to have a bit more of a description about what's going on.
• 25:02
  And I don't know if this point, if it might be useful, but it's up to you because I do understand confidentiality.
• 25:07
  But there might be a way that you can perhaps share a story or you know, a person that we could get a bit of a picture about what's going on and what difference that makes.
• 25:16
  Or it might be that you use a few different sort of smallest.
• 25:19
  Parts of a scenario to give some sort of concept as well.
• 25:21
  Please.
• 25:22
  As you can imagine, we, we've been doing this for some time now, so there, there's quite a lot of stories that that jump into your mind.
• 25:28
  But I think the one that depicts or describes what we're trying to do really well, there was a gentleman, um, that I think we saw within the first six months, in fact, first few months of the center opening called Ray.
• 25:39
  Um, and his videos on YouTube if, um, might be on other platforms as well.
• 25:44
  But, um, if you type in Ray's story, gene Bishop Integrated Care Center, you'll get see Ray and his lovely wife Val.
• 25:51
  So, um.
• 25:53
  So there's no confidential confidentiality issues te telling you about Ray 'cause he was happy and wanted his stories to be promoted and shared.
• 26:01
  So Ray was an older gentleman who would be described as severely frail.
• 26:07
  He was dependent on others for pretty much all his activities of daily living.
• 26:11
  Uh, his washing and dressing, his medications, um, his personal care needs.
• 26:17
  And, um, Val was his main carer as his wife.
• 26:21
  And, um, I think there was certainly some increased carer strain.
• 26:25
  Uh, Ray was identified through that risk stratification approach, um, but dis declined to attend to dis descended from attending 'cause he'd lost trust and faith in healthcare.
• 26:38
  Um, his comorbidities included conditions like heart failure, um, hypertension, so the usual things that, that people would tend to accumulate if you live long enough.
• 26:49
  Um.
• 26:50
  He was in pain as well.
• 26:52
  And, uh, so yeah, he, he, he declined to come to the center and, uh, one of our, um, advanced nurse practitioners, um, rang Ray and connected with him quite well on the phone.
• 27:04
  Then I think he went to see him just to try and encourage him to come and, uh, and, and then Ray came and Val came with him.
• 27:13
  Um, and as, and described, we have the carer support and information services part of the core team.
• 27:18
  So we were enabled able to carry out an assessment of carers strain or, or carer burden as well, which often is a reason why people flip into crisis in the first place.
• 27:28
  Um, uh, he.
• 27:30
  He had a home visit from our therapy team as well.
• 27:33
  Um, and one of the ray's biggest frustrations was his lack of ability to get outside.
• 27:38
  Um, and it was quite an easy fix.
• 27:40
  He needed, I think it was some adaptations at his back door and, um, an appropriate wheelchair so they could get Ray out.
• 27:46
  And there's this beautiful video of, well, it's a really sad video initially 'cause Ray's quite emotional in describing how he was.
• 27:53
  And then this sort of, this beautiful video of them.
• 27:56
  There's a local park, it's where they live called East Park and they're out having an ice cream and he's getting about, and you can actually see and feel his mood has lifted on the back of the interventions he's received.
• 28:06
  So, you know, as part of being seen, he saw that multidisciplinary team that Anna described.
• 28:10
  He did see a doctor, a nurse practitioner, a pharmacist, you know, he saw the therapists.
• 28:15
  Val got her carers assessment.
• 28:17
  They did get, uh, social work involvement as well.
• 28:20
  Um.
• 28:21
  And what the way Val describes the change in Ray was that she felt like she'd got her Ray back.
• 28:26
  Um, which, you know, is really powerful.
• 28:29
  Um, and then Ray Ray passed away.
• 28:32
  Um, I, I can't recall if it was about six to nine months after we'd seen him, which given his comorbidities and the evidence, we know that that was a, a very probable outcome.
• 28:45
  But I think for Val to say that, you know, she'd got her ray back for that short duration of time is, is so powerful.
• 28:52
  Um, Val then, um, there's a, I think it's a Friday, uh, lunchroom club sort of breakfast to lunch club that happens in the center of the building that's run by voluntary sector, um, the team that do the meals as well.
• 29:06
  And Val became a real sort of champion and advocate for that, inviting friends along to, to that as well.
• 29:12
  And so this, I felt like this center, Val was giving something back, but actually was gaining from that networking, that social interaction that's often lost as you get older.
• 29:23
  So that was really powerful and sadly, Val did die a little while, while back as well.
• 29:29
  But it was lovely that she still had this connection with, um, the Gene Bishop Center and actually their experience in the latter years of life absolutely epitomizes everything.
• 29:39
  It.
• 29:39
  Is that we have tried to achieve as a team through this.
• 29:42
  So yeah, I'd urge, I'd urge listeners just have a look at Ray's story 'cause I think it's really powerful.
• 29:47
  I hope I've done it justice Anna? Yeah, I think he hadn't been outta the house for two years had he? Um, so it's just beautiful to then see him.
• 29:54
  So delighted to be having an ice cream in the park.
• 29:57
  Um, it's lovely.
• 29:58
  And we can put the link up in the show notes and it sounds a lovely story and Fas and you know, something that I'll want, I'll watch afterwards.
• 30:05
  Definitely.
• 30:05
  And I think a lot of people will, but actually what you're talking about there is, you know, giving someone their way back, but you also gave him his quality of life back for that six months.
• 30:15
  And it sounds like what you're doing now is doing that for.
• 30:17
  Not just one person, but lots of people and you're working because you're working backwards, you know, from those really highly dependent, um, frailty, then you can start to invest in people before they even get to the point that Ray had got to.
• 30:30
  And doing that people centeredness, and I'm thinking about, you know, that is that do with approach that Adam lent spoke about, that you're doing, you know, what matters to you, what's important to you, and helping somebody to achieve that.
• 30:40
  And for him it was going out and having his ice cream in the park.
• 30:43
  That was really important.
• 30:44
  It wasn't about the ECG and the medications and everything else, which need to happen, but actually it was about all those other things that probably came from the social workers and the therapists and everybody else that came in, but also seeing that sort of community as an asset.
• 30:57
  So the fact that.
• 30:59
  Vow came in and then started to support that lunch club, and you've already got that community going on because that's seeing people as being not just, um, recipients of care, but almost builders of what, what it looks like and just their own, their own self, um, and what that takes them onto.
• 31:16
  So I'm just gonna, I could sort of say more really, but I think there's so much here to, to talk about that.
• 31:22
  I think rather than ask questions, I think what I want to do now is just ask you, is there anything else that, that you are really thinking about that you think I'd like to share that? Because I might not ask the right question, if not.
• 31:32
  So that's important to know and understand about what you've been doing, being able to.
• 31:38
  Build on what we were doing in the, those kind of proactive assessments, but then be able to offer more wraparound urgent care in the community has been really both, you know, rewarding for us, um, as clinicians in the system that I think really helped individual patients, um, kind of system outcomes.
• 32:00
  So we're able now to offer, which virtually every place in in the country has.
• 32:07
  I guess the difference with us is we're integrated with the kind of proactive, um, support is our kind of urgent response in the community for frail people and what's called kind of hospital at home or virtual ward model.
• 32:20
  Um, so that's trying to deliver more hospital based interventions, um, but in the community, so people's own home, um, including care homes.
• 32:30
  And so being able to tie those things together and do more where a lot of people say they want to be cared for.
• 32:39
  Has been, um, yeah, really rewarding and with hopefully good outcomes.
• 32:44
  I'm sure we'll cover this, but talking about data can sometimes be boring, but actually in this space when there was limited evidence, I do want to talk a little bit about how we've used data to drive a change process, if that's okay.
• 32:55
  And then maybe just a bit on, not just the system data, but actually the patient reported outcome data.
• 33:01
  'cause that's gonna feature heavily in the 10 year plan moving forward.
• 33:04
  So how we've, how we've used that patient experience data as well.
• 33:08
  Uh, a bit bit on the workforce as well in the future of, uh, the 10 year workforce.
• 33:14
  And then how we've embraced digital.
• 33:16
  'cause we cover a thousand square miles, so we've had to have a different approach for.
• 33:20
  Thinking about Chris Whit's work on coastal deprivation and how we've approached our communities in areas like on our, uh, northeast coastline, so sort of Linton and, uh, and Holden, us.
• 33:31
  Um, people might not know our geography, but we, we've got a very large northeast coastline, haven't we, Anna, with communities that have lived there for, you know, their entire lives.
• 33:42
  So a bit on that might be helpful as well.
• 33:43
  Yeah, that would be really useful.
• 33:45
  So I don't know, you know, it sounds like quite a nice line as well going through that data.
• 33:49
  So do you want to start there and then literally, you know, between you, I don't know, you probably know who's the best to answer each bit.
• 33:55
  Go through that workforce and then that digital, because if that sounds really good and that is that bit that you're talking about as well, that's that individual, but also that systems level working and, and difference that it's making.
• 34:05
  So thank you Dan.
• 34:06
  Yeah, so from a data perspective, we recognized that what we were doing back 20 17, 20 18, 20 18 when we opened was there was very limited data that actually this approach could make a difference.
• 34:17
  So we were using best available data for, uh, you know, and networking with lots of colleagues up and down the country.
• 34:24
  Um.
• 34:25
  Uh, and so what we decided we would do, uh, we is challenge the norm basically.
• 34:30
  So each provider organization has their own data and you know, there's always dispute as as to whether or not that data's accurate.
• 34:38
  Well, my data's telling me this, and you get stuck, uh, behind the data and that slows your journey down of, of progress.
• 34:46
  So what we decided, what we agreed across provider organizations, is that we would track patients using something called a strategic id.
• 34:54
  So that meant that patients were not identifiable and it meant that other provider organizations could look at that data as well, which was quite unique at the time.
• 35:03
  And we, um, what we did was we looked at 12 months before somebody had this proactive.
• 35:09
  Intervention with our multidisciplinary team and 12 months afterwards, and we compared that person's data in terms of their, uh, when we talk about secondary care being hospitals, their unscheduled secondary care activity.
• 35:22
  So that means emergency department, attendances, hospital admissions, and then we sampled within primary care to do the same thing.
• 35:30
  And then, so that was GP practices looking at unscheduled or on the day GP appointments and allied health professional appointments.
• 35:38
  Um.
• 35:39
  And we wanted to look at it 12 months before and 12 months after, so we could take seasonality out of the data.
• 35:45
  So if there was an improvement, people wouldn't turn around and say, well, you know, you're just looking at the data in summer, of course it's gonna be better, et cetera.
• 35:52
  And we also compared it to a group of patients who are yet to receive the intervention.
• 35:56
  But, um, but we're listed to receive the intervention based on that restratification we talked about at the beginning.
• 36:02
  And then we had a third group, which is people who dissented from being seen by the team, but we know their healthcare outcomes are often worse if people decline interventions.
• 36:11
  So there was a bit of a bias in that group.
• 36:13
  Anyway, the upshot of all that is we, we've got the system where we can track patients, um, and review their data.
• 36:19
  So I looked at it this morning, we look at it about once a week.
• 36:22
  Um, and if I tell you that within the first 12 months there was a 10%, so when we talk about improvement.
• 36:30
  As geriatricians Anna.
• 36:31
  And I want to make it very clear that if people need to be in hospital, they need to be in hospital.
• 36:35
  We still work in the hospital, we just do most of our work in the community.
• 36:39
  But I think there's a recognition that people end up there sort of by proxy.
• 36:42
  'cause the systems aren't often in place to support 'em in the community.
• 36:46
  So if we talk, when we talk about improvement in this space, we're thinking about a reduction in unscheduled hospital, attends emergency attends and admissions.
• 36:55
  So within 12 months we were looking at about a 10 to 15% reduction in emergency department attends and admissions for the cohort of patients that had received this intervention.
• 37:05
  When we look at the data now, so, so, and this is the, the important thing about how long it takes to see your improvement journey.
• 37:11
  Um, so.
• 37:13
  Today's data, we're looking at a greater than 50% reduction in emergency department attends and admissions for our most severely frail cohort that's even higher.
• 37:24
  And then for patients who are, um, deemed to be, um, frequent flyers, so that's five or more emergency department attend in the last 12 months or five or more emergency admissions, you're looking at, um, a reduction in emergency department 10 and admissions at about 70% and 85% respectively.
• 37:42
  So if you think about, um, the, the bed days saved within a hospital setting, that's looking at about 2 million pounds per year of bed days saved.
• 37:52
  Now, the reason I'm talking in statistics and money is because it actually.
• 37:57
  There, there isn't exactly a lot of money around in the health service at the moment.
• 38:00
  So you need, you have to be able to demonstrate your cost effectiveness to be able to invest in services.
• 38:06
  So we've got a fairly robust data set here that shows that if you invest in older people's care, proactively closer to home, which is what patients are telling us that they want, older people are telling us what they want and darzi, and the 10 year plan refers to this, then you can save money to invest.
• 38:23
  And the, the, hopefully the finances in the future NHS 10 year plan will follow the patient.
• 38:28
  So greater investment in community services.
• 38:32
  Um, when we looked at primary care, it was about a 10, again, about within 12 months, it was about a 10% reduction in GP emergency appointments and allied health professional emergency appointments.
• 38:43
  When you look at medication costs, just the raw costs of drugs, this concept of polypharmacy, you know, being on five or more medications is obviously very common in older people.
• 38:53
  But we talk about appropriate and inappropriate polypharmacy and inappropriate polys when people are on lots of medications that perhaps haven't been reviewed.
• 39:01
  Other circumstances have changed, and they're more susceptible to side effects normally 'cause of things like deteriorating kidney function, et cetera.
• 39:08
  So when you look at the element of de-prescribing, so reducing people's medications to try and improve their health, there's a cost saving of about a hundred pounds per patient per year just on rod drug costs alone before you think about the side effects of medications such as falls, impact on brain health, bowels and bladder, et cetera.
• 39:26
  So there's a cost saving from a meds medication perspective, from a primary care appointment.
• 39:31
  Perspective and from a secondary care.
• 39:33
  But I think more pleasingly for Anna and I, we carried out two independent, um, studies of patient experience, which was with our university partners at University of Whole.
• 39:43
  And we could demonstrate a sustained ipro improvement in patients physical and emotional wellbeing 10 to 14 weeks after this kind of assessment that were both statistically significant.
• 39:54
  And then we did a more qualitative study just looking at somebody, the patient narrative, the experiences of this kind of approach, which again, uh, was published.
• 40:03
  And again, we can share the links on those publications as well.
• 40:06
  So we've got quite a suite of an example of us using data to drive a change process.
• 40:11
  So limited data nationally at the beginning, develop our own data, share that wider with colleagues across the NHS and wider a field such as in Canada and various other places that we've networked with.
• 40:23
  Um.
• 40:24
  And so I think it's irrefutable now that actually if you deliver proactive care, you can have an impact on a patient level and a system level.
• 40:32
  And it's, it's nice that our team's been part of that journey.
• 40:35
  We thought this would happen, as in we thought it would improve things, but, but we really didn't know that it would at the time that we started.
• 40:41
  So there was a bit bravery within our commissioning colleagues to actually invest in this type of service back in 2018.
• 40:47
  Whilst it's all data, um, it's still exciting and the fact that you've measured it, and I think what I was thinking when you were talking about that first set of data is actually, of course, that's going to improve how people feel because if I'd spent less time in hospital, took less medications and had less side effects so that I was less likely to fall and I didn't have to think about all the, those other sort of side effects that you mentioned, bladder, bowels, all the rest of it, it then actually I'd feel a lot better.
• 41:12
  So the second lot of data, obviously you do want.
• 41:15
  But of course that makes sense.
• 41:17
  And as you say, we do have to sort of think about costing money to drive change and be able to prove that there's data there.
• 41:23
  But yeah, I'm pleased you held the norm.
• 41:24
  So thanks, Stan.
• 41:25
  Forgot one thing.
• 41:26
  I dunno if Anna was gonna say it, but, but, um, when we look at the data set, we recognize that people living with severe frailty might be in the last 12 to 18 months of life.
• 41:35
  So, um, colleagues listening might think, uh, well, and the public listening might think, well, your data's improved, perhaps 'cause people have passed away and then haven't.
• 41:43
  You know, use the hospital.
• 41:44
  Uh, in, in quite the same way, we actually filter such patients out of the dataset as well.
• 41:50
  Um, we, we can add them back in, but if, if somebody's passed away, they're not included in the overall dataset, because I think that would show probably a false improvement picture from a data perspective.
• 42:00
  Of course, what we're interested is, is when um, older people living with frailty naturally die, we, we are interested in their preferred place of care and preferred place of death and whether or not that can be achieved.
• 42:10
  So we do look at that data as well.
• 42:12
  But in terms of the overall system benefits, I just wanted to make that point clear.
• 42:17
  And we should say we have had help with some of our data from, um, NHS elect team in terms of how we've, I guess, learned to use run charts and things like that.
• 42:27
  Um, which again has been really invaluable.
• 42:30
  And our improvement kind of learning and journey.
• 42:33
  Thank you.
• 42:34
  So I know you were gonna go on to talk about workforce Anna.
• 42:36
  Mm-hmm.
• 42:37
  So I wonder if you might do that, and I, I know this is sort of perhaps a little sidetracked, but maybe as you do or a little bit further into that, I was interested earlier on that you were talking about how you work with, um, sort of the multi uh, disciplinary team, but also that wider almost.
• 42:55
  Um, I'm trying to think.
• 42:55
  Community, so you talked about the fire service and people like that, and I'm quite interested in that bit as well.
• 43:01
  So I dunno if that comes in here, but it'd be really nice to hear a bit more from yourself and or Dan.
• 43:06
  Yeah.
• 43:06
  So in terms of our workforce, um, so we've grown a lot, um, quite quickly I guess, over, um, the last seven years.
• 43:16
  When we started, it was a mixture of redesigning some existing roles as well as some new posts.
• 43:25
  So there was some new money put into the workforce initially.
• 43:30
  Um, and then as we've grown, it has been through those kind of new funding models of things like the urgent community response and hospital at home.
• 43:40
  So that has driven.
• 43:41
  Some of the further growth.
• 43:43
  But I suppose when we started, um, we were really keen to get kind of right people who we knew, you know, had a real heart for looking after older, frail people who were really bought into the kind of shared vision goals.
• 43:59
  And, um, trying to, you know, have, I guess a, you know, a see and solve approach rather than being quite task orientated.
• 44:08
  And we were also keen that we weren't gonna, didn't want to bleed one system and create, you know, more workforce problems.
• 44:16
  In different areas.
• 44:17
  So we've had quite a mixed approach to how we've tried to build our workforce, um, and tried to be as flexible as possible.
• 44:24
  So we've had some people on rotational role, um, roles.
• 44:28
  We've had split jobs, um, across organizations.
• 44:31
  So people maybe do a couple of days with us and a couple of days in the hospital or a community pharmacy, um, or still within primary care.
• 44:40
  And people have come from, um, already working with, within frailty or perhaps, you know, other kind of more generalist, um, settings, and then built up some of the frailty competencies.
• 44:52
  So we've had different approaches.
• 44:54
  Um.
• 44:56
  But I guess quite focused around who the, the, what we thought were the right people, um, to get them, uh, in post and then looked at.
• 45:04
  Um, we've created a kind of competency framework.
• 45:08
  Um, so tried to be less specific on roles, I guess, but what people, you know, are able to deliver.
• 45:15
  Um, and generally our retention has been really high, so very high from a doctor.
• 45:21
  Um, and, uh, nursing perspective.
• 45:24
  We have, uh, struggled a little bit more in terms of pharmacy and occupational therapy in particular, but I think that represents the particular challenges, uh, within, uh, that sector locally.
• 45:36
  Um.
• 45:46
  This concept, um, from, uh, colleagues, uh, down in, um, Epson and St.
• 45:51
  Hillier who again, have looked to do something different, uh, with their workforce.
• 45:55
  But the principle of it is, is that we've got a lot of, um, our, kind of, our workforce have overlapping skillsets.
• 46:04
  So if we think about people working within primary care, kind of frailty in older people's medicine and then, um, palliative care people are highly skilled in delivering holistic care and assessments.
• 46:17
  Um, and particularly for people, you know, older people, um, in the last few years of their life, there, there can be a lot of overlap and duplication.
• 46:27
  Um, but I guess we're really interested in how we can work better as those kind of broader teams.
• 46:34
  And hopefully, I think the 10 year plan can help us come together even more, you know, locally and.
• 46:44
  More broadly in these neighborhood teams of how we wrap around, um, yeah.
• 46:49
  Support for people.
• 46:51
  Use the skills that we've got within our teams, and then access the specialists as we need them.
• 46:57
  Um, and there's really good examples in other parts of the country who have really embraced this with.
• 47:02
  When they have had particular workforce challenges, for example, in kind of west, uh, Northern Ireland, um, and other kind of rural areas.
• 47:10
  So there is a lot of, yeah, shared, shared skills.
• 47:14
  Um, that's not to say everybody can just duplicate each other's work, not saying that at all.
• 47:18
  But there is, um, a degree of, uh, overlapping skills.
• 47:23
  And I think generally we just need to be smarter, don't we? As we all will try to work together moving forward and some of the digital enablement that can come, um, with that I think is gonna be equally important rather than us all doing detailed reassessments of the same kind of things.
• 47:39
  Um, if we can get to a space where for each individual person really have, you know, detailed information and background that is much more easily visible and that we build upon, rather than spending lots of time rehashing the kind of same, same things.
• 47:56
  Um.
• 47:57
  I think that'll, if we can get the right digital systems for that, that will be such a great enablement, um, for how we can yeah.
• 48:04
  Work together more smartly.
• 48:05
  Thank you.
• 48:06
  And you talk quite a lot there about sort of those different professionals and working together and that they all bring those unique skills.
• 48:13
  Um, you know, you've mentioned occupational nurses, quite a few different ones, so I wonder if you can just sort of give a little bit more of a.
• 48:22
  Picture of what that looks like for anybody listening as to how that works.
• 48:26
  Because quite often, you know, we all still talk.
• 48:28
  I'm going to the general practice and we still think about that.
• 48:31
  We're going there to see the doctor.
• 48:33
  Um, and even when people come in, I worked in general practice, they would say, thank you, doctor.
• 48:36
  I said, oh, I'm a nurse.
• 48:37
  You know, but because they're similar me, I wasn't wearing a uniform at that point in my career.
• 48:42
  They just assumed I was a doctor, but actually I was bringing something else and something different.
• 48:46
  Yeah.
• 48:46
  I wonder if you can just give it, it doesn't have to be big, but something to just give a little bit of a picture of what that looks like, that multi professional working so people can understand why it's so important.
• 48:54
  So I guess as a team, predominantly we're all co-located.
• 48:57
  The benefits of that mean, hopefully there is less duplication.
• 49:02
  We can share information.
• 49:03
  You can just walk across a corridor and say, I found this.
• 49:05
  Can you build on this in your assessment, for example.
• 49:08
  Um, or they've mentioned this, I don't.
• 49:10
  Know what to do next.
• 49:11
  You know, can you take over and bring, um, your expertise? And there's been a lot of shared learning.
• 49:18
  I think we've learned a lot around, you know, the support that's available through different professions, um, and groups.
• 49:25
  Um, so there's particularly, um, in our.
• 49:28
  Uh, I guess our first 12 months of coming together as a, as a new team together, there was, um, a lot of upskilling, um, and sharing about different kind of roles and responsibilities and how we could work more effectively together.
• 49:44
  So we do come together to discuss each individual person in the afternoon as a team.
• 49:50
  We used to do impression there is done on Microsoft Teams.
• 49:53
  Um.
• 49:54
  And again, I think that helps with continuing to upskill each other, sh share that information and make sure that, that we're not coming up with conflicting plans.
• 50:04
  So to bring that together, uh, for each individual person.
• 50:07
  So we do that for each of the, um, people that we're seeing from that proactive model that we described.
• 50:12
  I think that the opportunities for career development are significant in the team.
• 50:16
  Uh, I think you have covered that, but, um, you know, if you think about your non-medical prescribing cohort, it would traditionally come through a, a nursing route by background and actually our pharmacy.
• 50:26
  And that's not been the case with us.
• 50:28
  Um, the a that those groups are in there.
• 50:32
  But in addition to that, I'm just thinking about some of our, um, clinical roles that have come from a physiotherapy background.
• 50:39
  Colleagues that have come perhaps from a mental health nurse background that are working in what would be traditional class as physical health services, but really they should just be services for older people.
• 50:49
  Um, Anna talks about loca colocation and the importance of the gene bishop building, but um, colocation sort of promotes integration, doesn't it? If you're in the same building as somebody, it's hard not to start those conversations.
• 51:01
  And so I would say we were initially co-located with the homicide, fire and rescue, but over the first sort of 12 to 18 months, we worked on integrated pathways.
• 51:09
  So, um, thankfully we don't have quite as many fires locally as we used to.
• 51:14
  And so the fire service skillset has diversified and they now run our falls pickup service within whole and elements of the Easter riding.
• 51:23
  So if somebody presses their lifeline, it's actually on beside fire and rescue that are your first responders.
• 51:28
  If, um, somebody needs to be seen face to face.
• 51:31
  And so we've worked with them so that, um.
• 51:34
  They're fully aware of our proactive care pathways in terms of the benefit of coming to the Gene Bishop Center for that full assessment.
• 51:41
  And so they can book people in for that.
• 51:43
  They can also do that if they're in people's own homes doing a safe and wellbeing check, which the fire service also run.
• 51:50
  So they're one of our referral sources to get this sort of proactive assessment.
• 51:54
  Um, but in addition to that from a reactive services, so if somebody presses their lifeline, if they need a clinical response, they ring us, they ring the Urgent Community Response team, which, which is part of our reactive services.
• 52:07
  So we've trained the Humberside Fire and Rescue team to carry out, um, basic observations so, you know, blood pressure, pulse, oxygen levels, et cetera.
• 52:15
  So we can get a more, uh, objective assessment of the individual.
• 52:19
  They can of course ring as if they're just worried about the person as well.
• 52:22
  Um, and so that, that's been a, a really good link, hasn't it, Anna? I think between ourselves and the fire service and equally we can refer.
• 52:30
  People to them if we think they need a safe and wellbeing check at home, which was, you know, a really unique way of f fire and rescue working alongside health where there has been traditional barriers, I think, to that.
• 52:42
  Um, why sec, why the public sector sort of roles as well.
• 52:46
  The voluntary sector are heavily engaged with what happens within the Gene Bishop Center.
• 52:50
  Anna mentioned Gene Bishop and the work that she did for a k Alzheimer's society.
• 52:55
  Obviously really important to us, uh, working on integrated mental health pathways as well.
• 53:00
  Um, we actually run elements with a memory assessment service for older people from here as well.
• 53:04
  And we have a, a weekly dementia MDT multidisciplinary team meeting that has colleagues from the mental health background as our, our team and a clinical lead in dementia care and then Alzheimer's Society.
• 53:17
  Um, I mean, I could go on of the list of important voluntary sets or organizations in, in involved in older people's care, but I think for the ones that are traditionally seen to be more older people facing, we've, we've got really good working relationships there for us.
• 53:29
  Having people being able to work across the different areas and having the skillset for that has provided, um, a much higher level of resilience.
• 53:39
  So if we were all just broken down into kind of more discreet, smaller teams, um, and a bit more siloed, um, then I think there would be things that we would be, you know, canceling all the time because of sickness, for example.
• 53:53
  Um, and so everyone being able to work across, uh, different areas and therefore have a.
• 54:02
  Larger team.
• 54:03
  Whilst that brings challenges of managing a larger team, um, I think for us the benefits outweigh, um, the problems that that brings, um, and is rewarding in different ways whilst the kind of more on call urgent stuff can in lots of ways be, uh, challenging, um, is also very rewarding, um, in other, in other ways.
• 54:25
  So I think people being able to have a variety, um, definitely helps with our retention as well.
• 54:29
  Thank you.
• 54:30
  And it just sounds, um, fascinating and I think Daniel, I know, sorry, Dan.
• 54:34
  Um, I think Dan, that you were saying that, what you were saying there about the fire service and how they can refer to you and vice versa.
• 54:43
  I mean, to me that's sort of almost like a revelation.
• 54:45
  I know sometimes when I was first on my advanced nurse practitioner training and I'd refer somebody to the hospital and they say, oh, but you are a nurse.
• 54:51
  You know? Mm-hmm.
• 54:52
  So the fact that you are taking a referral from, you know, not saying, oh, but you are, you are from the fire service.
• 54:57
  You know, you're a fireman fire woman.
• 54:58
  That, that's amazing.
• 54:59
  And I'm sure that that really, to me, illustrates that though.
• 55:03
  You can't talk about every single service that you link in with, particularly from the voluntary sector, and there's so many that illustrates the type of.
• 55:10
  Working relationship you have and the impact that that has that, that coordination and that, um, understanding, but also just seeing the, the whole community there as an asset.
• 55:23
  So yeah, those things that you're describing there, both of you are, are really useful.
• 55:27
  Thank you.
• 55:28
  So before we finish, we probably need to sort of think about what, what are your key messages? What, what do you think people should take away from this? And I suppose it sort of might be at different levels.
• 55:38
  And is there anything that you particularly, you know, is there a call to action or something that you'd like people to do after they've listened today or to think about? One thing I don't think we've really mentioned yet is the opportunity for clinical leadership in this space.
• 55:51
  So, you know, everybody's time pressured at the moment.
• 55:54
  Um, and I think Juan and I didn't clarify at the beginning of the, the, the call was, um.
• 56:01
  Our background of moving into the community.
• 56:03
  So we started as hospital-based geriatricians working less than half of our clinical time in the community, but now we are community-based geriatricians working a small amount of our time in the hospital.
• 56:16
  So that's just our on calls, you know, the weekends in the hospital we're challenged us done.
• 56:20
  So she's doing really well's doing this now.
• 56:22
  But the, um, but that's the kinda shift that needs to occur.
• 56:26
  And it's not for everybody, but, um, you know, when Daisy talks about hospital to community.
• 56:33
  That means I think that it's gonna, it's gonna be a difficult challenge for organizations, but we're gonna have to, um, have some specialist input, uh, to work alongside colleagues that are working within a primary care and a community setting.
• 56:46
  So, you know, if you've got a Department of 10 geriatricians, do you need, like one person's amount of time in the community is a first step to try and deliver care close to home, and the same across various other specialties and disciplines as well.
• 56:59
  But I think that the clinical leadership aspect, you know, Anna and I do have dedicated time in the working week.
• 57:04
  A modest amount of time, but there is still some dedicated time to still continue to drive the changes that we've been trying to describe today.
• 57:11
  So that's, I think, quite unique.
• 57:13
  I think I've already mentioned the data, but you know, if teams are starting to do this early on, getting data sharing agreements in place, so, and deciding what it is that you're gonna measure and maybe running that past a critical friend or, or, or peer network.
• 57:28
  And NHS select's a good example of how we use them, but there others do exist.
• 57:33
  The third thing is, again, thinking about, um, the, the 10 year plan is digital features very heavily.
• 57:40
  And so we've been trying to embrace digital opportunities right since the beginning of the Gene Bishop Center.
• 57:45
  So.
• 57:46
  For people that are truly housebound or live in coastal areas.
• 57:49
  We actually send a member of the therapy team out to the patient's house.
• 57:53
  And then just like we're doing today, the rest of the multidisciplinary team dial in to complete that comprehensive geriatric assessment.
• 57:59
  But we have, um, digital stethoscope so we can listen to heart and lung sounds remotely.
• 58:04
  We can carry out a certain physical aspects of patient care.
• 58:08
  Alongside that, we use a AI scribing, use a product that will record the consultation that we can then edit the transcript for, and that's saving a significant amount of clinical administrative time.
• 58:23
  Um, obviously everything is validated and checked and we've got the right, um, safety in, in place to make sure that information is accurate, but that's allowing us to be more efficient with our time.
• 58:33
  You know, we.
• 58:34
  'cause we cover a large geography.
• 58:35
  We're using things like point of care testing so we can carry out a blood test at somebody's bedside or you know, if they're house bound or in their own home or in a care home.
• 58:43
  So every opportunity for teams like ours caring for older people, or in fact any demographic of patients trying to use these digital opportunities is so important moving forward.
• 58:53
  So there would be my three leadership data and digital Anna.
• 58:58
  I think now there's much more evidence about what works in the community for delivering care in a different way for older people.
• 59:04
  So how, what that looks like can is different in different areas.
• 59:09
  So for us, a building was a great catalyst for change.
• 59:13
  You don't need a building to deliver this.
• 59:15
  You can do it in different models the way Dan describes.
• 59:17
  But we don't need to pilot to get the evidence.
• 59:20
  We have the evidence of pilot how to implement I think, in different ways.
• 59:24
  And I.
• 59:26
  You know, these new shifts to, to neighborhood teams, centers, um, partnerships, I think can be that catalyst now, um, for areas.
• 59:35
  And the challenge is how, not what maybe.
• 59:40
  Yeah.
• 59:41
  And that's really interesting because, um, it.
• 59:44
  So often I hear pilots happening and you think actually you've had that pilot that's gone on and it is about learning and it's about that knowledge, um, translation, isn't it really? And knowledge mobilization actually.
• 59:56
  We've got that knowledge.
• 59:58
  How do we make it work? It works there.
• 1:00:01
  Why did it work there and how do we make it work here? And that might look different, as you say.
• 1:00:04
  It might not be around the building, it might be around something completely different.
• 1:00:08
  And of course, bringing in that data and that digital and, and clinical leadership is so important.
• 1:00:14
  And I think clinical leadership, along with time for reflection and, and, you know, thinking about what, what we're doing, none of this would happen because you do need to be able to stop, think, think what's working well, think what's not working so well, and start to think about.
• 1:00:28
  Actually, how can we do things differently, which is exactly what you have both done.
• 1:00:32
  Um, and I'm sure with a, a big team around you, but you've driven this from the beginning.
• 1:00:37
  So thank you so much for joining me today.
• 1:00:39
  I've really enjoyed it.
• 1:00:40
  And thank you for your patience with the call as well, breaking down partway through, which hopefully listeners won't be aware of.
• 1:00:46
  Thank you very much.
• 1:00:47
  Thank you for having us.
• 1:00:48
  Yeah, thank you.
• 1:00:49
  You're welcome.
• 1:00:49
  Thank you.
• 1:00:52
  I hope you found this episode interesting and inspiring.
• 1:00:55
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• 1:01:00
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• 1:01:04
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• 1:01:08
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• 1:01:21
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• 1:01:27
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