Frequently Asked Questions

Who is involved?

Each Connect site brings together organisations that support children, families, adults and the elderly who use locally provided health and care services and those providing wider services, such as housing, and activities.

Across Suffolk Connect is linking in with professionals, for example, Health (GPs, District Nurses, Occupational Therapists, Clinical Commissioning Groups), Adults Community Services, Mental Health, District Councils, Police and the Voluntary Sector. We are looking at how to streamline services to provide the best possible service, ensure there is effective communication and also look at how we operate services differently, for example, through Adult Community Service clinics at GP Practices or Simple Equipment clinics. Please see the area pages for more information.

We are keen to link more professionals and voluntary/community organisations into Connect, to build on the work that has already taken place and to further develop the Connect way of working. So, please contact us at [email protected] if you would like to find out more.

Why is this necessary?

Public sector organisations are facing ever-increasing demand for their services. This calls for a different approach. Through Connect and joint working, the aim is to deliver more high quality integrated services.

Current pressures include a decrease in funding combined with both an increased demand from service users and increased public expectations of what can or should be delivered.

Suffolk’s population is increasing, and by 2031 it is estimated that there will be a 55% increase in the number of people in the county aged over 65 and a 72% increase in people aged over 75. As the population increases and people live longer, this will mean more people living with sustainable long-term health conditions.

Connect is an important project to:

  1. Promote integrated care
  2. Ensure services can cope with the projected increase in demand
  3. Make sure that patients get the care and support they need, with each organisation working and communicating together with others more effectively and directly.
What is the integrated care model about?

The model is not just about the community working together. It also includes NHS 111, hospitals and paramedics. There are four elements to this new model of care.

  1. Prevention – This is about keeping people healthy and happy, ideally in own their homes, supported by local networks which they can use to get the help and support they need.
  2. Integrated Care Coordination – The focus is also on keeping people with multiple or complex health needs in their own home too. These people will be identified by health and social care professionals who will work together as Integrated Neighbourhood Teams (INTs). These professionals will plan and coordinate services so that the needs of both patients and their carers can be met.
  3. Urgent Care Response and Treatment – This will ensure a rapid response for patient assessment and treatment, reducing the number of telephone numbers needed when urgent and emergency care is required. The ambulance service and NHS 111 will work more closely together and there will be better management of people attending A&E and, where appropriate, referrals to community-based rather than hospital-based services.
  4. Returning to Independence – The Integrated Neighbourhood Team professionals will also have responsibility for ensuring people access the right rehabilitation services so they can get back to living a normal, happy and independent life as quickly as possible. The rehabilitation process includes not only practical support, but also ensuring all patients have access to the information they need to make the right healthcare decisions to support their recovery and future health and wellbeing.
How long has the project been running?

We have been working towards better integrated public sector working since 2015 when we initiated two early adopter Connect sites – Sudbury and East Ipswich. Currently, there are 13 confirmed sites (listed below) where Connect work is being focused upon.

There is still a lot of work to do; however, Connect has already brought staff/professionals together from social care, health, police, mental health and district councils to work with the voluntary sector, community groups and local charities. Monthly Integrated Neighbourhood Team meetings are held across the area with the aim of getting professionals and organisations working together as effectively as possible, based on the area needs.

Current Connect sites:

  • East Ipswich. (IP3/4)
  • West Ipswich (IP1/2)
  • South Rural
  • Felixstowe
  • Stowmarket
  • Eye / North West
  • Saxmundham/ Aldeburgh, Leiston and Framlingham
  • Woodbridge
  • Sudbury
  • Forest Heath
  • Bury Town
  • Bury Rural
  • Haverhill
What are Neighbourhood Networks?

Your Neighbourhood Network is defined by you. It is all your social connections, this can be family, friends, people you know through work, community groups, voluntary sector organisations, shops, GP practice and community pharmacies.

Your Neighbourhood Network can have a key role in promoting and supporting wellbeing and positive lifestyle behaviours. What we already know is that social connections are important to reduce social isolation and loneliness – people with better connections have better health and an improved sense of wellbeing.

Connect looks at how an effective Neighbourhood Network can help an individual. By making sure health and social care staff/professionals work together with local charities and voluntary/community groups, Connect teams are aware of what is available to benefit an individual within their Neighbourhood Network, and can help them to get the support they need.

There is a new role – Local Area Coordinator (LAC) – in place in Sudbury, East Ipswich, Saxmundham/Leiston and Beccles which has staff on the ground working with people to ensure they are able to access the community support and groups they want to.

What are Integrated Neighbourhood Teams?

A typical Integrated Neighbourhood Team (INT) will consist of staff from a number of different teams/ professions: social care for adults and children/families, health, police, mental health, district and borough teams, along with the voluntary sector. The staff from these different teams will work together to deliver a number of key objectives:

  • Reductions in permanent admissions to residential/nursing care
  • To demonstrate the effectiveness of re-ablement i.e. getting people moving again
  • Reductions in non-elective emergency hospital admissions
  • Reductions in forced evictions and homelessness
  • Better health outcomes (including less obesity, smoking and teenage pregnancy, and more breastfeeding)
  • Improved emotional wellbeing
  • Reduced rates of re-referral i.e. treating people multiple times
  • Ensuring that the ‘voice of the service user’ is clearly heard

INTs might do this by holding a number of multi-agency team meetings to discuss those customers/patients that they have in common. This is just one idea.

INT staff, who will remain employed by their own organisations, will offer seven-day cover to help people maintain their independence, enable self-management and support ways to prevent people going into hospital unnecessarily and help them leave hospital safely. These professionals will behave proactively so that people are given the right care, treatment or information early on. Each individual will have a named coordinator who will be responsible for that person’s ongoing care, meaning that they do not get lost in the system.

To make this project work, different organisations need to share information better. How will this happen?
  • There is already a data sharing agreement between some of the agencies within the INT; this needs further work
  • Regular multi-agency meetings between staff/professionals within the INT will see individual cases discussed
  • There should be a reduction in referrals and an increase in more informal requests for involvement along with increased support between colleagues
  • By working together, Neighbourhood Teams within a locality will share appropriate information between them
With so many organisations involved, where does accountability and responsibility sit?

This is a shared process, and the egalitarian answer is – it sits with everyone. You, the community in which you live and work, as well as the services you use. We recognise we are not there yet, and there is a lot to do. The project is being overseen by a multi-agency group of senior managers, but accountability and responsibility for NHS, social care and police services, etc, will remain with those bodies.

Many people are confused by the options available and don’t know the right place to go for help. How will this change?

This integrated care model aims to simplify access to information and services. The right tools, information and advice will be provided, and that is likely to be through Neighbourhood Networks and Integrated Neighbourhood Teams. You might have other ideas, which we would be keen to hear about. Access routes to urgent and emergency care services will be made more direct and less confusing.

Details of countywide contacts and helpful information links can be found – HERE .

We are promoting the use of Infolink (www.suffolk.gov.uk/infolink) as a key way of accessing information, and over time, additional information will be added to this website.

 

How will the project develop?

Connect is a way of working and will develop based on the needs of the community as well as government agendas of what services need to look like. It is a long-term project that aims to transform the way we manage people’s health and care needs.

Each area has a plan and this reflects what further work there is, both looking at health and social care working together, and how we best link in with the local community. Each area may develop slightly differently depending on the needs and learning that has been taken from the early adopter sites of East Ipswich and Sudbury. There are Implementation Managers across the areas whose job it is to make sure that Connect works.

Is Connect supported by all organisations locally?

Connect is working with other projects (for example – Building Community Capacity) to ensure that as many organisations are represented as possible, and that we are working together in the best interest of the local communities to provide joined-up services that produce better outcomes for people.

This has been growing across the Integrated Neighbourhood Team (INT) areas and there is increasing involvement of the voluntary sector. INTs are always keen to hear from organisations who would like to know more – please contact us at [email protected]

 

Can you share any Connect success stories?

We are currently compiling a number of case studies for this website to show how Connect is helping people across the county. The following success story is one example of the benefits being experienced by members of the public through the coordinated care approach of the Connect project:

A gentleman with type 1 Diabetes lived alone in a property that he shared with tenants. His wife lived abroad and he had no formal care in place. Poor control of his Diabetes had caused infections, lethargy, low mood and many admissions to hospital with hypoglycaemic (low blood sugar) episodes.

As part of the Connect project, a community matron, social worker, diabetic nurse specialist and district nursing team worked together with the gentleman and a named carer from a local care agency to draw up a holistic coordinated care plan in his home. They began by asking the gentleman what his goals were and he said that he would like to fly abroad to visit his wife.

The team then used the general principles of how to manage diabetes together with the existing hospital specialist care plan that had been devised for the gentleman to draw up and agree on a plan. It highlighted the importance of timely visits by the carer to help the gentlemen regain his independence by ensuring good nutrition (through planning meals and learning how to use a slow cooker), to help in monitoring glucose levels within given guidelines and to provide encouragement and support to help with low mood.

The carer followed the plan and progress was monitored through regular meetings between the carer, social worker and local area coordinator at the gentleman’s home. Within one month the gentleman’s episodes of hypoglycaemia had been reduced from many to just one. He was happier, less lethargic and able to function better. He was also able to book the ticket abroad to see his wife.

A huge improvement was made in this case through the coordinated care that was planned and put in place with the gentleman in his home by the specialist nurses, the community district nursing team, the community matron, the social worker and the care agency in liaison with the hospital. The named carer had a clear plan to work to and the support of a coordinated team.

From my perspective, how will this be different to what happens now?

Defining this will be really important to the project – so we are working on this with partners and the public. Ultimately, people who need support should have fewer nurses, social workers or other professionals coming to their door, and just one person to speak to if they have a problem. We need to simplify ways for people to get help, and share information better between services and voluntary sector.

If there is someone that I know that I think needs help what should I do/how do I help?

One of the aims of Connect is to help people be aware of what support is available to help them and their families lead a healthy and active life.

You will find contact details and links to useful websites to help you find the specific support you need – HERE

We are working on adding further information to this website to list ways in which you can help and what you can actively do. If you have any suggestions for additional information to be added to this website, please email us at [email protected]

Will this mean that services are lost, reduced or changed?

There is no plan to reduce services or change them. We still want people to get the care they need in the right place.

How would you best describe Connect?

Local people in Suffolk have called for health and social care services to work together much more closely and to link in with the local community. Connect is here to help make this happen by bringing resources together to provide health and social care services that are more helpful to you to live an independent life, and to enable you to take control of who is involved in your support and when.

Do you have a question? Fill out the form below and one of the team will get back to you.

You may be able to answer some of your questions by visiting the Infolink website.

 

 

 

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