North Norfolk leads elderly care revolution

North Norfolk is leading the way with a pioneering scheme to give elderly people care closer to home and to bring hospital beds into their communities.

From next month GPs and nurses at more than 20 practices in the district will be able to do more to help older people with illnesses to stay in their own homes, including giving them access to end of life care.

While North Norfolk will be the first area to get the new Care Closer to Home service, NHS Norfolk plans to roll it out in phases across the county.

The project includes creating 'acute community beds' which will give patients the same care, or even better, than they would receive in a hospital, but closer to home.

Health bosses said the scheme was at the heart of the county's plan to meet the health needs of its growing elderly population and would also help to free up hospital beds and reduce bed-blocking.

There are estimated to be as many as 800 frail elderly people in north Norfolk who have complex health and social care needs and who need extra support. They might be prone to falls, have heart and lung conditions or fall ill with infections frequently.

The aim is to provide a greater degree of support closer to where they live, at home or in a setting as close to home as possible. This will help to keep the patients well and living independently or to head off any problems before they get too serious.

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It follows the success of a pilot scheme running in Norwich, Cromer, Mundesley and North Walsham in which 220 older and more frail patients have been offered closer support. Since January, 113 potential hospital admissions have been avoided as a result.

For the pilot there were three acute community beds, one at Woodside House Care Home in Woodside Road, Norwich, and two at Benjamin Court, in Roughton Road, Cromer.

From December this will be increased to 12 in total, retaining the one in Norwich, while the other 11 will be housed at Benjamin Court, North Walsham Community Hospital and Aylsham Hospital.

Once vulnerable patients have been identified by their GP practices, they will be assigned 'case managers' - community nurses from Norfolk Community Health and Care NHS Trust (NCH&C). The case managers will monitor the patients regularly and ensure that, wherever possible, they are kept well and can stay at home.

In order to keep people independent and in their home for longer individuals will also be assessed for using telecare/telehealth. Telehealth units allow clinicians to monitor a patient's condition via a computer link.

If a patient's health deteriorates then they might be offered secondary care in one of the acute community beds.

Medicine for the Elderly clinicians from the N&N will be offering an outreach service to the GPs and nurses taking part, adding to the weight of expertise at community level.

In addition, volunteer support workers will build a relationship with each patient, offering help and advice.

Sheila Leach, a great-grandmother who lives with her husband, Ronald, in Mundesley, had heart problems and associated walking difficulties and is one of the patients who has been helped by the scheme.

She said at the time: 'It has worked very well for me. I have had a lot of help and I think everyone ought to know about it.

'It has kept me a lot better. My community nurse, Rosy, has helped me get up and walking – I can't praise her enough.'

Mrs Leach's case manager, NCH&C community nurse Rosy Longley, said: 'The benefits for patients has been immeasurable.

'These are people who were found to need some intensive support - if that had not been available they would most likely have had to be admitted to hospital.

'It has, without doubt, helped to remove the need for a lot of patients going into hospital.

'The personal health advisors have been invaluable. As well as flagging up health issues, they have helped the patients to obtain benefits which they were entitled to but often unaware of.'

NHS Norfolk's Assistant Director of Out of Hospital Care, Wendy Hardicker said: 'We know that this type of approach is what patients want and it works. If they are cared for at home or closer to home then very often the patients are supported, acute admission is avoided, recovery is quicker and confidence increases.'