A SUNDERLAND woman whose health problems meant she was visiting A&E up to twice a day, has hailed a new way of working that is helping her manage her condition at home.

Linda Douglas, 48, from Washington, who suffers from a range of complex health issues including osteoarthritis, osteopenia, curvature of the spine, and abdominal discomfort following surgery including gall bladder and appendix removal, was left desperate after experiencing pain so severe that she needed daily doses of morphine to control it. Now, thanks to a new service – known as All Together Better – Linda and her carer husband John are looking forward to a happier 2016.

All Together Better is bringing together health and social care in a bid to offer a whole range of care and support wrapped around the people who need it most, helping keep them out of hospital and in their own home, where most would rather be.

“We were at the end of our rope. Things had just got so bad that I was either in total agony, or so drugged up on painkillers that I slept round the clock. Life wasn’t worth living,” said Linda, from Blackfell.

“I would feel that I was taking up a bed in hospital, and taking up an ambulance that somebody really, really poorly might need, but at the same time, I had no other option. The pain would get so bad that I couldn’t cope and there was nobody willing to help me. It was a desperate situation. I used to just sit and cry. It was just awful.”

All Together Better, is designed to both support people who need short-term, temporary care to help get them home as soon as possible after hospital treatment, or to support them to live independently at home if they are frail, or they or their carers are unable to manage their care alone, but they don’t need to go into hospital.

The new care model sees a wide range of services providing ‘joined up care’ in a partnership that includes Sunderland City Council’s social care team and Sunderland Clinical Commissioning Group; Age UK Sunderland; Sunderland Carers Centre; local Hospital Trusts who provide services like nursing care; pharmacy and therapies, as well as all local GPs – all coming together to provide a round the clock support for those who need it most.

With five ‘community integrated teams’ based in the North, East, West, Coalfields and Washington areas of the city, and a single 24/7 Recovery at Home ‘hub’ bringing professionals together in one shared workplace, it is hoped that – through information sharing and working together – the teams will deliver care that is ‘holistic’ – that addresses all of the needs of the person.

“The difference is night and day. It’s life changing. I didn’t want to live life the way I was, in and out of A&E all of the time. But when you are in desperate pain, you just need a solution. And at the time, that seemed to be the only way. Now, I am managing with the care of John, and the care plan that has been put together by my GP, community matron, social worker, the North East Ambulance Service and my consultant at the hospital means that we are fully supported by a team, should we need their help.

As part of the programme – which aims to keep people living independently, in their home – it was agreed that training would be offered to Linda’s husband John, to allow him to administer drugs to deal with pain which is caused by the cumulative effect of major surgery on several organs in her abdomen.

John, 50, was forced to leave his job of 30 years, to become Linda’s full time carer, but is delighted that the support of the All Together Better team means she is beginning to regain some of her independence and her quality of life.

He said: “Watching the person you love in so much pain, and not being able to help, you just feel totally helpless. We were at breaking point. I would spend six and seven hours at a time at A&E with Linda, often through the night and the following morning, I would be going to work on two or three hours sleep. It was like a nightmare.

The difference now is unbelievable. The support we have received has given us our life back. It’s incredible…

The couple, who had been unable to spend a night away from home for fear that Linda would become unwell, have been able to celebrate John’s birthday and their wedding anniversary with overnight holidays, since John has been trained to administer medication.

“It’s so nice to be able to feel normal. To be able to do things normal couples do,” said Linda.

“My life was driven by fear. I was terrified of being unwell and not being able to get the care I needed to control my pain. I don’t need to worry any more. It’s like a weight has been lifted.

“I could never have imagined we would be able to get care like this. Our doctor, has been incredible and from day one, he just wanted to help us. It took him two weeks to read my medical file, it was like a brick because it is so big and heavy, but from the moment he understood my situation, he put everything in place to support us.

“And the council’s social care team have made some adaptations to our home so we can live independently. I have a stair lift, as my osteoporosis means I use a wheelchair and cannot walk. In fact, I actually broke my foot when I tried to stand up, so my needs are quite challenging. We also have care when we need it from our community matron. She comes out to see us every month or so, and makes sure we are okay and that the medication I am getting is keeping everything at bay,” she added.

“The whole thing is set up around me – to support me, and to support John. It’s just amazing. I can’t explain how much of a difference it has made to my life. I’ve gone from having a quality of life of about six percent, to 99 per cent”

All Together Better is one of the first of 50 ‘Vanguard’ projects funded by NHS England, designed to test ‘new care models’ that join-up relevant services for local communities to keep them well and out of hospital. – Sunderland is one of the areas that is blazing a trail for new models of care, and if the programme is considered a success by NHS England, the new way of working could be adopted by towns and cities across England.

Kerry McQuade, Head of Vanguard Sunderland, said: “People like Linda and John prove that this joint-working approach is what is needed to deliver a step change in care for some of the most poorly and vulnerable people in Sunderland.

“The fact that we have been able to support someone whose health needs meant she had become totally reliant on local health and social care resources, and give her and her husband the tools and support they needed to live a rich and independent life, is just fantastic and it really does vindicate the commitment made by the council, the CCG and the voluntary sector, to bring care together for the greater good of people in the city who need support most.”

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