Support for the people with the greatest health and social care needs in Sunderland has received a major boost after the All Together Better partnership was awarded £4.8million NHS Vanguard funding.

The new investment will enable the programme to continue working to improve the lives of those who need it most across the city, with Sunderland having been awarded the most of all 12 other MCPs Multi-speciality Community Provider’s (MCP) to get funding.

All Together Better – Better Health and Care for Sunderland is an innovative new collaboration, created a year ago [March, 2015] after initial funding was secured to become one of the first vanguards of its kind in the country.

It brings together teams of health and care professionals, alongside local support organisations to look at new ways of working that will improve the overall wellbeing, health, social care and emotional needs of some of the most vulnerable and frail residents, as well as provide valuable efficiencies for publicly funded services in Sunderland.

Happy senior woman holding hands with caretaker

Through a range of initiatives, All Together Better provides services directly in the community, offering care that wraps around the individual. It is designed to respond quickly to spikes in the health and social care needs of people who require a little bit more help than most, because of the complexity of their needs.

The aim is to offer care that prevents short term problems from escalating, delivering person-centred support that keeps people out of hospital, and at home, which may include a residential care home or extra care accommodation.

It is aimed at those who have the most complex needs usually older people with several long term conditions who are often already receiving support from health and social care services, often with the additional support of family members or friends.

However when this support is not enough, for example if they suffer an unexpected illness that worsens their condition, extra help is on hand from the All Together Better team.

All Together Better is delivered by a partnership of Sunderland Clinical Commissioning Group; Sunderland City Council, local Hospital Trusts and GP practices; Age UK Sunderland; Sunderland Carers Centre and Sunderland Care and Support.

Debbie Burnicle, Deputy Chief Officer, NHS Sunderland CCG, said: “This investment will enable us to help the people who need it most and is a clear acknowledgement of successful partnership working in Sunderland”

Elderly women on living room sofa“We are all working incredibly hard to ensure we offer joined-up services across city. Our partnership collectively plans the work delivered by All Together Better, and by securing continued vanguard status, along with funding that comes with it, we can pump-prime projects ensuring they deliver better outcomes for patients.

“We look forward to building on the successes of the last year, continuing to learn and grow our new way of working.

“It is a major undertaking, but one that we relish. We have overcome some challenges and will undoubtedly meet more during this next phase. However, we remain confident this new way of working will deliver better health and care to local people that is sustainable, efficient and ultimately improves their quality of life.”

Notable successes to date include:

  • Mobilisation of Recovery at Home – short term, 24/7 rapid response service based This multi-skilled team covers the whole city. Accessed by making a simple phone call to one single number the Recovery at Home team can respond quickly – usually within 1 – 4 hours – to assess patients’ needs, provide treatment and put in place additional care and support in the community, if required.
  • Creation of five multi-skilled ‘Community Integrated Teams’ (CITs) are in place in five main parts of the city, wrapped around GP practices, to provide a proactive, planned, high quality and co-ordinated response to vulnerable people, in poor health, with the most complex needs.
  • Development of multi-disciplinary team the (MDTs) to assess and support patients identified by their own GP, who need the most support and who can then be offered more effective, co-ordinated care.
  • Enhanced Primary Care – is led by the Sunderland GP Alliance and involves a range of project to identify how best to develop services further for people with long term conditions to prevent their condition becoming more complex and requiring more support. This includes how to provide more services from a community base and testing how the latest technology to enable better, direct care to people in their homes.