Sue Hughes, a district nurse who works as part of All Together Better’s joined up team, tells all about how the service is changing lives.

Sue Hughes works as part of the North of Sunderland area Community Integrated Team (CIT).  She tells us about her experience of joined-up working since the service was introduced.

“My role involves caring for patients in the community, primarily at home- – whether that is their own home, at a family member’s or a residential care home.  I also deliver care from a GP practice treatment room to those who can get to the surgery.

“Since we have been working as part of All Together Better, I have seen a lot of changes.  Referrals from a GP for district nursing are much quicker, so care is more rapid; we are sharing much more relevant information so there is less duplication of effort for both patients and the staff attending to them.  Patients really are right at the centre of care, as I am one of a team of professionals who sit on a ‘multi-disciplinary team’ (MDT), where we discuss a person’s needs holistically, both their health and social care as well as their wellbeing.  We can really see that working this way has meant we can plan much more effectively and get the right care to people when they need it most, keeping them as well as possible and out of hospital.

“I feel like I have a much greater understanding of how social care works since we started the MDT.  We have always worked together professionally but now we are physically sitting in the same room, with a GP and other colleagues, and focusing on an individual’s needs, it really helps.  Practical things like their role within in the team, their level, to the way they allocate cases and prioritise the need.  Knowing this means that when I am dealing with a person’s care, I can think ahead and understand how a social worker and other members of the MDT will be able to support them.

“Previously, although we always tried to understand the holistic needs of those we cared for, we might not have fully understood what our social care colleagues and the community/ voluntary sector could do to help.   A person’s social needs might be different to their clinical needs, but by understanding both and working together, we are able to find a balanced solution.

“I think it’s also helped in terms of understanding a carer’s perspective too. As healthcare professionals, our focus has always been on the patient but now we recognise the invaluable support carers offer.  It is vital we support them as much as possible and, as part of All Together Better, nurses are already joining up with the Sunderland Carers Centre to provide training courses around caring for people with specific medical conditions.

“By working with  organisations like Sunderland Carers’ Centre, my knowledge of how they could help was nothing like it is now, and I think this new way of working has helped that.  It means we can refer on with more confidence, and know we have a forum to discuss progress and get a picture of how that intervention is helping the person.

“I think we often approach cases with a much better starting-level of knowledge about the person’s history, circumstances and needs since MDTs came into place.  A doctor might talk about a person in an MDT meeting and discuss the case with a social worker, and weeks later, they might need medical care.  We can recall their history and it means that the person doesn’t need to keep repeating themselves – we go there knowing what has happened in the past and able to put together an effective care package.

“We triage rapidly, we arrange care and we have collective understanding and ownership – we all hear how that person is doing and what intervention or care has been put in place.  It actually makes the job much more rewarding, because you can see the part you have played in identifying a need and arranging care that can deliver huge changes to that person.”