Working better together to give patients a more personalised experience

The NHS is changing the way it works to ensure care is built around patients in our communities, rather than assembled around the teams and organisations that provide that care. Communities of Practice is all about giving patients a more personalised, consistent relationship with a team of care professionals, while allowing them to work better together and make the most of the range of skills they possess. 

Terrance (84) was referred to the Community Nursing Service for insulin administration, after being admitted to hospital. He had become increasingly frail with recurrent urinary tract infections and two recent falls. 

An assessment and care plan was completed for Terrance - whose wife, Audrey, is his main carer – and his case was discussed at the Community of Practice daily team huddle. A Community Nurse was assigned as the couple’s lead contact, with support from a social worker, physiotherapist and carer’s support. 

A set of goals was agreed with Terrance, including self-administering insulin and an appropriate exercise programme. A package of care was organised for the couple at home, with mobility aids and carer’s support for Audrey. A contingency plan was drawn up to ensure the couple knew what to do should either of their wellbeing start to deteriorate. 

Before the alignment of the various health and social care teams into Communities of Practice, Terrance and Audrey’s case may have been managed in isolation by the nursing team with the single focus of administering insulin. Other support would have required additional referrals and could have encountered delays and resulted in fragmented care. Terrance would have been asked to repeat his story throughout multiple assessments and received care without the benefit of team planning to address all the issues that were placing him at risk of his health deteriorating.  

Communities of Practice aim to tackle the workload and workforce challenges in our GP and community care services as well as keeping people out of hospital if they can be cared for well at home.