NHS neighbourhood trial brings care to the doorstep

Tony and Carol Trott receive support from the new NHS Neighbourhood Health scheme

A retired couple who have been suffering serious health issues say a new NHS Neighbourhood Health scheme has helped them to "enjoy life" again.

Tony Trott, 72, and his wife Carol, 79, from Capel-le-Ferne near Folkestone, receive support from one of six new pilot projects across the South East that have been set up to make it easier for people to get access to care on their doorstep.

The "pioneer" sites, which include teams working in Folkestone, Hythe, Surrey Downs, Hastings and Rother, are part of the government's Plan for Change to shift care from hospitals into the community.

Mr Trott said he had received extensive support from his local team, and now "things are so much easier".

The couple had been working in Spain for 10 years but returned home after Mrs Trott suffered three strokes. She now has dementia and has become unsteady on her feet.

Mr Trott, a former policeman and electrician, said: "Things were so bad that it put us off doing anything. Going out with Carol made me feel anxious."

There were frequent visits to an urgent treatment centre where his wife was treated for injuries from her falls. But he said just as things were getting critical, Jodie Harnden, a multi-disciplinary team co-ordinator with the local Neighbourhood Health team, stepped in.

Her job is to support those who are most at risk of serious illness or injury, bringing together health and care services to help people to stay at home and out of hospital.

Mr Trott said: "I know I can pick up the phone to Jodie, and she will make sure we get the help we need.

The team "have been brilliant. I would trust them with our lives," he added.

The NHS said that once the patient is known to the team, they can then reach out to them.

Ms Harndon said Carol was "flagged on our system as needing extra support. When I go in to assess a patient, I look at everything. How are they coping?

"The first time I met them, Tony said to me, 'We have lost all our confidence when we go out. We just want to be able to go for lunch again without having to worry.'

"I took my assessment back to the multi-disciplinary team, which includes services from the GP surgery, community and social care, and we quickly identified that Carol's medication needed to be reviewed, which could help reduce her risk of falling.

Neighbourhood Health teams are backed by £10m of government funding and draw together a range of professions, including community nurses, hospital doctors, social care workers, pharmacists, dentists, optometrists, paramedics, social prescribers, local government organisations and the voluntary sector.

The pioneer sites will initially focus on supporting people with long-term conditions such as diabetes, arthritis, angina, high blood pressure, MS, or epilepsy - in areas with the highest deprivation.

Neighbourhood Health teams help patients to navigate the NHS service

One of Kent Community Health Foundation Trust's frailty specialists is Dr Joanna Seeley. She said: "Both Carol and Tony were becoming frailer and were at risk of being hospitalised if their conditions were not better managed.

"Knowing how important it is to them to stay at home, we worked across NHS and social care organisations to put help in place to make life easier for them.

Dr Seeley described the NHS as "difficult and complicated to navigate.

"We can do the navigation for them."

Dr Tim Caroe, medical director for Primary Care Transformation at NHS England South East said the scheme will help "shape a new model of health that has people and the places where they live at its heart".

He added "We're not just fixing problems, we're trying to stop them before they start."