When Dennis retired, we decided to move to Weymouth. And out of the blue Dennis had a fall and broke his hip. From that point on, our lives changed. Dennis had a series of falls. He smashed his face in, he broke his nose, he broke his wrist,
broke his sternum. Things suddenly went downhill very fast. He was fitted with a pacemaker, he couldn’t catch his breath. While we were going through this we saw the neurologist, – no results. I think we must have gone through most of the departments in the hospital. A doesn’t talk to B. And there’s no conversation
between any of the consultants. And it’s just like fishing in the dark. At the end of the day we weren’t getting any answers. Three or four years ago life was quite difficult in terms of managing these patients. People with longterm conditions, and as they get older,
need help from a variety of sources. The teams were completely separate. Health teams completely separate from social care teams and that meant that nobody talked to each other and nobody joined up care, but also that there was no collaborative working really at all within the system. There was one night he was feeling particularly weak,
so I physically had to drag him up the stairs. It took over an hour. Dragged him across the landing by which point I just burst into tears. He just said: “please don’t cry” …. Sorry. I didn’t know what to do. I wasn’t strong enough to do anything. I couldn’t cope. We have a challenge with an ageing society, the traditional way of moving through the NHS, which is you go to your GP, you go to hospital if you need to, you get your treatment, you come home, you go back to work – isn’t quite so relevant to someone who is grappling with 5,6,7 long-term conditions. We decided to bring teams together. Health and social care, physical and mental health teams. They sit together in the same room. They take telephone calls. Whoever takes that phone call then engages the services of the rest of the team to help them solve the problem. There’s lots of people that you can turn to – people that can help you find the right way to help patients. This way of working actually allows me to look after a greater number of patients. My heart failure specialist knowledge can be shared with the doctors here, with the therapists, with the community matrons. I feel my skills are being used effectively and I can be effective because I have the backup of other people. Integrated care is more than just a buzz word – it’s a way of working. It’s how the NHS should operate because when you are dealing with people with long-term conditions, multiple long-term conditions, old people with frailty, they cannot afford the service to be disjointed. Rebecca came into our lives and we haven’t looked back. Immediately things started to improve – Dr Dean has been here with the consultant. No time limits. Lots more tests, pushed by Rebecca and the team to where we are now where after all this time we finally have got a diagnosis. Dennis has pulmonary fibrosis. It can’t be cured, it’s just trying to find a way of manage the treatment. And Rebecca and the hub have arranged all that. And.. we feel… as if people care now. And we’re not just a number, we’re a person. And, we’ve got help. Honestly. I couldn’t go back and I wouldn’t go back to what we had before. I wouldn’t accept going back to what we had before. This is something we know happens in some local areas, but that isn’t good enough, it needs to happen nationally and this is a really great chance to see that happen because integrated care should be a universal expectation, it shouldn’t be something relied on by your local area alone. Everyone should be able to access – and have a hub and a Rebecca in their lives.