Older man sitting at homePeople living with frailty are being helped to get the personalised care and support they need to maintain their independence at home – with dedicated teams now in place at local level throughout Northamptonshire.

Our county’s 16 Primary Care Network (PCN) areas have, or are currently putting in place, their own welfare support teams, whose role it is to identify and work with people who are at higher risk of hospitalisation and connect them with services which can support their individual needs.

PCNs are local collaborative networks of GP practices, organised by the practices themselves to ensure that together they are better equipped to meet the health and wellbeing needs of their populations. By establishing welfare support teams in each of these areas, the aim is to ensure that people can access supportive services closer to where they live.

Welfare support teams work in close collaboration with GP practice teams, local NHS providers, social services, other council services, voluntary and community organisations and befrienders, acting as the bridge between the individual and the services most appropriate for their circumstances.

The teams offer follow-up calls to patients who have been discharged from hospital, support local PCN frailty clinics and take referrals directly from GP surgeries. A holistic approach is taken to the service they provide, involving family members and carers in conversations about an individual’s needs where appropriate and taking into account both mental and physical wellbeing needs, as well as considerations for mobility, strength and balance.

Welfare support teams are able to complete home visits, make referrals to outside agencies and follow up with service users accordingly. They are often staffed by people from a range of backgrounds and from across health and social care, working cohesively with the service user to develop a person-centred assessment of their needs.

Northamptonshire’s welfare support teams have evolved from Age Well Wellingborough, a localised service established in 2018 which provides personal support for vulnerable older people in the Wellingborough area. Initially set up as a pilot project, Age Well Wellingborough continues to operate today, working closely with frailty leads at its partner GP practices to reduce hospital admissions and provide proactive support for local people before they reach crisis point. The service has helped to set the template and best practice for county-wide welfare support teams. The case studies below are just two examples of how local people have benefited from this service and how different organisations come together to support their individual needs.

Making the difference: how welfare support teams can help

As well as physical health needs, Julian* struggles with self-care as well as cleaning and maintaining his home.

These domestic difficulties began to mount up when he fell ill and needed a stay at Kettering General Hospital. Fortunately his local welfare support team were able to help after contacting him following his hospital discharge, and they visited his home to understand and discuss his needs.

Working with Julian’s housing provider and the voluntary sector, the team supported him to arrange clearance and a deep clean of his flat. They were also able to help him get his household bills in order and even assisted him with completing his census.

To take care of his health needs, the team made arrangements for Julian to receive his medication injections at home, as previously he had been liable to miss his clinic appointments. He continues to receive regular home visits from welfare support while longer-term care is prepared by social services.

Welfare support stepped in to offer help to Sharon* after her district nurse raised concerns that she had no food at home and very little furniture.

Following a discussion about her needs and difficulties, the team arranged for Sharon to receive food parcels and also helped her with donated furniture and essential household supplies.

They liaised with her housing provider to ensure urgent repairs were carried out, and worked closely with Sharon to develop a financial plan to help her budget for regular household costs.

To assist with managing her long-term health condition, the welfare support team have assisted Sharon with transport and accompanied her to medical appointments for moral support.

A plan is now in place for a personal assistant to help Sharon with her care needs, and the team are continuing to provide support until these arrangements are in place.

(*Names have been changed)