Taking time to listen to the vulnerable... a new service that gets results
An initiative that is having a major impact on the health and wellbeing of Cornwall’s most vulnerable people demonstrates how organisations working together can instigate change that transforms lives and benefits the whole system by addressing the increasing demands on urgent care services. Jackie Butler investigates
NATALIE Mitchell has a small but significant caseload of vulnerable people who take up a great deal of NHS time and resources in Cornwall and the Isles of Scilly – people who call 999 frequently.
As high intensity user lead for Cornwall, Natalie’s one-to-one work is having a significant impact on a group of individuals, many over the age of 60, for whom traditional health and care services have not provided solutions. And the results are flagging up the potential for much broader application in the future.
She may have no medical training but what Natalie gives this group of people is what they actually want and need – time and attention to help unravel the underlying roots of their distress, as well as tailored practical support to start addressing their problems.
Many of them have issues with alcohol or drugs, undiagnosed mental health difficulties and histories of trauma or abuse. Very often their patterns of behaviour mean they have exhausted other sources of support – from family, friends or their GP – so they call 999. Giving them an alternative that actually answers their need has been hugely successful.
The individuals she works with have all been flagged up by the South Western Ambulance Service NHS Foundation Trust (SWASFT) after calling the emergency line multiple times over a prolonged period. They
may have no acute diagnosis that warrants paramedics being repeatedly called out to them, nor any clinical reason to be taken by ambulance to the emergency departments at Royal Cornwall Hospital or Derriford in Plymouth.
Ambulance crews are required to work to operational clinical protocols if patients report specific symptoms. This can mean high intensity users may be taken to hospital and sometimes admitted. Some spend weeks as in patients before a safe and appropriate way to discharge them back into the community can be found.
Julie Green, programme manager for urgent care, NHS Kernow Clinical Commissioning Group, says: “It is important to appreciate that significant resources are deployed within SWASFT supporting frequently calling patients over the phone, or by visiting them at home and treating and discharging on scene. This is a very intensive use of resources and often does not actually solve the issue for the person whose needs are complex and require time to address.”
Until now, there seemed to be little scope to address the issue.
“These are the most vulnerable people you will ever meet. It is the biggest privilege to work with them because you see the change in them,” says Natalie, who has experience in education and with people struggling with their mental health.
“We have worked with 20 people since January, and seven or eight of my guys are now where they need to be and are not calling 999 or doing so less frequently. It represents a large transformation for a small number of people.”
She works for Volunteer Cornwall, funded by NHS Kernow Clinical Commissioning Group and aligned with SWASFT.
“Because I am based with Volunteer Cornwall it means I can be very agile and give a speedier response because there is more flexibility than within the NHS or local government. I can make decisions that impact on people instantly,” she explains.
The needs of her clients are, more often than not, far removed from the medical care the NHS is there to provide.
A high proportion have had very difficult starts in life and have lost all hope, getting into a cycle they cannot break out of. Some, initially, don’t even want to give consent to talk to Natalie. Change is frightening and there are no guarantees the outcome will be for the better.
“I will have a chat with them on the phone and then I can usually go and see them the same day, either in their home or somewhere else in the community,” she says.
“We just sit down with a cuppa and chat about what life is like for them. I say: ‘Tell me what’s going on’. Quite often it will be a rant against the system. You can tell them that you understand. Then we start talking about what their dreams and passions are… sometimes it takes some time for people to find those.”
After she has met them face to face, they will have daily phone conversations as well as support to go out and try new things. Gradually, as other solutions are put in place, they start to need her input less often, although the door is open if they relapse and want more contact.
“No two days are the same, one day I could be writing letters to GPs, courts and the next building fences in the woods to encourage someone to volunteer,” says Natalie.
Sometimes, although the problems are complex, the most effective support can be very simple, but have a profound effect. Other solutions can take time to identify.
“One woman needed some help to relax as her mind was always spinning so I set up a CD player for her and bought her a relaxation CD and that has really worked,” she says.
She can link with social prescribers at GP practices to arrange gym on prescription or, for example, mem
bership of the Eden Project. “There is no remit for what I do. I can talk about debt advice, access to specialist services such as drug and alcohol support, and housing issues. One client was being taken to court and needed support around that. The support is determined by the person.”
The personal touch is very important. Natalie adds: “I always send people cards. You don’t get many nice letters in the post if you’re in debt. We all like receiving a nice card. It will always be a positive message like ‘We can do this’. When you’re sad little things like that can make a big difference.
“One lady I literally had to hold her hand to get her to the gym; signposting just doesn’t work for some people and you have to take them. She now goes to the gym five days a week, swims in the pool and is losing weight and increasing her fitness – she is inspirational.”
Natalie says. “This is definitely tough love and I do set boundaries. Some people may think that I’m a soft touch but they soon learn that alongside the kindness there is a firm and fair steel.
“I have a rule that you can call me about anything from 9am up to 3.30pm. I am not a 24 hour service. What’s bothering you at 9.30pm was probably already bothering you at lunchtime.”
One person had this to say about Natalie’s input: ” Thank you, Nat. You have been fantastic. Nothing would have happened without you. You don’t give up; if you have to call someone ten times, you do it. You are like a Rottweiler.”
Natalie herself likes to quote something she heard at a national conference for high intensity user leads: “We are the Nanny McPhees of the system.
“When you need me, but do not want me, then I must stay. But when you want me but no longer need me, I have to go.”
Natalie admits she does find it hard to switch off from people’s distressing stories, often dating back to childhood, and she needs good support herself.
“Mentoring and clinical support is extremely important for me; I have an amazing clinical supervisor, Debbie O’nyons, who is a specialist nurse at NHS Kernow CCG.”
Julie Green was inspired by the pioneering work of senior paramedic Rhian Monteith (CORRECT) in Blackpool where A&E visits from “frequent callers” had been cut by up to 90 per cent and was determined to set up something in Cornwall.
“Rhian refused to accept there was nothing that could be done for these vulnerable people. She set up a programme funded by Blackpool CCG where she did some intensive work with people,” says Julie.
“She was having conversations about what mattered to them. Could she do anything to turn their lives around? She asked if calling 999 was working for them and if not then she said let’s try something different. I was fascinated by that approach and it certainly had results.”
Julie’s interest led to talks between the CCG and the South Western Ambulance Foundation Trust to set up the scheme now running in the county with the help of Volunteer Cornwall, who employ Natalie.
Julie says there are several reasons why there’s a need for this kind of programme, including the fact that people are living longer, but with long term conditions that are often complex and overwhelming, compounded by social difficulties.
“My favourite quote is ‘We have learned to prolong life without improving its quality’,” she says. “We have to do more to improve the quality of life for people who are facing difficult and uncertain futures with complex long-term conditions.”
“There have always been complex social issues around un-moderated alcohol consumption and now the low cost and availability of certain drugs, as well as people with undiagnosed mental health problems. Some people find themselves on the margins.
“These are people in their own bubble of despair… some of them might be calling 30 or 40 times a day. The impact they might be having in terms of using resources which should be going to someone else does not occur to them due to the extreme distress they are in – for them the call is genuine and is an emergency.”
When people in the broader health and care system discover what Natalie is achieving, they are now approaching her about people they are concerned about. At this point, because there is only one of her and the people are not on the ambulance service list, there isn’t the capacity for her to work with them.
“It would be easy to inundate Natalie with new referrals because there is obviously a high level of need. It is early days, but I do think this has the potential to be huge,” says Julie. “We would love to get more resources to grow Natalie’s team and this service.”
In monetary terms it is calculated that the saving to the NHS in Cornwall from mid-January to the end of July was approximately £60,000 – and that is just one single dedicated worker for the whole of the county tackling the tip of a potential iceberg.