Wakefield: providing integrated care from community hubs

Joint health and care teams have been established in the West Yorkshire district of Wakefield. The teams work from community hubs, helping keep people out of hospital. 

Joint health and care teams have been established in the West Yorkshire district of Wakefield. The teams work from community hubs, helping keep people out of hospital. 

How service provides holistic support 

Wakefield set up two hubs where council, NHS and voluntary sector staff work side-by-side to support people in the community more than eight years ago.

The hubs are funded by both Wakefield Council and NHS Wakefield Clinical Commissioning Group, but a wide range of organisations are involved in the partnership including Age UK, Wakefield District Carers and Wakefield District Housing.

A variety of staff work from the centres, known as Connecting Care Hubs. They include community nurses, social workers, housing staff and mental health workers. 

The two hubs operate from community locations in the east and west of the district. The hub in the east has a main hub and a small satellite hub as it covers a large area. 

Referrals come in mainly via GPs, but they are also received from hospices, district nurses and other health and council staff. They can include people who have mobility difficulties or have had falls through to people recovering from illness.

Around 4,000 people are helped every year. The aim is to keep the frail older people well and out of hospital.

Wakefield Council Assessment and Care Management Service Manager, Kate Parker, said: “These are people who are likely to need support from a wide range of health and care professionals. What this scheme means is that that care is better coordinated and, as a result, becomes more seamless.

When one of the members of staff go in they can quickly refer and bring in others. It allows a more holistic approach to planning care. For example, befriending, bereavement and shopping support can all be organised.

Joyce and Eric, both in their 90s, are just two of the people who have been helped. They were devastated when their home went up in flames. Their daughter was very worried that they would not regain their health and independence after the fire.

Through the Connecting Care Hubs, they received support from a social worker, physio, housing worker and Age UK. They were found new accommodation in an extra care sheltered scheme. 

Electronic care record ‘cornerstone of service’ 

A cornerstone in delivering the seamless service is the launched of an electronic care record, known as the personal integrated (PIC) file in 2017 as part of NHS England’s vanguard programme. 

“It links in with SystmOne, which GPs use. We ask them to provide us with the person’s story rather than recommending what support they need. We then plan and coordinate that care,” added Ms Parker. 

This is going to be even more important than ever as we recover from Covid. We actually saw the numbers being supported drop during the pandemic. I think people did not want to have people coming in their homes. But now we are seeing more and more people whose health and frailty has deteriorated.

Jo Webster, Chief Officer at NHS Wakefield CCG, said the approach has revolutionised the way people are supported. “People only want to tell their story once and then they want a solution. Many elderly people don’t have a single medical condition or social care problem, they need a package of help which meets their needs and what we’ve done in Wakefield. 

If someone has fallen for example and might be living on their own and socially isolated, they can be referred into the hub for support with all of these factors, which may be impacting on their health and wellbeing.

And local GP, Dr Phil Earnshaw, added: 

This has been fantastic for primary care because it saves so much resource. We have more time to use clinical expertise because there is a wider team supporting us. 

“All we need to do when we have a patient who is appropriate for the service is refer into the hubs and we know their needs are taken care of. The electronic care record system we’ve introduced means we can all see the patient’s record and that all individuals involved in someone’s care know what’s happened to that person from the beginning to the end of their journey.” 

Contact details 

Kate Parker 
Assessment and Care Management Service Manager 
Wakefield Council