PEOPLE are already feeling the benefit of health and social care teams working closer together.

56-year-old Angela had spent many years caring for her mother at home when the pressure started to impact on her own health and wellbeing. A social worker who had been visiting Angela’s mother at home noticed that Angela had taken to her bed but did not know why. The social worker, who was working in an integrated team with others from Bolton Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health, took Angela’s case back to the team. A mental health nurse visited Angela to assess her mental wellbeing and found she had become alcohol dependent, was not eating or looking after herself.

The social worker was then able to commission a care package to assist her self-care and monitor her diet. When Angela’s mum died, her situation deteriorated further but the carers quickly reported back concerns that Angela was suffering even more and refusing to eat.

The mental health nurse visited again to find Angela dehydrated, with symptoms that could indicate internal bleeding. The mental health nurse phoned Angela’s GP who advised that she should go into hospital – but Angela refused. She returned back to her integrated team and sought the help of the advanced clinical practitioner – a nurse who has undertaken further study into clinical practice.

The two nurses visited Angela again, to find that she had deteriorated even more and could no longer stand. Luckily, they were able to persuade her that she needed to go to hospital and they joined her in the ambulance. Angela was assessed, admitted and taken to surgery immediately as she had an internal bleed. She was very poorly and remained at the Royal Bolton Hospital for two weeks. While she was in hospital the integrated neighbourhood team was able to keep track of her progress and worked with the ward staff to make sure care was ready when she came home.

Angela had poor mobility, muscle wastage and was anxious – she had not left the house for over a year and had lost her confidence. The hospital’s physiotherapist had given advice and walking aids and she was supported at home with further therapy that gradually helped her to walk inside the house, and then outside. Her old carers continued to deliver home help and the mental health nurse continued to work with her at home to address anxieties, gave relaxation techniques and allowed her to vent her fears and feelings in a safe environment.

Angela now walks independently, is eating, has gained weight and has reduced anxiety. She no longer suffers flashbacks to this difficult period in her life. With encouragement from the community navigator has signed up to become a volunteer with Age UK.

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Angela had never been in hospital before or needed social care help so she did not know what to expect. When asked about the team she said: “They saved my life and are a great team. I’m feeling so much better and I’m really looking forward to getting back out to do things I used to enjoy – especially looking after my garden. I didn’t think I needed help and I would not have known who to go to anyway. I would not have wanted to have to speak to lots of different people about my problems. If it were not for the social worker telling the rest of the team, my story might have been different.”

Louise Waddington, the mental health nurse, said: “The fact that we were working as an integrated team meant we had an integrated approach to looking after Angela. I was quickly able to get help from the other professionals in the team, who also responded quickly. I didn’t have to waste time referring to other services and I knew who I needed to seek help from because I work alongside them all the time. Angela didn’t need to tell lots of different people her story and we were able to be there before and after she was in hospital with exactly what she needed without having to go back to the starting point of needs assessment. We’re all so pleased with her recovery.”