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The North Bucks Patient Support Service

The north of Buckinghamshire is a rural area with a higher than average number of socially isolated elderly people. The GP practices in the area work together to provide the Patient Support Service. This aims to keep people independent for longer by helping them highlight the areas of their life they would like to improve and then signposting them to appropriate resources.

This might be in relation to their:

  • personal care
  • nutrition
  • mobility
  • financial situation
  • managing a medical condition
  • improving their safety
  • reducing their feelings of social isolation

Support service

From the outset the aim of the service has been to work with older and vulnerable patients before they hit a crisis. The team receives referrals from GPs, members of the primary care team or patients’ families and carers. They have also worked proactively to find individuals who might benefit from the service by identifying those aged over 65 who suffer from a chronic condition and haven’t been seen in the surgery for over two years. Once identified, the team would then make a home visit, complete a full assessment and make recommendations on services which could help, whilst offering to refer to statutory and voluntary agencies as required.

In addition to the home visits, a befriending coordinator manages a group of around 30 highly-motivated volunteers who give up their time to telephone clients for a regular social chat.

The patient support team works as part of the integrated primary care team alongside physiotherapists and occupational therapists, mental health workers, district nurses and adult social care. Having the ability to meet regularly, share patient records and cross-refer puts the patient at the heart of what they do.

During 2018, the patient support service carried out 190 episodes of care in just 4 months. Anecdotal evidence from GPs suggests that the service reduces the need for home visits and helps prevent unnecessary deterioration in a patient’s health and well-being.

How they have made a difference

Elderly person

An elderly person confessed to the patient support worker that they were struggling to manage their medication because they could not read or write. By sharing this information, the GP and the pharmacy can now ensure that all instructions are given verbally. Not only has this made the patient more confident but it has also reduced their risk of hospital admissions.

A patient

A patient, who was profoundly deaf, then lost much of their eyesight. The patient support worker found charitable funding to purchase a mobile device with a speech-to-text function so they can now more easily communicate with family, friends and GP. This has ‘transformed' their life.

A widower

A widower was suffering from depression and low self-esteem due to their social isolation. The patient support worker suggested that they could consider a voluntary role and, with their consent, contacted a local National Trust property to arrange a trial period. This proved successful and they now feel a valued member of society - and have made new friends in the process.