Working as one team

Make boundaries invisible – Working as one team

Everyone involved in my care, regardless of which organisation they are part of, works as one team

We will have achieved this when…

  • The boundaries between organisations and areas are irrelevant to me because hospitals, GPs, community staff and the voluntary sector all talk to each other and work together to meet my needs.
    • When I have been in hospital and am discharged, the nurse I see in the community does not have up to date details of my conditions. Hospital staff, doctors and nurses need to talk to each other more. (Patient via online workshop)
    • Out of hours services – Out of hours services are not connected to Community Services – these services need to link up to prevent people falling through the gaps. (Patient via online workshop)
    • We need to join up health and social care into a seamless (as far as the patient is concerned) service of integrated care and support. (Manager, South East London)
    • Running community services in their traditional silos is no longer appropriate; they need to be closely connected to all other parts of the health and social care system if they are to be a major driving force in improving community health. Community Services how they can transform care, (The King’s Fund, 2014)
  • Teams of staff with different skills work together with me and my carers to help me achieve my goals.
    • The professionals involved with my care talk to each other. We all work as a team. (National Voices: narrative person-centred care)
    • Integrated teams are a good idea and allow for smooth working, better patient outcomes and increased patient satisfaction. (Podiatrist, South London)
    • A fundamental building block is the creation of integrated or multidisciplinary teams comprising all the professionals and clinicians involved with the service or user group around which care is being integrated. Making integrated care happen at scale and pace, (The King’s Fund, 2013)
  • Health services forge better links with voluntary organisations and other sectors e.g. Housing. I am supported to consider all aspects of my health and wellbeing.
    • We need – Connectedness and cooperation between services, the voluntary sector and the community. (Healthwatch Lewisham)
    • Joint working with all agencies – A person should be given holistic care – that is working with the client, family, neighbours, schools, voluntary agencies, council services – e.g. if the person is isolated or is in fuel poverty or can’t get shopping done – all agencies should work together to help. This should stop duplication, enabling resources to be shared widely. (Patient via online workshop)
  • As a young person, when I move into adult services, the change is well planned and I am offered continual support.
    • The transition from child to adult services is difficult – I understand it needs to be different but the process should be explained and gone through – with perhaps a changeover period when you still see the same team – one day doesn’t make a difference to a person but it does to the services they are offered. (Young person via focus group)
  • I can access my own care records and plans. This can also be done, with my permission, by anyone involved in my care.
    • I can see my health and care records at any time. I can decide who to share them with. I can correct any mistakes in the information. (National Voices: narrative person-centred care)
    • I was ill and the hospital asked me to physically go and pick up my notes from my GP and take them to the hospital. Having to repeat things is often distressing, health professionals should know about your conditions. If systems were linked up this would help with the personal touch. It is unbelievable, in this day and age, that information is not shared. (Young mother via focus group)
    • Integrated IT systems essential or efficient and effective care. Knowing what your colleagues in all agencies are doing is crucial for joined-up working in a person-centred way. (Clinical Director North London)


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