A little more conversation

Margaret lives with dementia and frailty, has a history of heart disease and, at the time, was fighting a urinary tract infection with antibiotics from her GP. When her confusion worsened and she became more unsteady, South East Coast Ambulance Service (SECAmb) was called.

In many situations, this would lead to a trip to hospital, but Margaret had already made her wishes clear. A RESPECT form, agreed with her GP, said she wanted to stay in familiar surroundings wherever possible and avoid hospital.

Margaret’s daughter, Alison, 53, said: “We have always felt she should only go into hospital if she really needs to. If she can be treated at home, that is where she does best. Hospitals can be overwhelming for her.

“We have seen how unsettled she can become in hospital. When she is well enough to say what she wants, she has always said she would rather be at home. We all agree with that.”

Fran Bewer, paramedic, said: “Margaret’s PNG number is 11, so she is deemed to be high risk. In the past, someone in Margaret’s position would often have been taken straight into hospital. Now we can take more time, assess properly and bring the right people together.”

Margaret was considered safe to stay in her care setting overnight and was referred to the Kent Community Health NHS Foundation Trust Home Treatment Service for review the next morning.

The service brings urgent care into people’s homes and care settings. It means people who are unwell but stable can often be treated without going into hospital.

The clinicians who treated Margaret (from left to right): Nicol Szudorova, Paramedic Fran Brewer, Vikki Carslaw, Community Nurse, Dr Virginia Winstanley, Advanced Clinical Practitioner Will Devereux, Primary Care and Frailty Physician Association Pamela Trangmar and Associate Practitioner Raymar Saker.

William Devereux, Advanced Clinical Practitioner, said: “We go out, see the person where they are, do the checks we need, start treatment and make a plan, there and then. It means people can stay somewhere familiar.”

A key part of the assessment was carried out using a bedside blood testing machine, which gives results within minutes rather than waiting hours for a hospital laboratory.

William said: “We were able to get Margaret’s results almost immediately. That meant we could understand what was going on much faster and avoid delays in starting the right treatment.

“It changes everything. Instead of waiting and worrying, we can make decisions in real time while we are still with the patient.”

Alison was there during one of the visits. She said: “What stood out was how calm everything felt. There were several people there, but it was all very organised. It felt like the care had come to Mum, not the other way round.”

She added: “The doctor really listened. I did not feel rushed. I felt like what I said mattered.”

The team found that Margaret’s confusion was linked to her infection but painful gout in her knee made it hard for her to move about.

Alison said: “When you are dealing with someone with dementia, changes can happen quickly. It is scary if you are not sure what is going on. Having everyone there at once made it much clearer.”

The quick blood results helped confirm the plan straight away. With no signs that further antibiotics were needed beyond what her GP had already started, the focus shifted to treating the gout.William said: “We look at the whole person, not just one symptom. The aim is always to keep things as simple and safe as possible and act quickly when we can.”

Dr Ginny Winstanley, Margaret’s GP and lead of the Primary Care Network in Tonbridge, said: “Margaret is exactly the kind of person who benefits from this way of working. When teams are connected, we can respond quickly, share information and make decisions together, with the person and their family at the centre.”

Magaret and daughter Alison

Vikki Carslaw, a community nurse, said: “Our teams know patients like Margaret well. We notice small changes quickly and can act on them with the rest of the team, which helps prevent things getting worse.”

Two days later, Margaret’s condition had improved and she returned to the ongoing care of her GP and community team, having avoided a potentially long and distressing stay in hospital.

William said: “People nearly always do better in familiar surroundings, when it is safe to treat them there.”

Alison reflected on how quickly her mum, who has four grandchildren and two great-grandchildren, was back to her old bubbly self: “She was a former landlady of a pub and has always been full of life. She even went to Graceland in America and had an Elvis tattoo when she was well into her 60s. Her drive in life is people, she loves to socialise and make friends and she adores her family.

“Mum has lived with dementia for 13 years, but parts of her are just the same as she always was, happy and upbeat. It’s horrible when she is down, as that’s just not her.

“Having the whole team around us, explaining things clearly and taking the time with us meant we never felt out of control and we feel confident, should she fall ill again, that mum is in the best hands.”