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Joined-up care: Sam’s story

What does joined-up care look like? Watch our video of joined-up care built around the needs of a patient.
Over the next 20 years, the number of over 85s in the UK will more than double, meaning many more of us with multiple, long-term health conditions. Our current health and social care system won’t cope. Fundamentally, it’s the same system as when the NHS was set up, designed to treat episodes of illness, one at a time. Already, we’re failing to give vulnerable people the care they need, and we’re set to run out of money, fast. Meet Sam. He’s 87, and suffers from emphysema - a disease that makes it hard to breathe - and also has Type 2 diabetes and arthritis. Sam was coping pretty well until his wife passed away, but is now lonely and increasingly depressed.
Sam frequently visits his GP, but finds it difficult to discuss all his needs in a brief consultation. If Sam can’t get hold of his GP in a crisis, he calls for an ambulance. Each time, Sam spends time in A&E and is often transferred to a ward as well. He sees lots of different health care professionals and has to explain his conditions repeatedly… frustrating! And, Sam often has to wait to be assessed by social services before he can go home. The result? A lot of unnecessary time in hospital. And when he gets home, a lack of co-ordination between his GP and social care often means he doesn’t get the support he needs.
Eventually, after several hospital visits in just six months, it is decided to admit Sam to a care home. But what if Sam’s health and social care services were more joined up? Let’s imagine one of Sam’s carers is given overall responsibility for co-ordinating his care - for example Kathy, a district nurse. Kathy meets with Sam, his GP and his social worker. Sam explains that he wants to manage his conditions at home and, together, they design a care plan, which they can all access online, any time. Sam now gets more visits from Kathy at home, which helps him manage his emphysema and diabetes.
On the occasions when he does have a crisis, Sam calls Kathy rather than an ambulance, so goes to hospital less frequently. And even when he is admitted, he is discharged after a quick review of his care plan, rather than having to be re-assessed. In this scenario, Sam’s health and social care is funded from a joint budget, so the team can make smart decisions about how it’s spent, and call on the help of other social services. For example, as his condition deteriorates, the team decide to fit a seat in Sam’s shower, provide him with an oxygen cylinder to ease his breathing, as well as a medication dispenser with a voice prompt to remind him to take his pills.
Kathy talks to Sam about his loneliness, and he agrees to weekly trips to the shops with a volunteer from a local befriending charity. So now, Sam doesn’t have to be admitted to a care home, instead getting the help he needs in his home. He feels happier, is healthier, and better use has been made of resources within the system. Let’s recap on what transformed Sam’s care. Put simply, local leaders in the NHS, social services and the voluntary sector created a shared vision of what good integrated care looked like, centred around the needs of people like Sam, and their carers. They pooled resources across health and social care, built multi-professional teams and created systems to allow Sam’s information to be easily shared.
Sound idealistic? Well, this is actually already happening in a few places. Now it’s time to make sure it happens everywhere. Let’s re-imagine how we provide care. Get inspired at

In the previous step, you found out how a patient’s journey through the system can be disrupted.

Now let’s see how joined-up services could lead to a better experience of care.

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