Focused Care Patient Stories, Hope in the Deep End Podcast
Hope in the Deep End is a podcast from the Shared Health Foundation in Greater Manchester. In this podcast series we are exploring all the different complexities of working in areas of deprivation, poverty and entrenched health inequalities. From clinicians to youth workers, we want to inspire, challenge and give inspiration to all those that work in the deep end.
In the following episodes, Dr Laura Neilson speaks to some wonderful patients who have been working with Ruth Chorley from Focused Care.
Case studies in Greater Manchester
Case 1 – Jonathan
Jonathan* was referred by a GP to a Focused Care Practitioner a year ago. He was homeless, addicted to drugs, and very angry. His relationship with his Mum had broken down, due to her own alcoholism, and he was estranged from his Dad.
The Focused Care Practitioner began by trying to manage his homelessness, registering him as homeless, and contacting appropriate services with him. Whilst this was still ongoing with no solution, she worked with him on his benefits, in addition to ensuring
he had things like food parcels until some money became available. He came to the surgery for showers. Eventually he was found a hostel place, which took 2-3 weeks to arrange.
He has now been awarded permanent accommodation of his own in a flat. He has stopped using legal highs. He has engaged with a Men’s Group and IT classes, which he even mentored in. He is still hit and miss with his engagement, but things are improving. He has got a job, following on from support from the Focused Care Practitioner with applications and interview help – he even had interview clothes provided by the team!
Case 2 – Alice
Alice* is a 49 year old lady, with complex medical and mental health needs, and significant social vulnerability. She was referred jointly to Focused Care by the Police and her own GP – both due to inappropriate and frequent contacts.
Living alone in a flat, she was regularly contacting the police concerned about her neighbours, whether or not there was an actual problem found.
Since engaging with the Focused Care Practitioner, she has found a safe point of contact and support, which has meant that she is now in touch with the Police less. She is supported to her medical appointments with the Focused Care Practitioner, and is more appropriately contacting health services. This is an ongoing case, for which there is no easy solution, but the help provided by a Focused Care Practitioner has enabled positive changes to be made.
Case 3 – Maggie, Central Manchester, October 2020 – January 2021
Maggie* is an 84 year old lady referred to Kate* at Focused Care by the Care Navigator (social prescribing team) due to concerns around her living situation. Maggie had no white goods so was only eating food which did not require cooking, had very poor home conditions, and was building up debt.
On checking surgery records Kate discovered that Maggie had not attended the GP surgery in over 22 years and on assessment found that Maggie did not have any heating, had poor home conditions, and had not opened her mail for several months and so had been unaware of the bills coming in. She no longer knew how to access her pension, so had been living off her savings to pay for food. Maggie was unable to explain how this happened and so Kate noted concern around memory issues. She had one friend who visited frequently but no other known friends or family, and Kate found no evidence of financial abuse from this friend.
Kate booked Maggie into the surgery for a full health check and was able to get her flu vaccination and whilst she had no significant health concerns was able to arrange a referral for a memory assessment at the same time. She also contacted housing to arrange repairs to the boiler. Kate contacted the DWP to find out where Maggie’s pension was being paid into, as Maggie had forgotten that she had opened a different account, and the passwords to it. Wendy was able to successfully apply for pension credit, and other relevant benefits as Maggie had been living on the state pension alone for years. This support has helped Maggie to pay off her debts. She also supported her with her housing and Maggie was rehoused in a new apartment under the Extra Care Support Scheme in time for Christmas, and now Kate is helping to furnish a new permanent home for her through local charities and donations. Kate also took Maggie to attend her memory assessment, CT Scan and her Covid-19 vaccination as she has no other family.
Maggie now has good routines, eats and sleeps well and has a warm, comfortable home. She is awaiting further results from the memory clinic, but is also part of a housing scheme which offers social opportunities (post-Covid!) and enriching activities. She has enough money to live comfortably, has a care package in place and the practice have taken Maggie under their wing.
Case 4 – Samia – Oldham, Jan 2021- March 2021
Samia* is a 32 year old mum with 4 children, the youngest being in primary school. She was referred to Becky*, Focused Care Practitioner, by the GP due to issues with social isolation. Becky found that due to severe agoraphobia Samia hadn’t been out of the house for 6 years. She didn’t attend appointments, someone else took the children to school and she had never had a cervical smear test.
Becky visited Samia for an initial assessment in January 2021 and told the patient that she wanted to help her with her issues. She cried and said that she had been waiting for someone like Becky to help her. Initially Becky worked extensively with Samia setting her small goals. She gave her the necessary visual and written information to help and set these targets. As well as verbal encouragement and practical support, Becky initially took small steps and supported Samia to stand outside, then moved to the bottom of the drive, and this progressed further and further as the weeks went by.
Samia is now physically more active, is accessing medical provision and has undertaken her first smear. She has also been to the dentist and had much needed work doing.
She is able to participate in her children’s education. She has enjoyed a family social outing, and is much happier and participating in family life. Samia is much less isolated which has also encouraged better self-esteem and mental wellbeing. This can only be better for Samia and the rest of the family.
*Real names have been substituted
The Guardian covered more case studies in Greater Manchester.