Joining the Dots is about changing the needs and hopes of older people. Following an event on 24 May 2011, we are trying to change the way in which we do business by:

    • Joining older people to the services which will most meet their needs;
    • Joining service providers to work more effectively;
    • Working with commissioners from the outset so the findings could be included in future commissioning

    We are learning from existing local and national ways of working, building on organisations and people; and testing new ways of working. This will lead to stronger networks and wider ownership of the recommendations by older people, service providers and commissioners.

    Main areas of progress and resulting benefits

    Challenge 1 – Joining services with older people - The Link worker

    Here, the need is for more 1-1 support for vulnerable older people to enable them to find and access services to meet their needs. 

    The main aims were to learn and build on existing practice and 190 people considered the best choice for Newcastle.


    • Ensure that staff know their local scheme well and understand the boundaries of their respective roles. Give them the opportunity to build trust and easier referral routes. An information day with staff from Intermediate Care and Community Nursing and voluntary community groups, highlighted an appetite from both groups to improve knowledge.

    • Strengthen networking opportunities by provide a strong information base and simple methods of referral. This is provided by Putting People First including Information NOW; My Care Newcastle; First Contact and ‘Just What I Need.

    • Further develop community-based provision which is open to all to give people in need extra support. This provision is patchy and would benefit from continued investment and innovative design; 

    • Make sure that information on how the ‘system’ is not working well is part of the policy, service design and commissioning. In response to the findings of the event, an area-based strategic link worker job description and person specification was written. This recommendation is on hold until the model can be tested.

    Challenge 2 – Joining the Dots between service providers
    Work to build relationships between health, social care (and to a lesser extent housing) and community-based VCS services has been delivered in partnership with the Occupational Therapist, a GP and Health Works Communities for Health project. This work has also drawn on the resources of a health trainer funded to work with older people.


    • Communities for Health Newcastle as an exemplar of community-based commissioning given the initiative grew out of evidence from a range of community engagement activity including WEHEAR and ‘Health Action Networks’ [Community Action on Health];

    • An operational model of successful GP to community referral including holistic assessment and goal setting for person-centred outcomes.  This has been developed through intensive work with GP practices to develop a simple referral process and feedback loops leading to trusted and effective working relationships.  The implementation of this model is variable between GP practices and requires further work;

    • testing out the interface between Intermediate Care and community based services, through undertaking research with Intermediate Care and Community Nursing services to understand the barriers; creating information sharing/networking opportunities (see Challenge 1) and by testing out working with the ‘older people’s health trainer’.  As part of developing a whole system re-ablement model it is proposed that new Therapy roles working between reablement and Intermediate Care can develop and extend the knowledge of , and relationship with community-based providers to continue effective and time referral, information sharing and signposting;

    • testing out a holistic assessment model using the Outcomes Star and sharing the learning with Intermediate Care, Re-ablement and Your Homes Newcastle. This has included understanding the skills and competences required in an assessor; the links with First Contact and preliminary discussions as to whether the Outcomes Star could provide a common framework for assessment and monitoring across organisations, thereby building a stronger evidence base for prevention.  This requires further discussion with partners and commissioners to establish whether it is appropriate to develop this model further;

    • testing out the ‘lead provider’ model as part of the Communities for Health project with HealthWORKS acting as lead provider sub-contracting with Search Project and West End Befrienders;

    • sharing the learning on ‘Social Prescribing’ at a VCS Open Forum event to gather views from the sector on the lead provider or alternative models and the potential of social prescribing as part of the mix of voluntary sector activity/funding.

    This element of the work has included creating opportunities for sharing information and learning on the following developments:

    • Diabetes Year of Care.  One result of this pilot project is that Newcastle Bridges GP consortium will be introducing care planning into their practice;
    • Provider Partnership Initiative and understanding the relationship between this work and access to community-based services;
    • Your Homes Newcastle Floating Support and Activity Provision pilots by facilitating two consultation sessions to inform this development and making a commitment to the steering group for this initiative;
    • ‘Patient Centred Care and Vulnerability’ PhD by Clare Abley, Nurse Consultant for Vulnerable Older Adults.

    Challenge 3 – Understanding how to respond to the needs and aspirations of older people, in particular those at risk of isolation

    This work has included:

    • A programme of workshops with front line staff, volunteers and older people to share learning.  This resulted in a ‘map’ of the services currently available to people with moderate to high level needs and evidence of the fragility of many of these services.  It also resulted in a shared understanding of key factors associated with working with this client group e.g. importance of trusted relationships; small things make a difference; need for universal/non-stigmatising services. 

    • Intensive case study work by the Occupational Therapist with four clients resulting in evidence of triggers for early intervention; the input required to deliver a case co-ordination approach which includes building relationships, identifying goals, addressing ‘disengagement’; empowering individuals to take action; the value of a ‘single point of access’ to community-based activity; a cost-benefit analysis of case co-ordination approach and recommendations for areas of further research/development e.g. virtual wards.

    • Testing out a ‘dementia café’ in a community-based setting which included building relationships between the Memory Clinic and community based support networks.

    • Initiating a service design approach with the Age UK Newcastle Befriending Service with a view to testing out new approaches to meeting the needs of isolated older people currently being referred for befriending or lunch club services.  This work will continue to be delivered by Quality of Life Partnership during 2011.

    What next?
    • A seminar being organized by JtD/C4H steering groups to share the learning from the work to date and engage partners in determining the next steps. (Provisional date: 24th March 2011)
    • To take forward the learning and activity from the JtD into a geographical ‘age-friendly city’ pilot building on the work in the West End and potentially exploring taking a similar approach which builds on the local resources and capacity in a.n. other locality in the city;
    • To work with partners to ensure that the learning from the JtD project informs the proposed Wellbeing Strategy for the city and the relevant JSNAs and supports the case for pooled budgets to deliver prevention;
    • To further explore the ‘lead provider’ or other commissioning models with GP consortia and the voluntary and community sector;
    • To further develop the referral protocols and assessment tools developed as part of the Communities for Health pilot with GP practices, Intermediate Care, Re-ablement and the Your Homes Newcastle Floating Support Pilot;
    • To further explore and test innovative models of provision for frailer and more isolated older people as part of the service design work being taken forward by Quality of Life Partnership/Age UK Newcastle;
    • To explore opportunities for taking forward the recommendations from the Intermediate Care component of JtD into the development of Intermediate Care and the Provider Partnership Initiative.

    Longer Term Challenge

    The primary focus of JtD has been on prevention and early intervention to prevent or delay the need for high cost health and social care services.  However, it is recognized that there will always be some people with complex needs for whom we need to find a more effective solution.  An issue highlighted by the work of the Occupational Therapist is the gap in case co-ordination which will enable the coordination of services to meet a client’s health, social and emotional wellbeing needs to avoid crisis situations/rapid deterioration when the client requires multiple services from multiple providers.  It is unclear given the current changes where the leadership to take this forward lies and it remains a longer term challenge.