Working together to support you home

Written by Cassie Simpson on .

Piktochart SuH imageIn Solihull we are improving the way we support people leaving hospital (from Solihull and Birmingham Heartlands). Some people stay in hospital longer than they need and it isn’t good for them. We want to ensure that people can return home safely with the right support in place for them, their families and carers. Health and social care teams in the community and in the hospitals are working together in Solihull to make this happen. This new approach is called SupportUHome.

Jenny Wood, Director of Adult Care and Support at Solihull Council and Jonathan Brotherton, Director of Operations at Heart of England NHS Foundation Trust are leading SupportUHome. Below they explain why this new approach is needed, how it will make a difference and celebrate an early SupportUHome success story.

What is SupportUHome?

SupportUHome is about people returning to independence after a crisis or hospital stay. We know that staying in hospital longer than needed is not good for people. The risk of infection increases and it’s hard to stay active and independent when you are in hospital, especially if you are older. We also want to make sure that people are discharged without delay. It’s better for them and means that the beds are available for other people who need to come into hospital.

To improve our services we needed to start bringing everyone’s ideas together: professionals, patients, communities and carers. SupportUHome is our way of doing that, as part of the Solihull Together programme.

We’re really excited about the improvements this approach has already delivered, particularly around delayed discharges from hospital. By September, our local data demonstrates delayed discharges in Solihull were less than 25% of those in April or May. It’s one of the most impressive levels of improvement in the country. And it’s because everyone has worked together, across all agencies, with the common purpose of providing better, and more timely, support for people leaving hospital.

Of course, there is more to do to get it right every time. But we are getting it right much more of the time compared to the start of the year. This is system change at its best, and more importantly, it is improving lives and outcomes for Solihull people.

Why do we need SupportUHome?

One thing that struck Jenny when she first came to Solihull is that staff working across social care and health do a really good job for ‘their bit’ of the system. But there isn’t a clear understanding of how services work together to support someone to return home safely from hospital.

The result is that services often don’t work well together. So while we have a committed health and social care workforce, and our intentions are good, some people we support get frustrated. This is either because they get lots of professionals going to visit them asking the same questions, or they fall through the net because everyone thinks someone else is providing the support needed.

Health and social care systems are complex. We know it’s a lot to ask of our staff, to understand that system, as well as doing their day job. But it’s something we have to do better because it’s key to us supporting people well. If our staff can’t understand the system, what chance have people using services and their families and carers of understanding it?

What is the vision for SupportUHome?

We are responding to what Solihull residents have said about the improvements they want to see and learning from how we all feel about ageing, illness and caring.

We understand that for most people, getting out of hospital quickly and continuing to live at home is of key importance. To achieve this, SupportUHome has made some commitments which focus on responsiveness and continuity of care.

Through SupportUHome we are now working on delivering the following commitments:

  • Make sure people have been supported to maintain or regain as much independence as possible, before decisions are made about the need for long term services
  • Aim to arrange support for hospital discharges within 24 hours of referral
  • Respond to a community crisis within 2 hours of referral whenever necessary/possible
  • Arrange for as few different people to provide care as possible, to provide continuity and personalised care

We are looking at how quickly services can respond. The clock is ticking once the referral is issued and we mustn’t miss the best opportunity to support someone home.

We also want to avoid too many people being involved in a person’s care. Sometimes it’s necessary because complex, specialist care is needed. But the number of people involved can be overwhelming and it’s not always necessary. Ironically, it can leave people feeling more isolated and unsure who to talk to. So our aim is to improve the continuity of care overall.

Why is it important that SupportUHome is part of the Solihull Together programme?

Solihull Together is all about making improvements that can only happen when a range of Solihull organisations and people are committed to making changes. SupportUHome fits the bill perfectly.

It is also critical that we consider how one set of developments, such as SupportUHome, affects other parts of Solihull’s health and care system, and vice versa. We monitor the impact through the Solihull Together Board which brings system leaders, clinicians and stakeholders together.

How will SupportUHome feel different?

For staff: we hope staff across health and social care will start to feel more strongly that they are part of a wider network of care for Solihull residents, especially those staff who support people for a short time. And we hope they will feel more confident about knowing what and where other services are, so that they can transfer people over to colleagues with a confident handover. There are sometimes gaps in the quality of handovers which is why people receiving care can be asked the same questions so many times. There is a quest for digital solutions to support this but in the meantime we can do better.

For people using services and their families and carers, they should not have to wait as long for the right support. In particular, they should not have to wait in hospital when they are no longer acutely ill. Also, they should feel confident about how they plan together with the staff on the ward, to prepare for hospital discharge. This includes always feeling able to ask staff questions and not going home with a key concern or question unanswered.

And what are the challenges over the next 6 months?

Our improvements to delayed discharges have been impressive, but this is the tip of the SupportUHome iceberg. There is still work to do to get it right for both the short and long term impact for people and carers.

What we will be giving serious thought to over the next 6 months is how to address the issue that some people are admitted to hospital who wouldn’t need to be if more responsive health and social care community services were in place. Most people don’t want to go to hospital and don’t like it when they are there, so what we want to do next is develop the services that will help with this. That is why one of our commitments is to develop community health and care services that will be able to respond to a community crisis within 2 hours, for situations when it is not about urgent medical care. This will be a real challenge, but it is not impossible and we know that if we can achieve these sorts of improvements it will take a lot of pressure off our busy hospital services. But better than that, it improves the lives and wellbeing of the people of Solihull.

If you would like to share feedback as a patient, carer or professional about SupportUHome or share your recent hospital discharge experience please email us at This email address is being protected from spambots. You need JavaScript enabled to view it.

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