1. “Care co-ordination needs investment” “‘ No’ needs to turn to ‘yes’ otherwise patients play ping pong” (GP) “A lot of admin and not so much people contact” (voluntary sector) “Dozens and dozens of phone calls are needed to get things done” (GP) “ I would like people not to be so picky. It’s often easier to do it yourself” ( district nurse) “Multi - disciplinary meetings are cancelled half the time” (district nurse) “Need a better understanding of roles, what they are and what they’re not” (social care) “Need to release time to care” “Patients have a basketful of problems; the frustration is getting someone to deal with them” (GP) “Feel you could do more but time only allows you to do the essentials” (district nurse) “We’re all working hard but not actually integrating” (GP) “There’s no time to build relationships with someone, for them to gain the trust to say the things that really matter to them” (social care) “We’re fire fighting and reactive, focusing on one problem at a time”(GP) “Hesitancy about voluntary sector” “We’re not a last resort or a way of doing things cheaper” (voluntary sector) “We’re not just an add on to take people out for coffee” (voluntary sector) “Like to see more value and respect, accept that not everyone’s health trained but have life experience” (district nurse) “There’s lots more the voluntary sector could do for us that could free up our time” (district nurse) “The public are wary of the fact that volunteers can turn around problems’” (GP) How it feels now – facing the ‘brick wall’…

2. …How it feels on the other side of the wall, five years on I bumped into the Mental Health Support Worker in the corridor this morning and had a quick catch up about a particular lady we were both supporting. The Mental Health Worker asked if the care package could be changed as the lady was now getting out and about, so needed a bit more flexibility in her support. I was happy to do so because I knew we were all working towards helping her achieve this goal (social worker) This week I got together with the rest of the team in my practice for our regular meeting to review the people we’d identified as being at high risk of hospital admission. Around the table there was a Voluntary Sector Coordinator, Social Worker, Mental Health Nurse, District Nurse, Therapist and me. The Hospital Discharge Nurse and a Respiratory Nurse joined us remotely. We discussed specific people, using the person’s own goals to guide our support planning, and agreed who should take the lead based on who had the right skills at that time (GP) I helped Mr H get back on his feet after a stay in hospital, by helping him to build his confidence and encouraging him to do his rehabilitation exercises. His daughter telephoned as she was worried that he wouldn’t cope but I reassured her that we’d thought ahead, talked to dad to find out what his concerns were, and got in touch with the key community contact to make sure he could still get to his social club. We even had Skype set up so they could talk more often (Volunteer) Today I got a call from the Community Line about Mrs B needing my support. I was given her background, her goals and action plans that were to get out of the house and meet people. It was great that all of the essential referral and assessment information had already been gathered, saving me some admin. I had access to her care plan so it was clear what my role was, how I could help her and who was co-ordinating her care (district nurse)