As the winter weather continues to sweep across the nation and seasonal pressures strain accident and emergency departments across the UK, health care professionals around Derby have teamed up to do things differently.

The Derby City Council Hospital to Home (H2H) team was set up in December last year at the Royal Derby hospital. It provides a single point of access for all adult social care referrals from the hospital to ensure a rapid response to support timely discharge.

The team of four social workers and six community care workers liaise with health staff, patients and their families to undertake an assessment of patients’ needs and put care in place to assist recovery at home or an alternative suitable location.

Derby City Councillor Martin Repton, Cabinet Member for Integrated Health and Care, said:

This is a fantastic service that will be running seven days a week in partnership with health colleagues including those from Royal Derby Hospital, Home First and London Road Hospital.

Hospital to Home and Home First are innovative ways of preventing people from going to hospital and ensuring they have the right medical and social care support they need closer to home.

In addition, if they are already in hospital then Hospital to Home and Home First will enable patients to be discharged from hospital much earlier than would otherwise have been the case and into a locally based facility – which will give them the right level of medical and social support as a stepping stone to go home.

The Council has a key role in supporting its health partners to reduce delays in discharging adults from hospital and increase the flow of people to their own homes or the most appropriate setting according to their needs.”



Councillor Repton also acknowledged that hospital admissions can be very difficult and emotional experiences for some people. This can lead to patients losing their confidence, sense of independence and therefore feeling very vulnerable. Sometimes the longer the frail and elderly remain in hospital, away from familiar surroundings and their family and friends, the less likely they are to return to their own homes. He added:

The Hospital to Home team work quickly and positively with their patients so they can remain independent and enjoy a good quality of life in a familiar environment. It is our ethos that people should not go into residential care unless every other community option has been explored.”

Jane Haywood, Manager for Derby City Council’s Hospital to Home team, said H2H staff worked closely with the Home First provider service to ensure patients can go home for their assessment. This enabled them to compile an accurate picture of the patients’ ability to live independently.

Pictured above: Hospital to Home Team based at Royal Derby Hospital

Jane said H2H based its work on the ‘discharge to assess model‘, which recognises that (where appropriate) people recover and function best in their homes. If independent living was not possible then H2H would be better equipped to consider alternative options. She praised her team and health partners. She said:

Our staff are highly skilled, motivated and work extremely hard under great pressure. They have a can-do attitude and offer brilliant customer experience. They are committed to being the best and treat their patients and colleagues with dignity, honesty and respect.

We couldn’t have done this alone and partnering with health professionals makes a very big difference when it comes to reassuring patients and their families about the joined up care we can offer.”

Lisa Marshall, Integrated Capacity and Demand Lead at Derby Teaching Hospitals Foundation Trust, added:

This is a really good example of health and social care working together for the people of Derby. Hospital to Home team has made a massive impact on our patients’ wellbeing as the team has been able to carry out timely assessments to ensure that patients are going home rather than into long-term care.”

Watch newly qualified social worker Claudia Lancashire (above), talk about her role in the Hospital to Home team.

Derek Lane praises Hospital to Home Team for “bringing mum home”

May Lane, was admitted to Royal Derby Hospital in November, last year, after she had a stroke. The 103-year-old retired ballroom dance teacher from Sunny Hill, Derby, remained on a ward for three weeks.

Her 71-year-old son Derek Lane, who is May’s carer, praised the H2H team for helping to “bring mum home” with an early discharge and for arranging home care. Commenting on her stay at Royal Derby Hospital, he said:

The ward staff who looked after mum were brilliant. It was her birthday four days after the stroke and she spent it in hospital where they made a big fuss over her and treated her like the Queen.”

Derek, a retired foreman, said it had been difficult to see his mum so unwell. He said:

Back in her younger days mum’s ballroom dancing took her all over the world. When she met my dad, an organ builder and fireman during the war, she settled down and had me and my older sister Georgina.”

In December last year, Lorraine from Hospital to Home asked mum if she wanted to go home and mum said “yes”.

Lorraine organised home care for the family so now someone comes four times a day, seven days a week, to care for mum. Lorraine also organised an occupational therapist to come to the house to arrange nutritional care for mum.

She also got in touch with local charities to come and spend some time with us and keep us company as it can get lonely!”

Derek concluded:

Mum is much happier at home. Having help makes life a little bit easier for the both of us. I would definitely recommend Hospital to Home, this service is special because it gives patients, particularly the elderly, some hope and they don’t feel like they are put on the scrap heap. They speak to people like human beings and they genuinely care about people.”


Published: Monday 6th February 2017