A TRIP to an emergency department or GP practice isn’t likely to be on the top of most people’s lists, but people from a very small section of the community feel like they have nowhere else to turn.

This group of people find themselves in healthcare services many times every year, usually without a medical need to be there.

With this high intensity service use ever increasing, a team of colleagues at Somerset NHS Foundation Trust got together with the Community Council for Somerset (CCS) – the largest community development charity in Somerset – to develop a project that looked at alternative services that could help those people.

And in an exciting development, the project reached the final of the Health Service Journal Patient Safety awards.

Karen Holden, Somerset NHS Foundation Trust’s associate director of clinical transformation, explains: “The main principles of the project came from a recognition that there are people in our community who were using the NHS on an abnormally high number of occasions, whose actual needs weren’t being met in a healthcare setting.

“Our hospital teams are focused on dealing with individuals medical needs, and don’t have the capacity to be supporting patients who have complex, individualised needs.

“We had the sense that we needed to do something different, and that the medical approach we used in the past wasn’t working for this particular cohort of people.

“We therefore began a conversation with the team at CCS about whether there was an opportunity to do something a bit different, and together we set up an improvement project, which gave us the opportunity to look at how we could set up personalised care for these patients – we called it Ubuntu.”

The project was so-named Ubuntu after the team listened to an NHS England colleague who explained all about the principle of Ubuntu – ‘for one, for all’.

Kristel Van Der Schyff, hospital team manager and Home First and Ubuntu lead at the Community Council for Somerset, explains the unique approach she and her team take to support individuals in the community.

“The Ubuntu team focus on taking the time to build professional, trusted relationships with each person. The result is a responsive, person-centred support system that taps into the individual’s community network as part of the solution, shifting the focus away from medical diagnoses and looking at the person as a whole.

“Every solution is unique because everyone’s circumstances are different. Ubuntu's flexible approach allows them to focus on people’s real needs and ensure that the support they provide makes a meaningful difference. This might mean something as simple as connecting individuals with their local knit and natter group or connecting them back to their GP.”

Neil Thomas, Somerset NHS Foundation Trust’s high intensity use lead, said: “The partnership with CCS has been crucial in getting people the right support they need at home and in the community, helping to avoid them coming into healthcare services.

“Part of what we’re attempting to do is break that cycle of this cohort of people having a really poor relationship with healthcare services.”