South Norfolk Council: helping the frail out of hospital

South Norfolk Council has worked with its partners to establish a hospital-based team that helps people when they are discharged. The service is reducing stays in hospital and is now being extended elsewhere in the county. This case study shows how district councils have improved the health of their local areas.

The health of people in South Norfolk and life expectancy is generally better than the average for England. But the district does have an increasingly ageing population.

Over the next three years the number of over 80s is expected to increase by nearly a fifth to account for seven per cent of the total population. Having an older population increases the likelihood of frailty and, as a result, falls, disability, admissions to hospital and the need for long-term care.

Every year over 700 older people are admitted to hospital after a fall alone – with one in five dying in four months. Preventing falls and helping older people has been one of the council’s key priorities in recent years.

Highlights of progress

Four years ago, South Norfolk established an Early Help Hub. It has brought together 16 partners, including the police, NHS, voluntary sector and county council together with the district.

The hub works across a number of different services from domestic violence to debt advice as well as working with older people.

It has helped create an environment where partnership working, reducing duplication and adopting a holistic approach is seen as key.

This in turn has helped South Norfolk improve the way it supports older people. There is a falls prevention service with leisure centres running Fit for Life classes and other support for vulnerable residents. The council estimates each falls prevention intervention costs £45 per person compared to the £2,000 plus cost of an A&E visit and hospital admission.

But the council has also worked with its partners to ensure those that do end up in hospital are given more support to help them leave quickly and then stay independent.

A team called District Direct has been created by South Norfolk in partnership with the three other districts that surround the area’s major hospital trust, the Norwich and Norfolk.

The team is co-located in hospital and staff on the wards raise the alert when patients are admitted that would be likely to benefit from some support on discharge. These are more often older patients.

The District Direct officers are able to assess the patient and their home environment to work out what help they may need when they return. They can arrange for a grant to be provided so the local care and repair team can provide housing adaptations such as walk-in showers and stair lifts.

They also work closely with the team of community connectors that is part of the social prescribing service. They can put residents in touch with exercise and social groups that are available locally.

Council Chief Executive Sandra Dinneen said some of the support is even more simple than that. “For example, the connectors will be in touch with volunteers who will be willing to call in and check the person is okay and perhaps bring them a casserole round.

“There are actually lots of people who are willing to help and volunteer – they just don’t know how or who needs help. By connecting people in this way you can ensure those who would not normally qualify for social care support can get help.”

Mrs C is just one of the people who has benefited from the support. She had been struggling to get about her house and was beginning to feel isolated. When she was admitted to hospital for a hip replacement, she was referred to the District Direct team.

She ended up having a ramp and rail installed at the front of her property, so she could get out more easily. She was also referred to the community connectors, who put her in touch with a backgammon group in the local area, which she started attending weekly. A friend made at the group who lives close to Mrs C now visits her regularly.

Future plans

An evaluation of the District Direct team during winter 2017-18 suggested it was having a significant impact. The analysis showed it had halved the average length of stay in geriatric medicine beds and overall saved 386 beds days and £77,000 in that time period. Replicated over a year, it would mean savings of £330,000.

The service has now been extended to two other hospitals in the area – Great Yarmouth’s James Paget Hospital and the Queen Elizabeth in King’s Lynn.

South Norfolk is also aiming to offer more support online to aid self-care and prevention. Referral forms can already be filled in online, but one option being considered is a web chat-style facility run by the Early Help Hub.

Lessons and key messages

The creation of the District Direct team is a perfect example of the challenges district councils face.

Ms Dinneen said: “It took us about 18 months of talks and negotiations to get it going. There can be an attitude that technically this is not the sort of thing we should be doing. But if you don’t work proactivel

The service was first established two years ago after the district councils put money in, but it soon became clear that the service could not cope with demand so it had to be suspended.

“It was very disappointing,” said Ms Dinneen. “But we didn’t give in. We worked hard to get it back up-and-running. We got the CCG, adult social care and the districts contributing. The key was having some people, particularly at the hospital, who really wanted to make it happen and could see the benefit of what we were trying to do.

“The problem with prevention is that you are asking people to invest in something to stop something that hasn’t yet happened. It requires faith in what you are doing.”


Sam Cayford
Health and Wellbeing Officer
South Norfolk Council