Buckinghamshire Joint Local Health and Wellbeing Strategy 2035

Sophie was being discharged following a short admission to hospital. She felt she wasn’t ready to go home as she had mobility issues and mild concussion. Once home, she struggled to get out of bed, cook or dress herself, this caused her to become very distressed.

After getting support from Age UK they were able to contact social services who were able to refer her to the Rapid Response and Intermediate Care Service (RRIC). Following this referral Sophie’s immediate concerns were addressed quickly, “Within two hours it was all sorted.” Sophie now has equipment she required to help with her mobility, such as a raised toilet seat and shower chair at home. The team also sent in carers twice a day. She is now looking forward to regaining her independence.

Age UK also continued to support Sophie, and a volunteer visited once the carers left. She has also been put on the waiting list for a befriender

At 50 Phil wanted to reduce the number of medications he was taking for his various health conditions, particularly high blood pressure, cholesterol, and Type 2 diabetes. He hoped that lifestyle changes could help him achieve this goal.

Health coaching identified that a primary barrier Phil faced to change his lifestyle was a lack of dietary knowledge. His previous beliefs about nutrition were not aligned with the goals of reducing his Type 2 diabetes and cholesterol.

After dietary support, in just six months Phil lost 12kg, reduced his blood sugars and lowered his cholesterol. These results were achieved through lifestyle adjustments rather than following a strict diet.

Phil also increased his physical activity, especially by involving his kids in fun exercises like bike riding and playing Pickleball. This further improved his health markers and helped him stay committed to a fitness routine that benefited both him and his family.

By making mindful choices and finding enjoyable, attainable physical activities, Phil was able to stick with the changes long-term and achieve his goal of reducing medications.

Avni was facing significant changes in her health and care needs relating to her breast cancer diagnosis and was admitted to Stoke Mandeville Hospital for palliative crisis management.

Avni had been living with her young family in a home which was unsuitable for her changing care needs, but it was vital to her that she spend her final months at home with her children and husband.

Close collaboration between Bucks Home Choice, Home First, palliative care, district nurses, and a community occupational therapist facilitated the search for and adaptation of a suitable property for the whole family. Bucks Home Choice staff visited the hospital to communicate directly with the family about their housing needs, and a multidisciplinary team (MDT) meeting ensured coordinated planning.

Avni passed away with peace of mind, knowing her family was supported and her wish to remain with them was honoured. Her family expressed deep gratitude for the compassionate care provided.

Susan was in her late forties and was struggling to manage her weight, knee pain, asthma management and immobility on some days. After reaching out for support, health coaching was suggested to her.

Susan attended small group and 1-1 sessions. Despite initial reluctance Susan and the health coach worked together to break down her barriers and explore the first steps towards change. The health coach encouraged Susan her to take more responsibility and accountability for her progress and Susan decided to try Intermittent Fasting, with the goal of first focusing on the time parameters of fasting. This approach allowed her to see some early positive results, which helped boost her belief and motivation.

Over the next seven months Susan began exercising regularly and lost 16kg, which significantly reduced her knee pain. This improvement in mobility allowed her to walk without a stick. Susan continued to make progress and tackle barriers along the way and now feels that the changes she has made are sustainable and Susan is embracing her new way of living. Phil was able to stick with the changes long-term and achieve his goal of reducing medications.

As a new parent Jade needed advice and support on breastfeeding. Matt had noticed that around the time Adeline was born his blood pressure kept dropping.

When Adeline was 2 weeks old Jade took her to a drop-in Health Visitor session at Health on the High Street in Aylesbury and whilst there, she was able to access support from a breast-feeding volunteer, which led to Adeline being referred for additional support for her tongue tie. She was also able to breastfeed there in a welcoming space, improving Jade’s confidence of breastfeeding in public.

Whilst accessing these health visiting services, Jade and Matt were able to do a quick health MOT which Matt used as he had noticed his blood pressure kept dropping. After using the kiosk Matt was able to make small changes with advice provided, his blood pressure return to normal.

Jade and Matt now track their health through regularly using the kiosk.

Reg was admitted to Wycombe Hospital for treatment following a cardiac event. He had been living independently at home with his wife prior to admission.

Reg’s wife very sadly passed away whilst he was in hospital, leaving him deeply worried about returning home. Although he retained decision-making capacity, he struggled to make choices due to psychological distress. Beyond requiring some rehabilitation, his primary needs centred on emotional and psychological support.

The discharge team coordinated a tailored plan, with ward staff arranging the logistics of his transition home. Onward Care provided food parcels and remote monitoring to ensure his wellbeing and Age UK provided a befriending service to combat isolation, whilst Home First implemented a care package to address daily needs.

This collaborative approach ensured that Reg received comprehensive support and was able to return home safely

Tony is a 25-year-old man who has a long history of rough sleeping, substance misuse, learning difficulties, suspected autism and self-neglect. As a child, he was under Children’s Social Services, he had Leukaemia and a stroke. During his adult life, he has been in and out of temporary accommodation, hospital and custody.

Tony was often found unconscious, walking into traffic, reported as missing, had multiple safeguarding concerns raised and emergency call outs were frequent. When offered accommodation, Tony would return to the streets and sleep rough.

The Making Every Adult Matter (MEAM) team started working with Tony in 2023. They worked collaboratively with Adult Social Care, One Recovery Bucks, GP and Thames Valley Police to support Tony’s needs and were able to do things such as GP going out to assess Tony where he was rough sleeping as he would not visit a GP.

Tony’s physical health has shown significant improvement. For the first time in a long while, he has maintained stable supported accommodation for two months, and he has slept in his room for four consecutive weeks. There has been a notable decrease in emergency service call-outs and he has not been admitted to hospital for 7 months, and safeguarding concerns have lessened, which is a sign of improved stability and overall well-being.

Jack is 16 and was referred to school nursing as peers had begun to comment negatively and refused to work with the student due to body odour concerns, leading to classroom disruptions. Despite previous interventions from mental health and parents, no improvement had been observed.

Jack has a diagnosis of Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder, Pathological Demand Avoidance (PDA) and Anxiety. Due to PDA, parents were hesitant to impose demands regarding hygiene, fearing it could lead to emotional dysregulation.

A personalised and coordinated approach was provided including engagement that consider Jack’s coping mechanism, support strategies were developed with Jack’s parents to encourage Jack to shower in a non-demanding manner, the school and parents were supported with advice and guidance from occupational therapists and neurodevelopmental nurses.

This personalised, tailored approach was essential for engagement. Jack, initially avoided interactions but began attending one-to-one sessions and the school and parents have reported noticeable progress. Including Jack showering twice a week, no body odour concerns were reported at school during the same period.

Beth, a 19-year-old young mother was diagnosed with ADHD, autism, and learning disabilities at age six, she was assessed at 11 as having a five-year developmental delay. She attended a special needs school and later college. Beth has experienced challenges with emotional regulation since childhood. After a brief relationship, she became pregnant.

The Family Nurse Partnership (FNP) have provided tailored support to Beth throughout her pregnancy and her early parenthood journey.

This has included:

• consistent appointment scheduling to establish routine with a consistent professional to build trust.
• providing accessible information to suit Beth’s need
• using a Health Passport and birth plan to amplify Beth’s voice.
• coordination of health professionals such as the Specialist Midwife and Perinatal Mental Health Team

Beth gave birth to a healthy baby girl, Anna, at full term. Beth quit smoking during pregnancy, is breastfeeding and engaging well with the Family Nurse Partnership (FNP). Anna is thriving and Beth is building confidence in parenting and is considering.

The Buckinghamshire School Aged Immunisation team identified a school in one of the Opportunity Bucks wards (one of the 10 wards that experience the most disadvantage in Buckinghamshire) that was very diverse which had a poor history of immunisation uptake and parental engagement.

The immunisation team worked with the school to increase uptake of immunisations. Two assemblies were held with the students advocating for the importance of immunisations, one was held by the deputy head teacher and the second assembly two weeks later was a question and answer session run by the immunisation team enabling students to ask questions collectively and on a 1:1 basis.

Resources were given students in different languages to take home. Telephone conversations were made to parents prior to the day of vaccination and then again on the day with the student present.

This led to a compliance of 98.7% compared to 72% the year before. It also helped to increase awareness of vaccinations to the students and their families and increased the positive relationship with the school.