Care Co-ordinators who provided regular checks and support with patients in north Cumbria are being praised for their vital work during lockdown and beyond.

They have a huge impact on supporting and identifying health issues among the more vulnerable and isolated patients in our communities, and are also a great help to clinical teams as services face increasing demand.

Care Co-ordinators are based in many GP Practices across north Cumbria, and their work ordinarily involves home visits as a way to identify concerns, and potential medical or social issues that patients have, allowing them to be linked up with appropriate sources of support as quickly as possible. The patients they see are often elderly or people who live with long term conditions, and they can access the service without the need for an appointment at their GP practice.

Anne Stoddart and Alex Corbett are Care Co-ordinators based at Castlegate and Derwent Surgery in Cockermouth, part of the Cockermouth and Maryport Primary Care Network and Integrated Care Community.

During the COVID-19 outbreak their team stopped doing home visits, but immediately put alternatives in place for their patients. They moved to a telephone welfare service to provide a listening ear and practical help for patients, who had quickly become isolated and lonely. Then as restrictions eased, Alex and Anne started visits to patients outside – usually in their gardens where possible. The visits were socially distanced and carried out in PPE, and meant that Alex and Anne were able to get a visual update on their patients and pick up on any physical or mental deterioration they had experienced. Following this they were able to suggest exercises to build strength and confidence, and could link people with volunteers in their community to support their wellbeing and social needs.

Anne said: “Lockdown was a worrying time, particularly thinking of the impact that the pandemic could have on mental health and physical activity levels of people who were shielding. Many patients also lost their support network due to family members also shielding. We wanted to find ways to inspire and to connect with people struggling with isolation and maintaining their independence, and so started using opportunities where we could have a conversation with patients and encourage them to take steps to improve their health or seek support where they needed it, while keeping us all safe.”

Anne and Alex have used their energy and creativity to support their usual cohort of patients, and have ensured links to health and community support throughout a challenging and frightening time.

Alex added: “We were concerned about patients who had seen their mobility suffer during lockdown, and so established socially distanced walks where we could join patients from a distance to build confidence and help them build stamina, whilst giving them the reassurance someone was nearby. We also provide exercise ideas to help people who work at home, and we’re available on the phone to provide encouragement.”

Patients appreciate the warmth and opportunity to connect into health services without the need for a medical appointment. This also builds confidence and helps people to make connections which will be valuable over the winter.

Dr Amanda Boardman, lead GP for safeguarding in north Cumbria, said: “The Care Co-ordinators have been doing all sorts of things to keep vulnerable and older people safe and supported, and to battle loneliness and deterioration in health, particularly during the COVID-19 pandemic. As well as providing support over the phone, they’ve been taking advantage of the good weather to do socially distanced visits using appropriate PPE. There are stories of this fabulous work from every town across north Cumbria, and patients love this approach and have responded well.”

The staff are highly valued by their teams at GP Practices, as it means clinicians have more capacity to focus on medical issues, and it provides assurance that potential problems and deterioration are picked up early to support speedy intervention.

Ed Tallis, Director of Primary Care for NHS North Cumbria CCG, said: “Anne and Alex are a really fantastic example of how our primary care teams are changing to support patients in a range of ways. It’s no longer a case that seeing the GP is the only or the right option - a range of new roles are helping patients to stay well and confident, and the Cockermouth Care Co-ordinators are a great example of those roles developing in GP Practices across north Cumbria.”