How the Ubuntu scheme is helping people who access healthcare too often

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

"This particular group of patients have been in the healthcare system for a long time, not really having their needs met, so they become very disaffected and very disillusioned, often presenting to us quite angry.

“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’.

“The name Ubuntu originated from when an ethnographer visited an African tribe and placed some sweets in front of a group of children, saying ‘first to the sweets wins them all,’” Karen continues.

“But the children took each other’s hands and calmly walked together to the sweets, so they could share them.

“The motto of the story is that in this tribe’s culture, there was a principle of Ubuntu – if one person gets everything, then everyone suffers, whereas by working together, everyone gets an equal share.

“It really resonated for us as a principle, and when choosing the project’s name, we wanted to keep the theme of personalised care at the centre of it, so we named it Ubuntu, knowing that we’d always need to keep explaining and reminding ourselves of the principle – just like we are in this article!”

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.

“CCS is already deeply embedded within local communities, with staff visiting every patient referred to the service in their own home to gain a true understanding of the individual, how they manage, and the resources available to them locally.

“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.

“By focusing on the whole person and integrating them back into the fabric of their local community, Ubuntu aims to increase wellbeing and help people rediscover a sense of purpose, ultimately empowering them to take back control of their own healthcare journey.”

Neil Thomas, our high intensity use lead, says our trust’s 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,” he continues.

“This is why our CCS colleagues play such a vital role, because it meant that people weren’t seeing ‘yet another healthcare colleague’, but instead someone finding out about and understanding their needs.

“It may of course still be that our CCS colleagues need to refer the patient into the health service, but through Ubuntu this can be done in a much more planned manner.

“We’re so excited that our project has been shortlisted for a HSJ Patient Safety Award, as this is great recognition of our wonderful Ubuntu colleagues, who put a lot of time and effort into building up relationships with those people who generally feel that they’re being let down all the time.”

How Ubuntu helped patient Janet*

Janet made over 6,000 calls to NHS 111, prompting a request to Ubuntu agents for urgent help. The intention was to keep Janet safe, and avoid her being barred from using NHS 111.

Initially, the difficult decision was made with Janet to disconnect her phone line to prevent further calls to NHS 111 at that time.

To ensure continued access to emergency assistance, it was agreed with Janet to put in place a personal alarm system in close partnership with careline colleagues. The system provided Janet with an alternative means to seek help when required – using a button on her phone to call for support.

Ubuntu agents observed that most of Janet’s calls were made during weekends and evenings, when traditional support channels were unavailable. To mitigate this, collaboration with a local care provider was intensified by designating them as a primary point of contact, and arranging for them to be available during extended hours to accommodate Janet’s needs.

Efforts were also made to enhance Janet’s support network and social engagement. She was introduced to the opportunity to volunteer at the library, providing companionship during weekends when she felt most vulnerable.

A review of Janet’s outgoing calls confirmed positive change, reflecting a shift toward more appropriate channels for seeking assistance and huge reduction in calls to NHS 111.

In April 2023 she called NHS 111 over 6,000 times and this reduced to 4,385 within a month, and then down to 785 in June. This fell significantly to 29 in September, and then in November 2023 it was down to just six.