I supported someone who attended frequent appointments with multiple health services. They had several physical and mental health diagnoses and there did not appear to be a plan to coordinate the services’ input. The appointments were difficult for the person to manage. Having to repeat their current situation and their history was extremely distressing.

 It could take several months for a referral to result in an appointment. Quite often, appointments would be changed or cancelled. The impact of this was that the person was not always able to attend appointments. Sometimes they presented what was seen as difficult or disruptive behaviour in service locations like GP practices. The person would then be prematurely discharged from services. Being without a GP for any length of time would be extremely detrimental to this person, and result in issues with medication and potentially benefit entitlements.

For people who have experienced trauma, new environments, meeting new people and changes to routine can cause huge levels of anxiety. It is also common for people that we support to have a mistrust of services, particularly statutory services, due to their past experiences. For example, waiting in a social work office can bring back negative memories and associations which can result in that person re-experiencing and re-living traumatic events. It can take careful planning and supportive conversations before someone agrees to meet with professionals. 

I felt it was important for this person to have some regular, practical support and assistance around managing these appointments. I requested a meeting with of the involved services; the person’s GP, a specialist dietician, the social work addictions service, representatives from the mental health team, a private counsellor, and support staff from two of Future Pathways delivery partners who had worked with the person.  

This meeting was organised by the addictions service. None of the other involved services attended, however some offered input for me to communicate at the meeting. The social worker attached to the addictions service shared that they planned to discharge the person. There were no alternative supports in place; although it was recognised there were many areas where support was needed because the person’s health and wellbeing was at risk. The social worker agreed that a community care assessment would be important.

After the assessment, a meeting was held with several professionals to discuss what statutory support was available and appropriate. The person was not invited to this meeting, but we agreed I would advocate on their behalf. After this, we discussed the proposed supports with the person who was able to share how they felt about what was suggested. They had input and control over how the care plan was developed.

There is now a coordinated support plan in place with weekly input through the community social work team. An expanded support network is building; the person now has a trusting relationship with a worker from a statutory service so it has been easier to establish connections with other supports. The person is visiting the GP and hospital less frequently and has built a better relationship with their GP because their needs are better understood. Regular reviews with the community social work team also ensures the person’s views are heard.