I have known a dear friend of mine ever since I moved to Manchester 38 years ago. We have seen many storms together, and over the years I have been able to rely on him as a friend, mentor and for support. My friend, let’s call him Sam, is now elderly, frail and has several serious medical conditions.

With his permission, this blog post will focus on his latest travails with the health service – much to applaud, and some that didn’t quite hit the mark.

As a part of his treatment Sam had been injecting himself with blood thinning medication to prevent blood clots. One of the trade-offs with blood thinning medication is always between the risk of clots versus the risk of bleeding. Unfortunately for Sam, he started bleeding where he had been injecting himself and this turned into an infected abscess.

By the time I visited Sam, the infected area had spread across his leg and his leg had swollen. He clearly needed to be referred to hospital. And that’s where the ‘fun’ started…

Sam visits one hospital to treat all of his serious illnesses, but on this occasion his experience was not the best. Sam had a poor handover at the hospital at the point of admission due to a lack of communication with his Bury-based GP. After a little friendly coercion the hospital accepted his GP’s referral and admitted Sam as a patient.

The day Sam was admitted to hospital, the NHS non-emergency ambulance was experiencing high demand and had a four hour waiting time, so as an alternative Sam was transported by a voluntary ambulance service called Hatzolah.

After a few setbacks to begin with, Sam and his family received the most magnificent care once in hospital. He had ‘pints’ of infected fluid removed from his leg and a pump inserted to drain the infection.

Sam had been discharged home on a Friday afternoon and by Saturday night, his wound was weaping and the dressings were wet and stained. His referral from the hospital for a district nurse had not been received by the service, and so the night nurse was unable to arrange to visit. In desperation, the family rang me.

I spoke to the night nurse who told me she would visit but unfortunately this didn’t happen. On the Sunday morning the day nurse did visit but as there had been a poor handover from the hospital regarding Sam’s needs and she didn’t have the correct dressings.

By Monday, the district nurse wanted the drain reinserting, however this doesn’t happen straightaway – there is a process which involves several phone calls and an assessment. Meanwhile Sam is in pain and the infection gets worse… he waits, stoic as ever.

Sam’s experience is another example of the NHS’ talented and dedicated staff working in a part of the health and social care service that is currently fragmented and poorly coordinated. Clinical pathways and professional roles designed to help patients often, and counterintuitively, make things worse. Processes can take time, staff often work in silos and within strictly defined professional boundaries. Meanwhile our patients wait to receive the care they need.

In Bury, a series of system wide transformational shifts are taking place to improve the health and wellbeing of our population. These changes will see the local NHS and social care partners working together to make a significant difference to health and care services for the benefit of patients like Sam and others in similar situations.

By having more coordinated services in place that focus on putting the right support in the right place, it will mean Sam and others with similar experiences will remain well for longer than is currently the case, with services talking to each other to prevent delays and duplication and improve patient outcomes and experiences.

The aim is to make changes so that services will be ‘wrapped around’ the patient – people focusing on delivering the care people need, and less concerned about bureaucracy, professional or geographical boundaries. With these changes set to take place by 2021, this will be an exciting new chapter for the NHS that will benefit local people across Bury.

So how is Sam now? Thankfully he is recovering, receiving magnificent care from his local district nursing team.