Overview of the programme of work
In 2017, we started to join up care between GP practices, hospitals, community services, social services and the voluntary sector. We wanted to move towards a system which arranges services around the individual and provides the support they need to stay or get well – whether physical, emotional or social. A Local Care Network (LCN) was created in north Southwark to support the different parts of the system to work together better.
The purpose of the programme of work
On a daily basis, the health and social care system across does amazing things. With a range of world-class services available across our major hospital sites and in our community, supported by a strong and committed workforce, together we look to support the health and wellbeing of our population.
But we know that things can improve further. Feedback from citizens and service users has indicated that they find the health and care system difficult to navigate and that it is not always responsive to their needs. Communication between different parts of the system is not always as good as it should be, and service users can feel unsupported and isolated. We wanted to fundamentally change this, and move towards a system which arranges services around the service user and responds to their range of needs – whether physical, emotional or social.
What did we achieve?
Who was involved?
- QHS directors and staff
- Practice staff from across north Southwark
- NHS Southwark Clinical Commissioning Group
- Guy’s and St Thomas’ NHS Foundation Trust
- Guy’s and St Thomas’ Community Trust
- Southwark Council
- Community Southwark
- An LCN Board was established in north Southwark with key people from QHS, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s and St Thomas’ Community Trust, Southwark Council, Community Southwark and NHS Southwark Clinical Commissioning Group. This was to ensure decisions could be made across the whole system.
- A Local Care Record is now available so that patients’ health records can be shared across the system.
- The LCN has agreed to work together to improve coordinated care for people in Southwark with three or more long term conditions.
- We held engagement events with local patients with three or more long term conditions to design coordinated care.
- We designed a model for coordinated care which included:
- Identifying patients via GP practices
- Developing a holistic health assessment
- Developing a care plan for patients
- Ensuring each patient has a named health professional
- Setting up meetings with hospital doctors, GPs, nurses, social care and the voluntary and community sector (multi-disciplinary teams) to discuss the care and needs of patients
- Developing methods of self-care so that patients are empowered to look after their health
- From April 2017 to March 2019, 2477 patients with multiple long term conditions living in north Southwark received coordinated care!