Neighbourhood working

QHS member practices are divided into five geographical areas called neighbourhoods in Southwark, which are; Bermondsey, Rotherhithe, Borough and Walworth triangle and south Walworth. Our neighbourhoods support delivery of our Partnership Southwark which aims to join up care between GP practices, hospitals, Southwark Council and voluntary and community organisations ensuring coordinated and improved quality of care for our population.

Following the Dr. Claire Fuller’s report “Next steps for integrating primary care: ‘Fuller Stocktake Report​’ which was published in May 2022, our Neighbourhood teams aim to work together in a Multidisciplinary approach.

Working in neighbourhoods ensures a focus on the local needs and priorities of our member practices and their patients. It means local connections and relationships can be established across GP practices and sectors such as healthcare and the voluntary sector in a meaningful way. We have a shared purpose and shared resources to deliver quality care and outcomes for our patients living in these neighbourhoods.

QHS have been working in Neighbourhood’s and has established links with our Partnership Southwark colleagues. For example, we have worked extensively with Bede house to deliver both Covid and Flu vaccinations. We are supporting our Southwark Council colleagues to deliver a Vital 5 check at various festivals and community led events during 23/24. We have also enabled, via ARRS funding, for our patients to receive in a primary care setting a Mental Health practitioner and First Contact Practitioner service.

GP practices are working more closely than ever with our partners including Guy’s and St Thomas’ NHS Foundation Trust, South London and Maudsley, Southwark Council, Community Pharmacy and voluntary and community services including our local settlements; Bede House, (Bermondsey), Time and Talents,(Rotherhithe), Blackfriars Settlement (Borough) and Pembroke House (Walworth).

This growing multi-disciplinary approach to developing and improving services is enabled and supported by our monthly Neighbourhood meetings led by the Primary Care Network Clinical Directors who are aligned to each Neighbourhood.

What has been done so far?

  • We have recruited two neighbourhood coordinators and a neighbourhood manager to support GP practices with this new way of working. One coordinator will work across Borough and Walworth and one coordinator will work across Bermondsey and Rotherhithe.
  • A neighbourhood programme was launched in November 2018, bringing together over 100 people from primary care, secondary care and the voluntary and community sector to explore areas of common challenge and scope improvement projects.
  • Our Care Navigators, based in GP practices have been trained at their local settlement and will refer patients who would benefit from services provided by the settlements.
  • Neighbourhood Champions including a GP, practice manager and practice nurse have been recruited to progress neighbourhood projects in Rotherhithe and the Walworth triangle.
  • Pilots were launched in the Walworth triangle and Bermondsey and Rotherhithe neighbourhoods to look at solutions for people with mental health issues. You can read more about this in our Year in Review 2018 – 2019. 

What are the plans for the future?

  • We will continue to provide training, share best practice and support and develop new ways of working across practices.
  • We will continue to work on pilot projects and share learning with other neighbourhoods.
  • Our neighbourhood development work will support the work of our Primary Care Network and Partnership Southwark.

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