Overview of the programme of work
It is recognised that the needs of some patients are social rather than clinical in nature but they are still at risk of being admitted to hospital or being in crisis. Evidence shows that providing additional support focused on social needs (e.g. social isolation) would reduce this risk or provide a more appropriate management response should a crisis arise.
Quay Health Solutions is working with Age UK Lewisham and Southwark, the CCG and other local partners within the Local Care Network to deliver a Care Navigation Pilot.
The purpose of the programme of work
We aim to ensure care is designed and delivered around the needs of the individual, through partnership working. This area of work is part of our coordinated care programme, supporting people with multiple long term conditions and frailty. Services should be joined-up to promote improved outcomes for individuals in need of health and social support, enabling them to live not just longer, but better lives.
What has been done so far?
Primary Care Navigation (PCN)
Practices in north Southwark have paired with local pharmacies and have identified reception, health care assistant and counter staff to attend a primary care navigation training programme.
The role of the PCN is designed to release clinical capacity and provide better outcomes for patients where their needs would be better met through a social intervention. The PCNs are trained to identify support and signpost patients to local services. The PCNs are supported by the SAIL Care Navigator for more complex cases.
John was 97 years old and kept getting nuisance calls when he was trying to sleep. He found them very distressing and was calling the GP practice to ask his GP to help. He wanted the GP to call the estate manager to make the calls stop. The primary care navigator explained that it might be better to speak to a SAIL Navigator rather than a GP since the problem was not medical. The SAIL Navigator called John to reassure him and then referred him to Trading Standards who have agreed to visit John and put blocks on his phone so he doesn’t get cold callers anymore. John has stopped calling the GP for help about this now, and feels confident that the issue will be resolved soon.
Please see this PCN case study from Old Kent Road Surgery which highlights the impact of PCN on the practice.
SAIL Care Navigation
A SAIL Care Navigator from Age UK Lewisham and Southwark works across a number of host GP practices supporting patients identified as needing additional non clinical support.
SAIL Care Navigators support people to stay healthy and independent by assessing their needs and co-ordinating an appropriate package of support. The service is for patients with high levels of social need, so the agreed plan might include supporting people to access new social groups and activities, learn new skills, access benefits advice or practical adaptations in the home.
The Age UK Lewisham and Southwark SAIL Care Navigator works closely with GP practices across a number of sites and takes referrals via the SAIL checklist. The SAIL Navigator has close links with the wider voluntary and community sector and social care colleagues.
“Thank you so much for your efforts with Sarah. She left a message for me on Wednesday saying how thrilled she was with the help you have given her. I am truly grateful, you are making a big difference to her wellbeing” Ranya (Dr Zeineldine Aylesbury Medical Centre)
“Thank you so much for this and updating me – it’s really useful – you’ve done a great assessment of actually what she wants and needs! Your plan sounds perfect – I’m really grateful for this and I think all below would really benefit Georgina.” Vicky (Dr Burt Manor Place)
Rose had become very isolated and saw no one except her daughter. She told her nurse during a holistic health assessment that she loved sewing. It turned out she was an incredibly skilled seamstress who made all her own clothes, but had nothing to sew for and was giving away all her material. The navigator told Rose about Blackfriars Sewing Club and took her on the bus. She was welcomed into the group and was thrilled at the idea of sewing bags and cushions for the club to sell and raise money for a sewing machine. She told her son she had been wasting her life all this time, and has now joined the group every Thursday for seated exercise and lunch as well as sewing.
What are the plans for the future?
Via neighbourhood working we are planning to up skill more practice staff. We will also aim to work more closely with our settlements (Time and Talents, Pembroke House, Bede House and Blackfriars) to ensure that more patients are referred to these services and receive the support they need.
Anyone working in a practice can access support for patients from a SAIL Navigator by completing a SAIL checklist. Patients can also self-refer.