Coordinated care

Overview of coordinated care

Coordinated care is one of the focus areas of our Local Care Networks (LCNs). In 2016/2017 LCNs agreed to prioritise the delivery of coordinated care to people with complex needs; i.e. those people with three or more long term conditions (LTCs). In Southwark we are using a framework developed by NHS England that we have adapted to meet the needs of our population, you can read the full document here ‘Transforming Primary Care in London’ (chapter three).


Why coordinated care ?

NICE published guidelines in 2016 which suggests optimising care for adults with multiple long-term conditions could reduce unplanned care such as emergency GP and hospital appointments. Coordinated care aims to improve quality of life by ensuring there is shared decision making based on what is important to each patient in terms of treatments, health priorities, lifestyle and personal goals.


What have we done so far?

What positive outcomes have we achieved?

  • We have talked to many patients with three or more long term conditions to support the development of coordinated care in Southwark. You can read about this engagement work here.
  • A local framework for delivering coordinated care and a patient pathway has been developed. The framework includes:
    • proactive identification of patients with 3+ long term conditions
    • holistic assessment of a person’s physical, emotional and social needs
    • proactive and person-centred care planning
    • improved multi-disciplinary working across all those involved in a person’s care
    • promotion of, and support for, people to self-manage their condition and improve their health and wellbeing.
  • Our LCN received a runner-up award at the Patient Experience Network National Awards in March 2018 for our engagement work around coordinated care. You can watch a short film of our Director Louisa Dove and Rosemary Watts, Engagement Lead at NHS Southwark CCG talking about how we engaged local doctors, nurses and patients to develop the coordinated care pathway in Southwark.

The table below provides further information on the framework and what has been done so far.

Key component of coordinated care

Description of approach

What has been done so far

 1. Proactive identification of patients Practices will identify patients who would benefit from coordinated care and continuity with a named doctor or nurse, and will review those that are identified on a regular basis. Al GP practices in north Southwark have identified their patients with three or more long term conditions.
 2. Named professional Patients identified as needing coordinated care will have a named doctor or nurse who oversees their care and ensures continuity. GP practices are currently agreeing a named doctor or nurse to oversee the care of each patient they have identified.
 3. Care planning  Each patient identified for coordinated care will be invited to take part in a holistic care planning meeting in order to develop a care plan that can be shared with anyone involved in their care (family, GP, nurse, hospital). GP practices have begun inviting patients to take part in a holistic care planning meeting.
 4. Patients supported to manage their health and wellbeing Primary care teams will support patients to confidently take responsibility for their health and wellbeing. GP practices are taking part in initiatives such as the Care Navigation programme to support people to look after their own health and wellbeing.
 5. Multidisciplinary working    Patients identified for coordinated care will receive regular multidisciplinary reviews by a team involving health and care professionals with the necessary skills to address their needs. QHS holds regular ‘multidisciplinary working meetings’ for health and care professionals to discuss care plans and provide peer support.

What are our plans for the future?

  • We want to work in our neighbourhoods (Borough, Walworth, Bermondsey and Rotherhithe) so that we can build close links with local community and voluntary organisations to support patients to manage their health and wellbeing.
  • We will have neighbourhood based multidisciplinary working meetings.
  • You can read more about neighbourhood working here.


Further information

You can watch a video by the Royal College of General Practitioners (RCGP) that shows how coordinated care will work in general practice here.

Southwark Talking Therapies (IAPT) are running a series of self management classes and support groups for people with long term conditions. Please download the flyer  for further information.