Joined-up careDavid Smith, Head of

Transformation – Integration

NHS Southwark Clinical Commissioning Group

The Southwark population

Early stages of LTC

(25%)

People experiencing inequalities or putting

their health at risk

(50%)

Early stages of LTC

(25%)

3+ LTC(9%)

EoL(1%)

Health and wellbeing

group

(16%)

People with multiple complex needs where standard services are not effective who need personalised care

Illustrative of the amount of health and social care resource used as a person moves up the model.

What are people in Southwark saying?

What is the problem? How can we fix this?

‘I can’t access care when I need it’

‘I have to repeat

myself endlessly’

GPs to work together in groups - “federations”

to provide more appointments- 8am- 8pm, 7 days a week

Better communication between teams, named contact,

single/ joint assessments

What are people in Southwark saying?

‘Helping me when I am already ill is too late!’

‘We’re running out of money – are my services going to be under threat?

What is the problem? How can we fix this?

More money to go into prevention to

keep people mentally and

physically well

Bring all providers together to ensure services are joined

up under one contract

How will we achieve joined- up care in Southwark?

We want to bring together health, social care and voluntary sector providers to deliver joined-up care for the people of Southwark. These groups of providers are called Local Care Networks!

GPs and practice nurses have already come together to form two groups, one in south Southwark and one in north Southwark (federations).

Groups of GPs and Practice nurses (federations) As well as providing GP appointments

8am- 8pm, 7 days a week, they are working together to provide extra services for patients such as smoking cessation and health checks.

Local Care Networks will also bring together more providers…

Mentalhealth

Socialcare /

worker3rd sector

District nurses

OT / Physio

GPs

PharmacyGPs

HCA

Practice nurses

Carers

Diagnostics Care Co-ordinationPatient

Urgent and emergency

Local Care Networks will operate beyond usual GP hours in order to reduce referrals to emergency care

Health visiting

Family health

Community matrons

Benefits advice

Local Care Networks will include: • The two GP groups• Hospitals (GSTT and King’s)• Mental health services• Community services• Social care• Housing• Voluntary sector

How will we achieve joined- up care in Southwark?

Specialist input shared between LCNs:

Virtual clinics, specialist nurses, consultants, geriatricians, end of life expertise, specialist rehab

Wider community support:

Police, fire service, schools, Housing

These groups of providers will be paid for outcomes instead of activity to ensure that care is high quality and patient focused

What are the next steps?

Patient We are working with patients, doctors, nurses and health care managers to decide which areas to focus on first e.g. frail older adults?

We are working with Lambeth Clinical Commissioning Group to join our resources to develop joined-up care together (Southwark and Lambeth Integrated Care, SLIC).

We are looking at how we can share good practice of joined-up care across the whole of south east London (Our Healthier South East London Programme).