New way of working coordinates care in Greenwich

Lynda Harris whose mother has benefited from new joined up working in Greenwich
Lynda Harris whose mother has benefited from new joined up working in Greenwich

Last October, our work with partners to join up health and social care services in Greenwich was highlighted nationally as a beacon of success and has recently been awarded additional funding.

Integrating care services is about organisations including the NHS, councils, social services, the voluntary sector and individuals working closely together to deliver services tailored to individual patients' needs by sharing information and resources, communicating regularly and effectively and avoiding duplication.

Greenwich Coordinated Care (GCC) is a shining example of how the NHS and care systems can work together to provide better support at home and earlier treatment in the community. So much so, that it has been chosen as one of 14 initiatives nationally to be declared a ‘Pioneer Project' by Care and Support Minister Norman Lamb.

The pioneers were selected by an internationally renowned panel of experts drawing together global expertise and experience of how good joined up care works in the community.

Jane Wells, Director of Adult Community services at Oxleas NHS Foundation Trust said: "We were delighted to be chosen as a Pioneer for health and social care. To then be awarded extra funding in recognition of the great, practical and patient focused work that has been led by staff on the ground was just fantastic news."

GCC is a partnership between Oxleas NHS Foundation Trust; Royal Borough of Greenwich; GPs; Greenwich Action for Voluntary Services; Greenwich Clinical Commissioning Group and Lewisham and Greenwich NHS Trust. The partnership has been so successful that NHS England has awarded £90,000 of funding to further enhance the service.

One of the GCCs earliest successes was the award winning Greenwich Joint Emergency Services (JET). JET works in the local community to make sure that patients who can receive treatment at home or in short term residential care do not have to go into hospital unnecessarily.

So far, over 2,000 patient admissions have already been avoided due to JET and over £1m has been saved from the social care budget by joining up health and social care services. Feedback shows that one in three people would have gone to A&E for treatment if the JET team had not been involved and a similar number say they would have continued to ‘struggle at home'.

The GCC is now forging ahead with its next step on the pathway to integration, the Eltham ‘test and learn' project, working closely with clusters of GPs to extend coordinated care across all services.

As the name suggests, ‘test and learn' works by building on what works well and changing what doesn't. It provides a unique opportunity to be creative and design services in a way that suits the individual patient and their specific needs.

Eltham was chosen as the test area because the local population has a relatively high level of older adults suffering from multiple medical conditions. The project began by seeking views of local GPs as to the needs of their patients and linking the NHS and social services databases to enable a review of all of the care services needed by a patient.

The Eltham ‘test and learn' team consists of a GP, a care navigator, a community assessment and rehabilitation manager, a social worker and a psychologist. Sometimes district nurses, specialist nurses, social workers, housing officers and voluntary services join the team depending on the specialist skills required.

Jane continued: "GPs increasingly see the value of coordinated care and since the project began in November 2013, referrals have steadily risen to a current total of around 82."

Lynda Harris cares for her 89 year old mother Joan who has a number of long term health conditions. Lynda said that before being contacted by GCC she had no single point of contact for support services and had to coordinate care herself at a time when Joan was having frequent admissions to hospital. Lynda said: "In the past, every time I tried to get a social worker to visit I'd be told your mum isn't allocated one at present and I'd have to go through the whole process again to get one. But now, I just call my contact Marite Austrins at GCC and she gets the ball rolling. She sends me information such as getting a ramp so I can get Mum's wheelchair in my car and calls every week to check that everything is OK."

The goal of GCC is to reduce hospital admissions, subsequent admissions to long term care and multiple visits to GPs who may be struggling to resolve issues arising from complex cases.

GCC so impressed the Government that it sent its House of Commons' Health Select Committee to Woolwich Town Hall on 6 May to find out more.

Following the success of Eltham ‘test and learn' the model will be tested at a new site with a younger population in Greenwich later this year.

Published on 9th June 2014