Joined-up care David 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…

Mental health Social care / worker 3 rd sector District nurses OT / Physio GPs Pharmacy GPs HCA Practice nurses Carers Diagnostics Care Co-ordination Patient 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).