You said, Lewisham Health and Care Partners listened
Following the summer Frailty summit, Lewisham Health and Care Partners *(LHCP) have agreed to develop a more integrated approach to support people in their own homes.
Lewisham Health and Care Partners (LHCP) held the Frailty summit in July 2018 to listen to local residents' and professionals' views about working together better to improve support and care for people who are frail. Over 100 people attended two events; patients and carers and also representatives from a variety of organisations including Lewisham and Greenwich NHS Trust, Lewisham Council, South London and Maudsley NHS Foundation Trust, local care homes and Lewisham Clinical Commissioning Group.
What we heard at the summit
A number of areas were highlighted on the day by participants:
- A lack of overarching coordination of care both within and across different providers of health and social care.
- This is made worse by a lack of connection between health and social care information and systems.
- There are often low-level mental health issues, loneliness, depression and difficult family relationships that, if managed better, could improve the patient's and their family's overall confidence and ability to support themselves.
- The current system lacks mechanisms to identify someone's needs earlier.
- Therefore, frailty is often picked up late when a person's situation has become more difficult to resolve.
There were some great suggestions to improve on these issues, including:
- Having a systematic assessment of home and health early to prevent a person's situation becoming more complex.
- Having a frailty care coordinator.
What we are doing about this
The LHCP have used the ideas and issues raised at the summit to influence existing programmes of work, including:
- Forming four neighbourhood 'Care at Home' teams, staff from adult social care, therapies, district nursing and the neighbourhood co-ordinators will work in a flexible way to deliver co-ordinated assessment, planning and care delivery; support hospital discharge and support admission avoidance.
- Developing Lewisham SAIL Connections to provide a quick and simple way to access a wide range of local services to support older people in maintaining their independence, safety and wellbeing. LHCP are now considering how to extend the reach and offer for social prescribing beyond SAIL and increase the scale and uptake.
- Developing local care networks to focus on improving communication at a neighbourhood level and to bring together health and care professionals to identify and resolve local issues, such as improving referral processes. Over the next few months, these networks aim to strengthen further links to the voluntary and community sector.
- Lewisham & Greenwich NHS Trust (LGT) are testing ways to transform the current Ambulatory Care Unit (ACU) at University Hospital Lewisham into a 'community hub' to provide a coordinated response to patients for assessment and treatment in the community. A pilot is running with patients from three Lewisham GP Practices until the end of February 2019. The service aims to see patients that are too unwell to visit their GP practice or cannot wait for their GP to support them, but are not so sick that they need to call emergency services. Through better coordination it will also help increase the speed and experience of discharge from hospital.
- Lewisham Health and Care Partners have procured a Population Health and Care Information Management System to enable better information sharing across Lewisham providers of care such as primary care, community care, acute care, social care and mental health services. Together we are looking at how we can use this system to better manage frail elderly patients to prevent them becoming frailer.
Folake Segun, Director of Community Waves (Healthwatch Lewisham), who chaired the event said "The Frailty Summit was a successful engagement event. The planning was inclusive and the participation on the day was good. I was pleased to see a mix of residents, patients, service users and professionals all engaged and working together to improve future outcomes."
By working together, Lewisham Health and Care Partners want to better support people to maintain and improve their physical and mental wellbeing, to live independently and to have access to high quality care when needed.
Want to get involved in future discussions about frailty?
Join our engagement list and we will let you know about future opportunities to get involved (if you signed up at the frailty summit you do not need to complete the form as we have your details).
*Lewisham Health and Care Partners is a partnership of the main health and care commissioners and providers in Lewisham. The partners include NHS Lewisham Commissioning Group, Lewisham Council, One Health Lewisham Ltd GP Federation, South London and Maudsley NHS Foundation Trust and Lewisham and Greenwich NHS Trust.