Local care networks


In 2017, we started to work together in Lambeth and Southwark to develop a new way of working across health and care through local care networks.

By being more joined-up services can be more responsive, ensuring people have the help and support they need to keep themselves as healthy and well as possible.  

Our work to develop neighbourhood models of care builds on what we have learned from local care networks and coordinating care for people with three or more long term conditions. 

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Why were we doing this?

We have lots of great services in Lambeth and Southwark, with a range of world-class services available across our major hospital sites and in our community, supported by a strong, committed workforce. 

However, people tell us they sometimes find the health and care system difficult to navigate and it does not always respond to their needs. Different parts of the system do not always communicate as well as they could and people can feel unsupported and isolated.

We want to move towards a system which arranges services around the individual and provides the support they need to stay or get well – whether physical, emotional or social. Local care networks help us do this by supporting the different parts of the system to work together better.  You can read more about this in the Southwark Five Year Forward View.

Improving care for people with three or more long term conditions

 


Through local care networks we put in place a new way of working to improve coordination of care for adults with three or more long-term conditions. In developing this new approach, we engaged with people with three or more long term conditions and their family members, and you can read more about this work here.  

The new approach:

  • Identifies and works with people with three or more long term conditions 
  • Looks at all of a person's physical, emotional and social needs 
  • Plans care with the individual and their family member or carer (where appropriate) to agree how to best support their health and well-being 
  • Improves team working, involving all the professionals looking after a person (for example GP, community nurse, hospital specialists, social care providers and care navigators) and reduce duplication – for instance so people don't have to repeat their story to multiple health and care professionals

People identified through local care networks still access services in the same way, either through their local GP or another professional. However, care is better planned and co-ordinated around the person. Care should be easier to access, with less repetition, better communication and with a continual review of the person's needs.

As the care networks develop, this type of working will be extended to improve care for more residents and we will continue to build on and improve these new ways of working.

Who is involved in local care networks?

Local care networks involve all the staff, agencies and organisations that can care for a person, such as:

  • GP surgeries, including GPs, practice nurses,  and care coordinators 
  • GP Federations, which represent GP surgeries and provide some services on their behalf
  • NHS provider trusts:
    • Guy's and St Thomas' NHS Foundation Trust (acute hospital and community)
    • South London and Maudsley NHS Foundation Trust (acute hospital and community mental health)
    • King's College Hospital NHS Foundation Trust (acute hospital)
  • Voluntary organisations such as Community Southwark, Age UK, local settlements and community groups  
  • Healthwatch Lambeth and Healthwatch Southwark 
  • Community services such as pharmacies