Who: Hosted by Lambeth Clinical Commissioning Group (CCG) and Southwark Clinical Commissioning Group
Start date: January 2018
End date: Autumn 2018
South East Lambeth LCN - £30,000
South West Lambeth LCN - £30,000
South Southwark LCN - £20,000
North Southwark LCN - £29,000
Supported through: Multiple long-term conditions programme
Care for people with multiple long-term conditions is often fragmented. They are frequent users of health and care systems, and the lack of coordination between these systems can sometimes have a negative impact on people’s health outcomes.
Local Care Networks were set up to help address this fragmentation and join up care. We have supported the development of these emerging networks and have backed them to start testing practical ways to address the issue. This exploration is also informing how we may work in partnership with the networks moving forward, to improve the lives of local people with multiple-long term conditions.
The learning from these projects is expected to feed into the wider plans for Local Care Network development.
Local Care Networks bring together representatives from primary and secondary care, social care, patients, carers and community organisations to join up care for people. They are the statutory system’s response to the challenges of managing patients with complex conditions and are working to develop a deep understanding of local populations, the assets within communities, and the health and social challenges that people face.
There are five Local Care Networks across Lambeth and Southwark, and each supports a population of 80,000-130,000 people. Local Care Networks oversee three interconnected workstreams:
We have supported each of the networks to run small, practical projects to explore ways to address specific needs of the local people they care for, including:
These projects are in progress and lessons will inform the future direction and development of the networks.
Over 19,000 people living in Lambeth and Southwark currently live with three or more long-term conditions. These people are five times more likely to attend A&E than people who have no long-term conditions. They also attend six times more GP consultations, on average.
People with multiple long-term conditions often struggle to navigate the different parts of the health and care system they need. While individual services may be of high quality, they cannot always work together effectively. This can have a big impact on people with complex needs, who often find themselves ‘lost in the system’, attending multiple appointments and having to repeat their history to each practitioner. It also results in inefficiencies for the system.
By supporting the development of Local Care Networks, we aim to help build a strong structure that can join up different health and care providers and give people care that is centred around their needs and not limited by organisational boundaries.
The hosts for this work are the CCGs in Lambeth and Southwark - the NHS bodies responsible for the planning and commissioning of health care services in each borough. The Local Care Networks comprise of tens of organisations including GPs, social care, pharmacists and community groups.
With their cross-system representation, Local Care Networks have the potential to transform the care of people living with multiple long-term conditions. In Lambeth and Southwark, each Local Care Network has around 2,500 people living with three or more long-term conditions, and around 30,000 people with one long-term condition within its boundaries.
In the short term, the networks present a major opportunity to improve care for people already living with the most complex needs.
In future, the networks could provide a platform for improving the way local health and care systems intervene earlier to prevent people’s progression of multiple long-term conditions.
Some of the short-term benefits of this work have included:
On the back of our funding, north and south Southwark have both secured ongoing funding to continue to test how they can better join up care for people with mental and physical health problems. This will include continuing to test the role of mental health nurses in primary care and multidisciplinary teams to address the specific issues faced by people with serious mental illness and diabetes.
The development projects supported through this work are still in progress and we will share some of the lessons in autumn 2018.
Project Manager: Kate Langford
31 October, 2018
A Challenge Fund to support research projects aiming to help us understand more about the health, social and community factors that may play a part in people’s progression from one to many conditions.
05 October, 2018
"Just one thing after another": Living with Multiple Conditions explores how it feels to live with multiple long-term health conditions (MLTCs).
28 July, 2018
We've looked at data and talked with local people to learn more about how and why people progress to multiple conditions.