Who: Pembroke House, coordinating a partnership of voluntary, community and private organisations
Start date: January 2018
End date: 2025
Supported through: Multiple long-term conditions programme
Find out more: Email the scheme leads
Our Neighbourhood Schemes focus on driving change within a small geography, testing whole-system solutions to health challenges facing the local communities.
Walworth, in Southwark, is a microcosm of the modern inner-city life, with vast sways of regeneration surrounding estates that have some of the highest levels of deprivation in the UK. The area also has a high prevalence of people living with three or more long-term conditions.
We’re working with partners in Walworth, combining action from many organisations to pioneer a whole-systems approach to tackling multiple long-term conditions in the area – to slow people’s progression and improve their quality of life.
Partners have a shared commitment to make Walworth a great place to live and work: where people with multiple long-term conditions - and everyone else - can enjoy the best quality of life.
September - November 2018
As one of our neighbourhood schemes, the work in Walworth looks to coordinate and layer up many different initiatives, testing a whole-systems approach to tackling complex health issues in a small geography. The scheme is looking to build on the long history of community work in Walworth, and the local momentum, to create a platform where we can learn and share lessons, test new approaches and inspire others to work differently in addressing health inequalities in communities.
Coordinated by a local settlement organisation Pembroke House – which has been working with diverse communities in Walworth for over 130 years – the scheme is looking to work with health and social care providers to develop new integrated models of care. It is also drawing on partners who approach multiple long-term conditions from outside of the traditional health lens, including perspectives from business, campaigning, performance arts, media, architecture and urban design.
The scheme is bringing together partners who approach multiple long-term conditions as something wider than health and healthcare. It is including perspectives from campaigning, performance arts, media, architecture, urban design and more to agree a shared approach to building a strong and vibrant community.
The scheme aims to unite perspectives on Walworth, and about how best to serve local people, that usually develop in isolation. Health and social care providers and commissioners, for example, often see the Walworth ‘neighbourhood’ as a helpful structure for organising local services. Meanwhile, for the local residents for whom these services operate, it is the place where their lives are lived - with personal history, social connections and much more attached to it.
The scheme believes both perspectives are important and can be combined into a collective approach that builds a strong and vibrant community. It aims to do this through activities including:
Other potential projects include:
Supporting social prescribing in Walworth - building on excellent work already happening in the local area, including Primary Care Navigators based in GP surgeries, Guy's and St Thomas' Neighbourhood Nursing pilot, the Talking Therapies Southwark & Pembroke House Community Development Partnership, and Safe and Independent Living (SAIL) Navigators.
Expanded multi-disciplinary team meetings - bringing together different perspectives and organisations to share insight around people with the most complex care needs and building the relationships required to provide effective care.
Developing new ways to engage with people with multiple long-term conditions - investigating how to bring clinical expertise out of the clinic and into the community, and the community into the clinic.
What works in Walworth may not automatically work in another areas so an additional goal of the scheme is to understand what is translatable - be it an approach or specific projects - and to share the learning.
In Lambeth and Southwark, almost one in five local residents (140,000) lives with at least one long-term health condition and over 19,000 live with three or more.
The Walworth area, in Southwark, has some of the highest levels of deprivation in the UK. The area is undergoing significant change, due in part to major housing developments in the Heygate Estate, the Aylesbury Estate and soon the Old Kent Road. The area also has high numbers of residents living with multiple long-term conditions and local research indicates that many of them slip through the net and don't always get the support they need.
But despite these difficulties there are already high levels of engagement between the community and health sectors and an established network of people and organisations with energy and enthusiasm to develop new neighbourhood models. This makes Walworth a prime place to trial new holistic approaches to tackling multiple long-term conditions in a small geography.
The scheme works from the premise that, for people with multiple-long term conditions, quality of life is about more than their medical treatment. It also means sharing life with good friends, being active, having a sense of purpose, holding down a good job and enjoying a comfortable home.
Starting from the needs and wants of the local communities, the Walworth Neighbourhood Scheme is looking to drive a lasting difference in multiple long-term conditions in the area - slowing down the progression from one condition to many, as well as improving the quality of life of people managing complex conditions - by combining efforts to coordinate and integrate statutory care with other activities that address the long-term drivers of health.
Pembroke House is coordinating efforts with many partners from local health, voluntary and community organisations and groups as well as local businesses.
We’re working with partners in Walworth to test, evaluate and build the evidence of whole-system approaches to improving the lives of people with multiple long-term conditions. At the end of the two-year pilot, the scheme aims to have contributed to:
Our neighbourhood schemes are also allowing us to test and hone how we, as a place-based foundation, best support work on the ground.
Through our experience in East Walworth, we are looking to help develop a successful model by being embedded in a local area, closer to our communities and more able to test and learn ideas and see results as they unfold, iterating where needed.
Lindsay lives in Elephant and Castle. Originally from New Zealand, he has struggled with mental health his whole life. A diagnosis of depression was followed by granulomatosis – a rare condition of the blood vessels – and diabetes Type 2.
He came into contact with Pembroke House through Talking Therapies Southwark, a service which helps people with mental health issues through therapy and connecting them with opportunities for social interaction. He now volunteers as a gardener at Pembroke House and is looking to get back into work.
"The first time I got unwell, the first time I was diagnosed, was with depression, in about 1996 or 1997. It had probably been going on for quite a while. I’d probably had the condition for many years, since my late teens, early twenties, and it wasn't until I was 35 or 36 when it was diagnosed.
"I don't have any close family or close friends. The NHS is my support network. I have a very fine GP. He sent me along to a counsellor and that helped a great deal. I've also been on mindfulness courses, that were excellent.
"I get a lot of satisfaction out of coming to Pembroke House. Basically, it's fun. It's helping me get back into the idea of working again."
The Walworth Neighbourhood Scheme builds on lessons from the learning partnership we run with partners in the area between August and December 2017. This partnership set out to:
Through this work, we learned that:
We also identified a number of challenges that need to be overcome:
Portfolio Manager: Gabrielle Allen
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.