Inspiration: Greenwich Coordinated Care

Inspiration: Greenwich Coordinated Care

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Organisation: Oxleas NHS Foundation Trust, Greenwich Clinical Commissioning Group, Royal Borough of Greenwich, GAVS, Healthwatch, Lewisham and Greenwich NHS Trust


Greenwich Coordinated Care (GCC) integrates health and social care services to address the needs of people with on-going complex health, care and other needs. It takes the needs of individuals as its starting point and embeds a truly person-centred approach in the development and delivery of care plans.

GCC includes all local health services (community health professionals such as district nurses, psychologists, occupational therapists etc, mental health services), social services, voluntary services and housing services.

These local services are aligned around clusters of GP practices and are viewed as ‘communities of practice’; grouping patients and service users according to their level of risk of deteriorating health and increasing need for services (risk stratification). People who are at most risk are intensively supported for a time limited period by a Care Navigator who coordinates multidisciplinary care planning and joint care plans.

Brief Summary

We have used recent research which shows that many people with long-term conditions also have mental health problems, leading to significantly poorer health outcomes and reduced quality of life. We also know that people with serious mental illness have significantly reduced life expectancy and poor physical health.

We enable care planning for each individual that is absolutely centred around the individual’s needs and priorities which they themselves have identified, using personal ‘I statements’. The fact that many different services and specialists are involved in our co-ordinated care approach means that people can expect to have attention paid to the things that make them feel better, not just what someone else thinks they need. For example, one individual said that having a downstairs shower so that they could feel clean would make them feel less depressed and more able to cope, whereas in contrast their GP perceived that treatment for their diabetes was their greatest need. The co-ordinated care approach can provide both the shower and the treatment and that is incredibly satisfying for everyone involved.

Staff from all the services involved (community, mental health, primary care, social services, housing and voluntary services) have developed their understanding of how they can support people with the most complex needs and have learned more about each organisation’s services, including the services offered by multiple voluntary and community organisations. Staff have also learned a new way of talking as part of the Greenwich approach – not “I’ll make a referral” but “I’ll talk with my colleagues”.

We have redesigned local mental health care pathways so that they can be delivered within the new integrated structure. The full involvement of our mental health services is now a key feature or our work.

What has been the most challenging aspect?
Bringing together all the different professional groups to engage with each other and change their professional behaviours to work in a more integrated way has been challenging. However, we have had fantastic commonality of purpose and commitment from senior executives in local government, the community trust and commissioners. This meant we have had high-level support to work on creating a common vision and purpose.

What are you planning to do next year?
We will continue to extend our model of integrated care across the borough. We will adapt, test and learn from our model which will enable us to continue with a flexible delivery model from summer 2015.

An evaluation of the Eltham test and learn project will be completed later in the spring and will report on the impact on use of acute and community services before and after involvement with GCC.

We have developed a set of criteria against which to evaluate our success. We are working with the local Healthwatch to evaluate people’s experience of how GCC has affected the support they receive and their experiences. We are also working public health colleagues to calculate the impact of the new model in terms of the cost of providing care, the processes we have developed and their subsequent outcomes.

Area of work

In relation to the four foundations of our declaration, this project aims to:

  • Care is about me
  • Working as one team
  • Happy staff with the right skills
  • Make London healthier and happier

Service user involvement?

Healthwatch are members of the board and have proactively engaged service users and participated in action learning and qualitative feedback discovery interviews with service users receiving GCC.

Advice for others

Spend time engaging with staff so that they are integral to the process and so that a shared purpose develops that will overcome organisational boundaries.

Link for more information

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