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379 Health: The NHS in action


Integration—that’s


what you need NHS Greenwich Clinical Commissioning Group has found innovative ways to integrate healthcare services


I


t was once the case that older patients in the Royal Borough of Greenwich faced long stays in hospital. Health services were


not integrated with social care teams and, as a result, the over-65s spent too long awaiting community support. Today, the story is very different. Gone is this “silo” approach


—where different departments operate independently—and, in its place, NHS Greenwich Clinical Commissioning Group (CCG) has created an efficient, streamlined service. “We used to have a lot of fragmentation, which led to delays in people getting care packages so they stayed in hospital longer,” says Dr Rebecca Rosen, GP Clinical Commissioner at the CCG. “Now the approach is joined up and quick. Integration has led to significant reductions in hospital admissions and delayed hospital discharges, and a range of rehabilitation services being provided at home or in intermediate care facilities.”


Caring outside hospital Tere will always be health emergencies at care homes, GP surgeries and A&E units. What Greenwich CCG has done is ensure that teams of nurses, social workers, occupational therapists and physiotherapists work together to respond within 24 hours. Te Joint Emergency Team (JET) liaises with GPs and identifies people who need help but don’t necessarily need admission to a hospital or a care home. Instead, patients are assessed and treated at home or through short-term residential care in the community. Te Hospital Integrated Discharge Team enables people to leave hospital safely more quickly by organising the support they need, and Community Assessment and Rehabilitation Teams (CAR) provide rehab and support to aid their recovery. Care navigators have meaningful conversations with people to understand the whole picture and what it would take to improve that person’s health and well-being. From this a personalised plan is co-produced. Some people, for example, might prefer their partner to get them ready instead of being assisted by a stranger. “Tis is all about supporting people to stay at home for as long as they can,” says Jane Wells, Oxleas’ Director of Adult Community Services. “People can


“Now the approach is joined up and quick. Integration has led to significant reductions in delayed hospital discharges”


regain their independence where possible, without assumptions being made about their needs.” Transforming health and social care through partnership has


won the teams national praise. In 2013, Greenwich was selected by the government as a “pioneer” in the world of integration. Chosen from 100 applicants, Greenwich Coordinated Care (GCC) was recognised for saving nearly £1million from the social care budget and allowing people to be cared for in the community rather than in hospital. Making services more responsive to local people won the GCC the top award for innovation in social care at the Municipal Journal Achievement Awards 2014. Te transformation has been achieved through a partnership between the CCG, the Royal Borough of Greenwich, Oxleas NHS Foundation Trust, local GPs and the local voluntary sector.


A breath of fresh air Te CCG has also worked in partnership with the Royal Borough of Greenwich and others to reduce high levels of smoking in the borough, partly a legacy of the Royal Arsenal in Woolwich, where factory workers were given free tobacco. Since several key services were set up in 2000, including a “Stoptober” campaign, the number of smokers supported in quitting has grown year on year. Greenwich now has one of the lowest smoking rates in London. Football has also helped draw people to stop-smoking services through an outreach programme delivered by Charlton Athletic Community Trust, with community drop-ins and support groups run at the team’s home ground, Te Valley. Te combined services made contact with 27,000 people in a single nine-week period in 2013. Greenwich CCG and its partners have demonstrated that


breaking down barriers and silos in the NHS can transform everyone’s futures and life chances. — www.greenwichccg.nhs.uk


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