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​​​​Leading healthcare project reduces emergency admissions in Greenwich

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Bottom pic left to right: Norman Lamb MP, Councillor David Gardner, Dr Ellen Wright, Jeremy Hunt MP, Dr Krishna Subbarayan, Eric Pickles MP and Councillor Denise Hyland

The leading-edge integration work of Greenwich Coordinated Care (GCC) has been recognised nationally today as the Rt Hon Jeremy Hunt MP, Secretary of State for Health, visited Sherard Road Medical Centre in the Royal Borough of Greenwich with colleagues the Rt Hon Eric Pickles MP, Secretary of State for Communities and Local Government and the Rt Hon Norman Lamb MP, Minister for Care Services. They were keen to see first-hand how joining up health and care services is working successfully on the ground.

Greenwich has established and sustained truly integrated community health and social care teams since 2011 and in 2013 was selected as an Integrated Care Pioneer site. In the Eltham practice the ministers visited today, they met with elected councillors and health and social care professionals from the Royal Borough of Greenwich and Oxleas NHS Foundation Trust, who together with the local voluntary sector are GCC. They also met the Chair of Healthwatch Greenwich, Leceia Gordon-Mackenzie, Greenwich CCG clinical commissioner and local GP, Dr Krishna Subbarayan, who has been leading the work that was piloted in Eltham, and a carer, Linda Harris, whose mother Joan has benefited from the care being provided.  The GCC work involves blending the integrated teams together with primary care, community care, social care and the voluntary sector to create services tailored to the needs and preference of the individual. The pilot focuses on the most complex patients with more than three long term conditions who are at high risk of being admitted to hospital. Once people have been identified as needing the service, the Care Navigator will listen to the patient or their carer to understand their individual needs. The team that this individual patient needs to help them then meets to solve as many of these complex problems as possible and will often find innovative solutions. Each individual has a named professional who coordinates their integrated care plans, so that patients don't have to repeat their story to numerous professionals.

By working in this integrated way, since 2011 Greenwich health and social care has:

  • achieved a reduction of about 100 admissions per year, even though there is an aging population, and has improved from the highest rate of emergency admission rates in the country in 2004 to the 9th best
  • reduced admissions to care homes by 35% - by providing care at, or closer, to home and helping people maintain their independence
  • put joint emergency response teams in place - professionals from across all health and social care work together to respond to crises in two hours, preventing people ending up in hospital unnecessarily
  • made savings in health services, which have been reinvested in more community care
  • reduced social care spending by £900K

Health Secretary Jeremy Hunt said:
"The work in Greenwich is a leading example of joined up care and we heard first-hand how this is making a difference to patients. We want to make this vision a reality for patients across the country and help deliver a sustainable future for the NHS."

Secretary of State for Communities and Local Government  Eric Pickles said,
"It was great to see for myself the pioneering work that is going on in Greenwich. Better care is about the improvements we can make for some of the most vulnerable in society so that they can have dignity and independence in old age. The services in Eltham do exactly that."

Care and Support Minister Norman Lamb said,
"Too often care is uncoordinated, leaving many people needlessly going back to A&E again and again. But the approach in Eltham is helping to keep people healthy and out of hospital by bringing the right professionals together and really listening to the patient and their families.
"The Greenwich Pioneer is showing fantastic leadership and demonstrating how we can improve care and make the money go further."

Councillor Denise Hyland, Leader of the Royal Borough of Greenwich commented,
"Greenwich is proud to be a pioneer in the integration of health and social care. The joined-up approach that has been developed by services in Greenwich is making a real difference to local patients and their families."

Councillor David Gardner, Cabinet Member for Health and Social Care added,
"Our partnership with the local health sector and voluntary groups continues to achieve some very impressive successes. This can be seen in the figures – such as the savings in social care budgets and the reduction in unnecessary hospital admissions. Just as important as these statistics are the stories we hear from local patients who tell us what a difference it makes to their lives, to have services planned around their needs, and a single point of contact for all support services."​

Jane Wells, Director of Adult Community Health Services at Oxleas NHS Foundation Trust said, "We work as one team with our local Council, Royal Borough of Greenwich and Greenwich CCG to deliver a seamless service for our patients. Patients within Greenwich Coordinated Care have one, named care coordinator as their point of contact for any issues from health to housing, transport or care needs, this reduces delays, duplication and the stress that being ill and in need of help can often cause."

Dr Krishna Subbarayan, a GP Commissioner and local GP at Sherard Road Medical Centre said, "Following our 'test and learn' pilot in Eltham, the Greenwich Coordinated Care team are now working with GP practices in Woolwich, Thamesmead and Plumstead to roll out the programme to benefit other local people with complex needs. The approach has really improved the experience of my patients. In one particular case, a patient who was attending A&E several times a week by ambulance has now only attended three times over the last three months when calling 111. Their housing issues have been sorted, they have received appropriate financial advice and support, their diabetes in much more controlled and their overall health has improved."

Greenwich Coordinated Care will be a major feature of Greenwich's Better Care Fund (BCF) initiative.  Nationally the BCF is one of the most ambitious ever programmes across the NHS and local government, creating a local single pooled budget to incentivise the NHS and local government to work more closely together around people, placing their wellbeing as the focus of health and care services.  The BCF requires the NHS and local authority in Greenwich to pool a minimum of £7.9m in 2014/15 across NHS and social care budgets. 

In 2015/16 the Royal Borough of Greenwich and NHS Greenwich CCG are proposing to pool £19.8m of resources.

The better care fund proposals will help Greenwich to build on the work so far and to create multi-disciplinary and multi–agency 'communities of practice' in which GPs will play a central role.  

About Greenwich Coordinated Care
Greenwich Coordinated Care is jointly delivered by the Royal Borough of Greenwich, NHS Greenwich CCG, Oxleas NHS Foundation Trust and the local voluntary sector.  GCC has won praise from the social care and health sectors, from Government ministers and from healthcare experts.  GCC has also received two national awards, the Municipal Journal Achievement award for innovation in social care and the Improvement and Efficiency "Gold in the Transformation in Health and Social Care" award from the Improvement and Efficiency Social Enterprise, and has recently been shortlisted for a Health Service Journal Award.