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​​​​​Local Care Networks update​

 

Background

 A Local Care Network (LCN) was set up in each of the three Lambeth localities 18 months ago. This came out of the need to think differently about care for patients with long term, sometimes complex, conditions.  The LCNs bring together health, social care, voluntary sector services, patient groups and citizens. The overall aim is to maximise the health and wellbeing of the local population by agencies and communities working together in an integrated way that delivers improved outcomes for local people and value from the system.

About six months after formation their focus was directed to help people with three or more long term conditions plus two or more risk factors, for example, pain, high BMI, unstable HBA1C .

The central question is always how as a care system we can do things differently for patients with those conditions and complexities.

At the same time the LCNs are also acknowledging specific issues in the the rest of the local population and what their needs might be. Examples of these include: in the North, health services for the Portuguese population; in the South West, a focus on healthy lifestyles; and in the South East locality geriatrician support.


Amanda Williams, Assistant Director of Local Care Network Development, who has been seconded from GSTT explains progress so far and plans for 2017

"Our current efforts are on strengthening the governance and framework that will support the LCNs to operate effectively. Boards were established six months ago, with interim chairs, which have been working on the roles and responsibilities and work plan priorities. The boards will be strengthened by the recruitment of chairs for a fixed term until March 2018. The recruitment is now underway​.  As well as a board each LCN has a Forum that includes a wider membership. The Forum has been invaluable in checking and contributing to the care coordination plans and to identify projects that come from the community, from the ground up. It is a good place for local services to network. Connections have been made between primary and community health and care services and local voluntary sector organisations/ charities.

"Another crucial element to the success of LCNs will be the development of a communications and engagement strategy to ensure that all partners in a Local Care Network, including GPs, understand the aims and the role they play within the network. It is essential that patients/ carers and communities are involved with the development of the LCNs. We will be be working with the patient group, voluntary sector and citizens representatives to agree and move forward with an engagement plan that supports co-production."

In early December the LCNs held a development day for the LCN Boards to discuss forward planning.​

 "We discussed our vision, purpose and ambition," says Amanda. "along with the need to establish a better infrastructure for the LCNs, including a programme team."

Detailed planning is required and identifying what the LCN work means to professionals and communities on the ground. We need to look at workforce development and IT/ data sharing support so that we can be effective in our integrated working. .

 

What's happening now?

At present the LCNs are testing how they can work with people who have several long term conditions at a few practices. This includes identifying the patients and clinically sorting them into three categories:

Red: These are patients with very complex conditions and needs. These patients may benefit from having a lead specialist and  streamlining of their numerous hospital appointments . Other ideas for improving their experience and health outcomes is to have just one annual review by the lead specialist which takes a holistic view of their health and a care coordinator who will help them to navigate their way through the system and promote self-management where possible. ​

Amber: This is a group of patients who may be starting to use services more. Again they may benefit from support from a care coordinator. Some of these patients may be able to self-manage and if we provide additional voluntary sector support to them and their carers it will help reduce A&E attendance and unplanned admissions. There is wide variety across this group in terms of need and for some providing additional signposting to local voluntary sector services may enable them to regain their independence.

 

Green: Patients who have long term conditions and are independent and coping well. They are in a position to look after themselves and they may benefit from some voluntary sector support. The aim is to keep them 'green' for as long as possible.

 

Amanda says: "With this approach we need to be looking at the whole person (and their carers) and we will need to engage with them to understand their goals, motivations and their personal assets. This will lead to an integrated care plan.

 

"Some people may need care coordinators – this could be a mix of formal and informal care, care navigators, social care. We are also looking at how to make best use of our community assets, such as the existing healthy living champions and primary care navigator roles.

 

"This current testing stage is crucial for working out exactly how care coordination can work and then to look at scalability. The pilots will be rolled out from April 2017 and we are looking at how practices can be supported to be involved. GPs are vital to the LCNs' success; they hold the patient lists to help us reach everyone. They are respected and trusted by their patients and many are already working as named professionals."