What is Southwark and Lambeth Integrated Care?

Southwark and Lambeth Integrated Care is the partnership between the local GP Federations, the three local NHS Foundation Hospital Trusts (Guy’s and St Thomas’ NHS Foundation Trust, South London & Maudsley NHS Foundation Trust and King’s College Hospital NHS Foundation Trust), Southwark and Lambeth Clinical Commissioning GroupsSouthwark and Lambeth local authorities and people in Southwark and Lambeth, supported by Guy’s and St Thomas’ Charity.

Our vision is to increase the value of care we provide for the people of Southwark and Lambeth, so they can lead healthier and happier lives.

This means communities and health and social care professionals can be supported to work better together to provide pro-active and preventative care that gives local people control of their own health and well-being. For professionals, we need to make the right thing to do the easy thing to do.

Group listen to woman at Citizens' Forum

To achieve this we have set ourselves a clear mission, to:

  • Focus our joint efforts on providing the right care in the right place at the right time
  • Support the sustainability of the health and social care system, the statutory and independent organisations within it, as both are vital to deliver high quality care
  • Move resources (e.g. money and staff) between the partnership, to improve how we work together
  • Support health and social care professionals and local people to share learn and develop together
  • Support health and social care professionals, carers, volunteers and families to maximise their contribution to the care of local people, whilst making the most of community services

Alone we can’t tackle the challenges we face, but together we have the ability to improve care for our vibrantly diverse urban communities.

Wenda and Rai talking at the Citizens' Forum

What are we trying to do?

To improve the quality of care across the two boroughs, we need to work as one integrated system with one budget. In doing so it is also important that we focus on creating services that:

  • Empower people to manager their lives well, making the most of their capabilities with additional support from resilient social and community networks
  • See people as whole people, taking all of a person's medical, psychological and social needs into account
  • Are proactive and preventative so that services offer support in the right place and at the right time.

In support of this we have made a commitment that by April 2016 we will:

  • Fully implement health management techniques with risk-based assessments, multi-disciplinary reviews and care management for people with complex needs
  • Deliver the plans within our Better Care Fund
  • Establish five Local Care Networks with nominated clinical directors and general management capacity
  • Roll out a better information sharing system across health and social care providers, so clinicians can get the full picture they require whether they see a person in a GP surgery, community setting or hospital
  • Agree new contracts for health and social care service providers, to underpin integrated working.

Woman making a point at the Citizens' Forum

We have learnt and achieved a lot since the partnership began in 2012, such as:

  • We’ve tried ‘top down’ approaches to implement models of complex elderly care and we’ve found that approach unsuccessful; but when combined with ‘bottom up’ investment in primary care development we are now having much more success
    • Five localities are now establishing Local Care Networks – covering all 92 GP practices, and each has prioritised care coordination, community multi-disciplinary team working and holistic assessment for delivery at scale
    • And we’re already seeing impact: the number of appointments in primary care have increased significantly and we are one of the few areas nationally to see emergency admissions reducing compared to last year (down 1.4% on the same time last year)
  • We have genuinely and deeply involved our local population in our transformation; our Citizens’ Board sits at the heart of our work with representation at all levels of the programme governance and decision-making.

Our main lesson has been that the challenge is really about engagement, accountability and leadership. For that reason, our strategy focuses on cultural and workforce development, rather than focusing on just service and system design.