Our Neighbourhoods

Why are we working in neighbourhoods?

Working in neighbourhoods ensures a focus on the local needs and priorities of our member practices and their local patients. It means local connections and relationships can be established across GP practices and other health and care partners including GSTT, SLAM and the voluntary and community sector.

What have we done so far?

• We have a team working at IHL that support neighbourhood delivery
• We currently hold monthly meetings in each neighbourhood
• This year, we received funding from GSTT Charity to run a pilot project in our Dulwich and Peckham neighbourhoods to support patients with COPD.

What difference has this made?

A COPD case study

Working in our neighbourhoods, we brought people from different services together to consider what some of the key issues were for our local residents and identify some areas we may be able to work on together. We had leads from general practice, mental health services, social care, the voluntary and community sector. We agreed to focus on people with COPD who particularly suffered from breathlessness, anxiety and depression.

What we did

• We agreed to focus on two GP practices initially and test a clinical and a non-clinical co-ordinator.
• We identified patients and asked clinicians to review these to consider people suitable for this small test and developed patient communications.
• We recruited a pharmacist and non-clicnical link worker from a local voluntary and community organisation and arranged appropriate training for them.
• We developed a suitable assessment and care plan for patients (ensuring appropriate patient consent/data sharing agreements were in place).
• Support was provided to patients over three months.

What we learnt

• Patients really benefitted from this support. The nature of need varied, but social isolation and living alone were significant factors. Co-ordinators liaised with a lot with other services to resolve issues for patients and found that a joint approach with a clinical and non-clincal role could be very effective.
• Highlighted importance of knowing what services were available in the local area. The good working relationship between the pharmacist and the non-clinical link worker was really helpful in improving and sharing knowledge of local services.
• The team of local health professionals and leads from social care and the voluntary sector that took part found it both useful and energising to work together, build relationships and understand each others' role.