- Establish a robust and effective federation with strong leadership
- Ensure that our member practices are engaged in the work we are doing and agree upon the need to come together to develop new ways of working and delivering care
- Deliver a high quality and safe Extended Primary Care Service (EPCS) that supports practices through providing additional capacity and makes it easier for patients to access an appointment
- Deliver high quality Population Health Management (PHM) services through both practices and hubs to ensure all practices can offer their patients the same care
- Support our member practices to be more effective and resilient organisations
Local people are able to access excellent, proactive and coordinated care consistently and equitably, delivered in a model of primary care that is financially viable and which offers sustainable and fulfilling careers to the whole primary care team.
To work with member practices so that they are better able to work together (and with other partners) to maximise their financial sustainability, to support practical workforce development and to enable more consistent and equitable delivery of high quality care.
- professional: open and trustworthy, reliable, efficient
- dedicated and committed
- making a difference
Improving Health Limited (IHL) is a group of 18 GP practices (member practices) in south Southwark. We have been given funding by NHS Southwark Clinical Commissioning Group (CCG) to improve the quality of care in general practice and improve the health outcomes of local patients. As part of this, we support our member practices to deliver the Population Health Management contract, the Personal Medical Service contract, the Extended Primary Care Service and the Community Dermatology Service.
Population Health Management (PHM)
We want to ensure we are delivering services around our populations, and that all patients can access the same offer of care irrespective of which practice they are registered with. IHL are providing a number of services through practices and within central hubs which are outlined below. Some of these services aim to identify potential health issues e.g. high blood pressure, earlier on so they can be proactively managed and prevent avoidable health conditions. Others aim to support patients with long-term conditions or more complex needs through comprehensively assessing their needs and providing on-going support.
- High blood pressure checks to diagnose hypertension (Ambulatory Blood Pressure Monitoring)
- NHS Health Checks – heart and circulation checks for those aged between 40 and 74 years
- Assessments for our frail, elderly population to manage their medical, emotional and practical needs (holistic assessments)
- Patients with complex health and social care needs will receive tailored support from an integrated case manager who will work with the different organisations and co-ordinate their needs (case management)
- Help to stop smoking – is the above list up-to-date?
PHM also focuses on improving the management of long-term conditions and patient experience.
What does each practice in south Southwark do to provide PHM?
Each GP practice must:
- provide PHM services by seeing patients at the practice or by referring patients to central services
- meet the targets set for providing these services to patients
- ensure that there is a high quality of service at the practice
- have clinical and administrative staff to manage and organise the delivery of PHM services
Personal Medical Service (PMS)
The PMS is a locally agreed contract between the CCG and individual GP practices. The PMS contract includes: providing flu vaccinations, supporting people who; have suffered from a stroke, have hypertension, have chronic heart disease or have diabetes. It also includes supporting people who are at the end of their lives. In south Southwark, IHL support our member practices with the delivery of the PMS primary care services for our population.
Enhancing access to primary care in south Southwark and improving patient experience.
Delivering coordinated care for people with three or more long-term conditions in south Southwark.
A collaboration between IHL, Guy’s and St Thomas’ Foundation Trust and King’s College Hospital Foundation Trust dermatologists and local GPs to deliver great access to dermatology management advice, community clinic assessment and secondary care management.
Improving the health and wellbeing of our local population by engaging with patients to improve the uptake of services and supporting GP practices to meet their targets.
Joining up care between GP practices, hospitals, community services, social services and the voluntary sector to provide ‘integrated community-based care’.
Joining up primary care services at a local level, focusing on the specific needs of local populations.
Improving quality across general practice by delivering a package of clinical guides.
Working in neighbourhoods to ensure a focus on the local needs and priorities of our member practices and their local patients
Pharmacists working across GP practices to reduce the demand on GPs and improve quality and safety of prescribing medicines.
Supporting our member practices by providing training, and development programmes.