Read are services working together to deliver proactive care for patients
What we did
Thanks to 46 local people, we can report how services could focus efforts on collaboration to improve care for people who need to use multiple health and social care services.
Nationally and locally there are plans for services to work more closely together, to co-ordinate and communicate with each other more, particularly to support patients with complex health needs or those who need support from multiple services across health, social care and the voluntary sector. And, for many years local people have been telling us that better communication and co-ordination between services and better communication with patients could make a real difference to helping them manage their health.
Proactive care was set up to focus on patients in Wandsworth with complex needs and frailty. We wanted to hear from patients about how this was working for them, to provide some insights for decision-makers looking to re-design how services work together. To hear from patients, we worked with Central London Community Healthcare NHS Trust CLCH) who lead proactive care work.
Findings and recommendations
We found that most patients had a positive experience of proactive care. Our findings highlight ways to improve and better understand the benefits of proactive care.
Communication
- Patients reported good communication between GPs and District Nurses (DNs), but that communication could be improved amongst other professionals within multidisciplinary teams (MDTs)
- Most patients reported that they did not understand what proactive care was, compounded by the fact that most patients reported that they did not receive an opt-in letter describing it.
Our recommendations:
- Further research is needed to understand where gaps in communication lie and how this can be improved. This will highlight specific gaps in communication and how to better facilitate information sharing between teams. This may lower the need for patients to reshare information with different professionals, improving experiences
- Ensuring that letters are received and confirming patient understanding at their first contact when admitted on the pathway may improve patient understanding of proactive care and their involvement in their care
Accessibility
- Older patients, patients with physical disabilities, and vision impairment reported having difficulty filling in forms and using e-consult services, which led to delays in care
- When asked how proactive care can be improved, 17% of patients made suggestions to improve accessibility (the most common theme mentioned)
- 9% of patients reported needing further information, advice and guidance around accessibility
Our recommendation:
- Proactive care should ensure that the Accessible Information Standard is adhered to and patients are offered multiple ways to engage with services
Patient Independence and A&E visits
- 41% of patients agreed that proactive care helped them to regain or maintain independence
- 71% reported that it helped them to avoid unplanned A&E visits
- Most patients felt that they have an active role in their care
Our recommendation:
- Further research is needed to identify factors that impact patient independence. Services could ask more questions at the beginning of the pathway to understand achievable goals for independence. They should ensure this is discussed by the multi-disciplinary team and included in follow-up with patients. Questions could include whether accessibility is related to patient independence. Additionally, they may want to ask if factors related to the type of care offered may inadvertently restrict patient independence
- Further research is needed to identify factors that enabled 71% of patients to avoid unplanned A&E visits to help services increase the proportion of patients avoiding A&E and provide learning to be used more widely
Information, Advice and Guidance
- 89% of patients reported knowing who to call if they had questions about their care. - - 50% of these respondents reported that they would call their GP
- 61% of patients said they did not require further information, advice or guidance to support their health, but 39% of patients said that they did.
Our recommendation:
- It may be useful for CLCH to understand what information, advice and guidance patients may need, and barriers preventing them from receiving information.
What happens next
We will share the findings from this report with people who are planning co-ordinated care in Wandsworth. CLCH will provide a response to this report shortly.
Information and resources
If you are someone who can benefit from proactive care you will be contacted by the proactive care team. If you are not a proactive care patient you might be interested to have a Universal Care Plan. This allows your wishes, along with your individual care and support needs, to be shared digitally with healthcare professionals involved in your care in London. Find out more about it here.
The NHS App can also be useful to co-ordinate your care. You can use it to manage prescriptions (order repeat prescriptions directly through the app and select a pharmacy for electronic pickup), view records & results (Access your GP health record, including test results and consultation notes, often before they are discussed with a doctor) and to book/manage appointments. You can also set up 'proxy access' which means you can link the accounts of children or people you care for to manage their appointments and prescriptions. For help on using the App, see this website.
