Bromley health services are finalists in the national Healthcare Transformation Awards 2017. This is for the joint work to provide proactive and joined up care for the most vulnerable patients in Bromley. These awards recognise best practice and excellence in the improvement and transformation of services for patients.
In 2016, in a first for Bromley, health organisations and voluntary services signed a formal agreement to work together to provide more joined up care for patients. This care is provided through a new model called an integrated care network, which was designed in partnership with clinicians, health and social care staff and patients. There are three of these networks in Bromley. In each network is a multi-disciplinary team (MDT) made up of GPs, hospital doctors, nurses, therapists and care navigators. The MDT then liaises with social care when required. These teams are working together to care for and support patients with complex health conditions and their families.
Dr Angela Bhan, Chief Officer of NHS Bromley Clinical Commissioning Group (CCG) said, “Patients are benefitting from our improved way of providing more joined up care. We have brought in extra staff, used improved technology, introduced new geriatric advisory lines for staff working with older patients and have invested in a new Elderly Integrated Unit at Orpington Hospital which is providing short term hospital care for frail patients who need to be assessed and helped to get back to more independent living. To be shortlisted for this award recognises the hard work that has been put in by the whole Bromley health and care system, and the difference we are making to the lives of our patients”.
Dr Ruchira Paranjape, Bromley GP and a clinical lead at NHS Bromley CCG said, “We are absolutely committed to providing the best possible care to our local population and believe this way of providing care is enabling us to do it. GPs in Bromley are identifying patients who would benefit and referring them to the MDT. These are usually patients with complex long term conditions and who are at high risk of being admitted to hospital. It’s a great example of the benefit of the CCG and providers working together to support patients”.
Andrew Hardman from Bromley Healthcare and Chair of the Joint Operational Group which oversees the new service said “The new MDT approach has already delivered significant improvements in how our services work together more effectively to support patients and families to continue to live independently”.
Colin Maclean, Chair of Bromley Third Sector Enterprise said, “The voluntary and community sector is delighted to have an even greater role in supporting patients to improve their health and wellbeing. Our new team of Care Navigators are a central part of the MDTs and are supported by our partners with access to voluntary and community sector support, especially with the new development of a Social Prescribing Portal which helps referrals onto non-health services. We have a crucial role in signposting patients to the services which support them to stay well as well as engaging in local communities.”
Dr Hasib Ur-Rub, Chair of Bromley GP Alliance, which chairs the 3 MDTs, said “The MDT has been incredibly beneficial for those patients referred into it, helping resolve some very complex physical as well as mental health and social care needs of this vulnerable group. It has also facilitated health care professionals to work with multiple agencies bringing about solutions for patients that may otherwise not have been found”.
The daughter of a patient cared for through the MDT process said “I can’t thank you enough for everything you have done for my family. It was such a relief for me personally to be able to hand over the management of mum’s various problems to someone knowledgeable and competent, instead of travelling through unfamiliar territory on my own when much was at stake for us.”
Notes for Editors
- More information on the Integrated Care Networks is available on the Bromley CCG website at www.bromleyccg.nhs.uk or contact Kelly.firstname.lastname@example.org
- Bromley organisations working together to deliver this care – NHS Bromley CCG, Bromley Healthcare, King’s College Hospital NHS Foundation Trust, Bromley GP Alliance, Oxleas NHS Foundation Trust, St Christopher’s, Bromley Council Social Care services and the Bromley Third Sector Enterprise.
- More information on the Healthcare Transformation awards is available here. www.healthpluscare.co.uk/nhs-englands-official-healthcare-transformation-awards
- Care navigators are employed by the voluntary sector to sign post patients onto relevant voluntary and community based services that will help them live more independently.
- Patient case studies:
A 59 year old male known to the community mental health teams had made 16 emergency calls to NHS 111 and visited the A&E department at the Princess Royal University Hospital four times in the six weeks before he was seen by the MDT. After visiting him at home and seeing how he was living he was provided with advice on benefits, contact was made with a food bank to provide assistance, and support was given to help him with his energy bills and credit added to his Oyster card so he could get to appointments. In the six weeks since he has been seen by the MDT, there have been no emergency contacts.
A 74 year old female had been discharged from hospital but lives alone in an upper floor flat and her carer is a friend who isn’t local. She has complex health conditions including heart disease, chronic obstructive pulmonary disease and is confused. In the last two years she had a minor heart attack and has had breast cancer. She has refused support with personal care, won’t take her medication and refuses to go to a memory clinic. After being assessed by the MDT she had a memory assessment, a social care package was put in place, she had a medicine review and home oxygen was supplied. She is now being supported by the Bromley Care Coordination service (provided by St Christopher’s).