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Improving Health (IHL)

We are a GP Federation providing formal structure for the collaboration of the 20 GP practices in South Southwark across two natural communities – Dulwich; Peckham and Camberwell. The Federation aims to enable the improvement of health outcomes and the quality of life for our registered population of approximately 140 000. By working together within IHL our member practices can benefit from taking a wider population view of the needs of their patients, pool resources to meet these needs equitably, and benefit from economies of scale and sharing of best practice to deliver innovative healthcare solutions. The federation acts as an umbrella organisation and provides a vehicle for practices to deliver locality-wide services collaboratively ensuring equitable access to high quality services. The Federation is central to Local Care Networks which brings together partners to focus on delivering better outcomes for our diverse population. The legal infrastructure and governance processes that have been established also enable the members to jointly hold formal contracts that would otherwise not be available to them in their individual practice capacity.

13 April 2016
Local Alliances:
Southwark Dementia Action Alliance

1. Action Plan

1. The National Dementia Declaration lists seven outcomes that the DAA are seeking to achieve for people with dementia and their carers. How would you describe your organisation’s role in delivering better outcomes for people with dementia and their carers?

IHL are committed to both improving the outcomes for patients with dementia and their carers as well as improving diagnosis in patients’ known primary care settings (GP practices). We are doing this through a number of work streams and innovative new ways of working, committed to being dementia friendly as a federation of 20 practices. We have arranged dementia friend awareness sessions for our staff and patient population as well as encouraged DAA membership. We want our patients with dementia, those who may have dementia and carers of those with dementia to feel valued, understood and supported by our GP practice staff in South Southwark.
We are also involved in a pilot with our local commissioners to diagnose more patients in GP practices, reducing waiting time for diagnosis and ensuring patient’s care is continued by their usual practitioner in a known environment.

We are also implementing a project whereby our GP practice staff are being trained up as primary care navigators to provide effective signposting. This is running concurrently with a pilot we are conducting with navigators from the SAIL (Safe and Independent Living) who are working with our practices and patients to better signpost patients and carers to appropriate support services.  

2. What are the challenges to delivering these outcomes from the perspective of your organisation?

Engagement from our member practices could be a challenge as General Practice are facing an extremely busy and difficult time in the current NHS climate. To date, our member practices have been keen to try new ways of working in the form of SAIL and Primary Care navigators and improve the outcomes for our patients who have or may have dementia.
It is difficult for GP practices to release staff for training and so we have ensured that training and awareness sessions are arranged locally to our members and offered in-house sessions where possible.

There can be resistance to change in terms of GPs diagnosing patients with dementia in primary care and working to a different pathway which initially may require more of their time. 

2. Actions

  • Create a dementia friendly workforce

    We are committed to engendering a dementia friendly workforce in South Southwark so that our patients and carers have support in their GP surgeries and can be signposted by staff to useful services. We will facilitate this by providing dementia friend awareness sessions to our staff and encouraging our member practices to register as members of the DAA. We have already provided two awareness sessions for our practice staff and we have more planned in coming weeks.
    We are also piloting SAIL (Safe and Independent Living) navigators and Primary Care navigators in South Southwark practices. These pilots not only engage and train our staff but also raise awareness of available services for our patients 


    2016 - Second Quarter Update

    New member

  • Increase the level of dementia diagnosis and post diagnostic support delivered in primary care

    Our GP federation is committed to identifying and mapping local capacity and capability in dementia diagnosis and we are currently piloting a new way of working where GPs can diagnose dementia in the patient’s surgery. We are also hosting community clinics where a specialist nurse is diagnosing patients in their surgery. This is helping share knowledge and expertise with our clinicians in primary care and strengthen our relationship with our local memory service. We are ensuring that we are using resources such as the dementia specialist nurse and navigators, providing facilitation where needed to help our member practices engage in these new ways of working and maximising the support for our patients and carers with dementia that is designed around their needs.
    We have already held one patient awareness session in the Nunhead Community Centre where patients from all 20 of our member practices were invited to attend and more are being planned for the year ahead. We are encouraging our patient population and community to become more aware of what is available to them. 


    2016 - Second Quarter Update

    New member

  • Increase our dementia diagnosis in South Southwark to ensure we know who needs care and support

    We are supporting our member practices to identify patients who may have dementia (based on their medication and medical records) but have not yet been diagnosed. We have previously reconciled data between our practices and the South London Memory Service to ensure that we are all aware of our diagnosed patients to maximise the care and support offered to them. We endeavour to do this again this year and on a more regular basis. Our member practices meet quarterly and we support them in identifying patients on their clinical systems and they share learning and best practice to agree service improvement plans. 


    2016 - Second Quarter Update

    New member