Better Care Together

Better Care Together is a Waltham Forest-wide programme to join up all of the different health and social care services in our borough. This type of work is also commonly known as ‘integrated care’.

In 2011, if you had a long-term condition and lived in Waltham Forest you were more than twice as likely to be admitted to A&E than in most other parts of the country. 20% of people accounted for around 80% of hospital costs – a staggering figure which was only explained by clinicians and patients describing the care as ‘reactive’, ‘uncoordinated’ and ‘with unnecessary waste’.

With resources dwindling, and with integrated care beginning to show dividends in other parts of the country, our CCG piloted a programme to provide extra support to patients who visited hospital the most. This rapidly evolved into a much more ambitious programme of integrated care, known as Better Care Together, which is run in conjunction with Waltham Forest Council, Barts Health NHS Trust, North East London NHS Foundation Trust, and voluntary organisations, including AGE UK.

Two of the main focuses of work include extra support for people who are likely to visit A&E, and getting Waltham Forest's health and social care organisations to work together more effectively.

Extra support for people who are likely to visit A&E

Since we put extra support in place for people who are at risk of being admitted to hospital in an emergency, total admissions to Whipps Cross Hospital have dropped by 24% (1,806 episodes).

GPs and community matrons regularly assess patients to see how at risk they are of being admitted to hospital during an emergency. Since the work started, 9,000 people (3% of the borough) have been reviewed, and this year we aim to increase that to 16,000 (5%).

Those who are at risk are asked if they would like to be enrolled on our integrated care programme, where a multi-disciplinary team of clinicians and social care workers regularly monitor their health and provide any additional support necessary:

  • A rapid response team provides fast medical care and responds to 99% of calls within 20 minutes
  • AGE UKMetropolitan Housing and the British Red Cross have become partners, helping people get home from hospital and keeping them safe once they’re there
  • Much of this work has been made possible through an ambitious IT programme, which is upgrading the IT systems in GP practices so all of the different health and social care organisations in Waltham Forest can talk to one another

Anthony Kirk (71): “In the past I would have gone into hospital for treatment, and that would be the only treatment I would get. Now, the rapid response nurse comes in daily to give me the treatment I need which leaves me in my own home environment. It’s a great improvement.”

Getting Waltham Forest's health and social care organisations to work together more effectively

By getting health and social care organisations working together as one team we can shape services around the needs of the people who use them, rather than asking patients to go and speak with lots of different organisations to try and get the care and support they need.

Some examples of the work we are doing in this area includes:

  • Working with Whipps Cross Hospital and community health teams to develop one team that discharges all patients from hospital. Historically, people leaving hospital could be discharged by different teams, but now there will be a single point of contact for them, and their family and GP.
  • A programme to allow people at the end of their life to die in a place that they choose, that is safe and with plenty of support from the right people
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