Early findings show older patients in North West London benefit from new NHS care plans

Older patients and health professionals have welcomed a new care plan, after a trial began in four GP practices in Hillingdon in November 2015.

Dr Martin Hall, Partner of Devonshire Lodge and Clinical Lead for the CCT
Dr Martin Hall, Partner of Devonshire Lodge and Clinical Lead for the CCT

Early signs suggest this new care plan could reduce trips to A&E and boost quality of care. The single care plan is accessible to the patients, their carers and health professionals and helps make sure their care is fully planned and patients have more information at their fingertips on care and services available.

To deliver the care plan a new team of doctors, nurses and healthcare professionals was created, called the Care Connection Team (CCT), made up of:

  • a new nursing role, known as Guided Care Nurses (GCNs), who oversee the overall delivery of the care plan;
  • care coordinators, the team’s first point of contact who collects daily patient referral information and;
  • GPs, who make the final judgement call on all care plan interventions and referrals.

This new team of community healthcare professionals have been working with patients aged over 65 from four GP practices in Hillingdon (Devonshire Lodge, Abbotsbury, Harefield and Mountwood) to help keep patients out of hospital, providing them with the care they need in the community and in their own homes. Whilst the GPs remain responsible for their patients’ care overall, the CCT identifies patients who would benefit from coordinated support.

The CCT has had an early impact, with patients with long-term conditions feeling better supported by the NHS to manage their care. Patients reported that an increase in support gave them a better understanding of their health status and they felt less likely to attend A&E.

Dr Martin Hall, Partner of Devonshire Lodge and Clinical Lead for the CCT said: “It is really encouraging that the patients, who benefited from the Care Connection Team’s support, felt confident in the teams work and did not feel they needed to rely on any other healthcare intervention during the pilot”.

The CCT manage their own list of patients, providing healthcare professionals with:

  • better management of patients across NHS services;
  • a proactive approach to daily community services and referrals to specialists and;
  • allows more time with GPs. 

Early indications suggest that the CCT supports primary care services in providing better management of long term conditions, more community services are being used and patients receive the full benefit of programmes that can be offered outside of hospital. The CCT will continue to focus on prevention and self-care in order to reduce avoidable spells in hospital.

For further information please contact Ayesha Baker, Communications Officer, North West London Collaboration of CCGs on 020 3350 4639 or at Ayesha.Baker@nw.london.nhs.uk



Notes to editors

  1. This new model of care was piloted by Hillingdon Health and Care Partners, a partnership between the Central North West London NHS Foundation Trust, the Hillingdon Hospitals NHS Foundation Trust, MetroHealth GP Network and Hillingdon 4 All (a group of third sector organisations that collectively provide health and social care services)
  1. By supporting the team to critically appraise the models performance, we have identified ways that the model may be improved prior to further role out across Hillingdon and North West London.
  1. The Whole Systems Integrated Care (WISC) programme is working to create a health and social care system that is truly seamless so that people receive the right care and support at the right time and in the right place. You can find out more information at: https://www.healthiernorthwestlondon.nhs.uk/bettercare/integratedcare
  1. We are a collaboration of the eight NHS Clinical Commissioning Groups in North West London who are working with patients and the public to design, develop and implement major transformation programmes to improve healthcare services for the two million residents who live there: www.healthiernorthwestlondon.nhs.uk