New services provide more joined up care for Ealing residents


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People in Ealing are benefiting from improved health and social care services aimed at older people and those with long-term conditions such as diabetes or heart disease.

People in Ealing are benefiting from improved health and social care services aimed at older people and those with long-term conditions such as diabetes or heart disease.

Ealing Clinical Commissioning Group (CCG) and its local GPs are central to the changes, which have already helped to reduce referrals to other services and mean patients no longer have to repeat the same information to different services.

Cuckoo Lane Surgery, one of three practices in Ealing who piloted the new model of joined up care, recruited a care coordinator to act as a link between the patient, the surgery and different care services.

The pilot concentrated on 60 patients who were identified as being frequent users of primary – or GP – services and secondary emergency care.

When Geraldine Ruddy’s father, Patrick Geelan, health deteriorated and was admitted into hospital, she was put in contact with a care coordinator working from Cuckoo Lane surgery.

Geraldine said: “I had no previous involvement with health and social care, so when my 87-year-old father went into hospital, I found the experience daunting. But being put in touch with Fahim Ahmed [the care coordinator], it has made a huge difference. 

“He took a proactive role in supporting my father, mother and me. He was able to explain, in terms we understood, what was happening. When worried, I was able to talk to him. He knew the names of social workers working on my father’s case, what assessments were being done. He offered continuality, and I always felt like we were his priority.

“He gave us the confidence to know we’re doing the right thing in respect to my father’s care and the courage to be positive. “

Julie Belton, operational and strategic director at Cuckoo Lane Surgery, said: “Previously, for patients who were known to have complex needs, we were only able to treat their medical care, but we found there were other things they wanted to see treated just as much as their illness.

“They were either living alone, had no support or they needed to be admitted into hospital, but wouldn’t go as they had no one to look after their partner they cared for or a pet.

“Bringing a care coordinator on board has changed this. They have been able to get proactively involved, signposting patients to services and putting care packages together jointly, with input from the patient. The results have been very good.

“A measure of the success is that, since our care coordinator started, we have not had to make any referrals other specialist clinician services, meaning people are getting back to health quicker.”

Leading the changes is Whole Systems Integrated Care (WSIC), an alliance of health and social care partners from across North West London who have been working to bring different services together. 

Clare Parker, chief officer of Central London, West London, Hammersmith & Fulham, Hounslow and Ealing CCGs said: “We are working hard to improve the quality of care for people in Ealing by making local services much more joined up around the needs of people we’re helping to get and keep well.

“This is particularly important now as people are living longer and have more health and care needs, each of which may need different types of doctor, carer or specialist to treat them.

“People are fed up with fragmented, inefficient care, and patients certainly don’t want to keep having to repeat the same information to different doctors or carers.  

“In North West London, our Whole Systems Integrated Care (WSIC) programme is about giving people more say in how, when and where they receive care so that they are empowered and supported by a team of carers to maintain their independence and lead a better quality of life.

“It’s pleasing to see such good progress being made in areas like Ealing, and we are committed to building on this so we can lead this change for the benefit of individuals, families and carers alike.”