
BEST PRACTICE REPRESENTATIVE 2019
THE PARLIAMENTARY REVIEW
Highlighting best practice
36 | NHS LEEDS CLINICAL COMMISSIONING GROUP (CCG)
Leeds Care Record is a joined-up
digital record which brings together
important information about patients,
enabling clinical and care staff to view
real-time health and care information
across care providers and between
different systems.
Our Adult Social Care dataset went live
in Leeds Care Record in 2016.Since
then, integrated care between the
council and Leeds Teaching Hospitals
NHS Trust has evolved at a fast
pace.The system helps practitioners to
obtain an up-to-date medical snapshot
and gain a holistic understanding of
the patient’s health journey. Areas
such as adding safeguarding flags and
more detailed information on care
plans have been identified for future
development.
Local care partnerships
The NHS in Leeds and Leeds City
Council are working towards
integrating systems and ways of
working to improve services for local
populations. Our work is built around
strong, well-established and locally
based “neighbourhood teams” that
combine community health and adult
social care services. These were integral
to our national NHS Pioneer status.
We have supported local care
partnerships by investing in a locality
leadership infrastructure from
general practice, and by supporting
the development of the Leeds
GPConfederation.
For example, our Child Family Hub
aims to improve access to specialist
children’s doctors. It has already
reduced the number of “unnecessary”
paediatric outpatient appointments
at hospitals. In a strategic approach,
it has brought together GP practices
in one part of Leeds to work with
staff from schools and the city’s NHS
trusts, creating a “hub”. A consultant
from Leeds Children’s Hospital
carries out clinics in the community,
meaning families don’t need to travel
unnecessarily to appointments and can
access them earlier. Previously, there
would have been an average 12-week
wait to see the paediatrician in hospital
following a referral: those patients can
now see the consultant within one
month – and GPs can get advice on
their case within two days.
Social prescribing
There are many factors which come
together to affect the health of
individuals and communities. Where we
live, our environment, genetics, income,
education level and relationships with
friends and family all have significant
effects on health and wellbeing.
Social prescribing is an intervention
to address unmet patient needs by
increasing knowledge about local
services and voluntary groups that
could provide appropriate support to
improve and encourage self-care and
facilitate health-creating communities.
Social prescribing puts patients in
contact with a link worker who could
help people access community-based
services that suit their needs much
better than a medical intervention.
Examples of this may include debt
advice or referrals to a Citizens
AdviceBureau.
Our Leeds Health and
Wellbeing Strategy
aims to improve the
health and wellbeing of
everyone
Our Child
Family Hub
aims to
improve access
to specialist
children’s
doctors and
has already
reduced the
number of
“unnecessary”
paediatric
appointments
at hospitals
“
“
37NHS LEEDS CLINICAL COMMISSIONING GROUP (CCG) |
HEALTHCARE & PHARMACEUTICAL
An example of this is Caring Hands.
Caring Hands is a collaborative project
between patients at a medical practice,
GPs and nurses, a social prescribing
scheme and third-sector organisations.
Caring Hands volunteers have
undergone training in befriending,
confidentiality and risk assessment.
They offer vulnerable, socially isolated
and anxious patients an additional
helping hand and listening ear when
geographical distances and increased
work pressures mean family members
are less able to be there.
Collaboration between different
organisations and volunteers can make
a real positive impact to patients’ lives
by tackling issues such as loneliness
and isolation. Services like these make
a huge difference to people’s health
and wellbeing.
Frequent attenders project
This group was set up in partnership
with Leeds Teaching Hospitals NHS
Trust, Leeds and York Partnership
NHS Foundation Trust and Barca, a
local community and voluntary sector
organisation. Their goal was to reduce
the number of attendances at A&E
by a specific cohort of people who
have been identified as being frequent
attenders and who would benefit from
mental health and psychosocial support.
Through joint working and
collaboration, the team have adopted a
consistent approach to understanding
and meeting the complex needs of
individuals who frequently use crisis,
emergency and urgent care services.
In their first year, the team achieved
a reduction of 31 per cent in
attendances for the selected group,
surpassing the 20 per cent target.
Following this success, the team have
selected a further cohort of frequent
attenders to work with, and have fully
integrated a case manager from Barca
into the team.
Leeds – continually innovating
All of this puts Leeds at the forefront
of health and care innovation
nationally. Our approach in Leeds is
built on firm foundations working
with all partners in a co-operative
way that also includes clinicians,
citizens and the third sector. Our
democratically elected members have
been central to this approach, working
closely with staff at all levels via our
Community Committees and in local
carepartnerships.
While we have achieved success,
challenges still remain. The key ones
are to tackle health inequalities and
unwanted variations in quality of
care. Beyond this, we must adapt
to an increasingly elderly population
with more long-term conditions,
for example diabetes, high blood
pressure and chronic obstructive
pulmonarydisease.
We are open and learn from each
other and our communities. Ultimately,
we believe in our people and we
believe that through working together,
co-producing solutions and shaping
opportunities, we will improve
outcomes for all ages and in all
communities despite the challenges we
face as a large urban area.
Collaboration
between
different
organisations
and volunteers
can make a real
positive impact
to patients’ lives
by tackling
issues such as
loneliness and
isolation
“
“
Ragbir Thethy,
consultant paediatrician
from Leeds Teaching
Hospitals NHS Trust at
the West Lodge Surgery
in Farsley