One Croydon

 

Working together to help people live the life that they choose

 

The One Croydon alliance is a partnership between the local NHS, Croydon Council and Age UK Croydon.

Focused initially on improving the health and wellbeing of older people in the borough, from April 2018, the Alliance will be extending its remit to consider the health needs of people of all ages in the borough.

Working together across the alliance, we want to join-up the services available to offer more coordinated support that will help look after peoples’ physical and mental health and wellbeing.

Our One Croydon Alliance partners are: Croydon Health Services NHS Trust, Croydon Clinical Commissioning Group, Croydon Council,the Croydon GP Collaborative, our mental health colleagues at South London and the Maudsley NHS Foundation Trust, and Age UK Croydon.

Meet Robert

Hear Robert's story and how his life has changed thanks to the support of One Croydon’s Personal Independence Coordinators, with Age UK Croydon.

 

Transcript of video with Robert highlight the role of Personal Independence Co.pdf  

Delivering real benefits for people in Croydon

Here are some more examples of the positive impact One Croydon initiatives have had in our community so far:

More than 100 hospital admissions were avoided in Croydon this winter [2017/18] by trying to tackle the issues that can affect someone’s health and wellbeing – such as loneliness, mobility problems and long-term conditions – that could lead to hospital treatment if left unattended.

At one of the busiest times for the NHS, when GPs and A&E services have seen record numbers due to the recent cold weather and peak winter demand, the One Croydon initiative is helping to ease the pressure on frontline services by enabling health professionals to work together to keep people well.

As part of the scheme, confidential multi-agency meetings known as ‘huddles’ have been set-up between GPs, social workers, pharmacists and other healthcare professionals, to proactively plan and review the care and support available for their patients. 

The meetings form part of Croydon’s six new Integrated Community Networks made up of a GPs, community nurses, CCG pharmacists, social workers and Age UK Personal Independence Co-ordinators.

The first network to get up and running was the north of the borough.  Within just the three months of the pilot, participating GPs saw a reduction in unplanned hospital admissions, whilst other practices that had not yet adopted weekly huddles as a way of working saw an increase in unplanned admissions during the same period.

Every GP practice in Croydon is now working as part of an integrated Community Network, and are running weekly ‘huddles.’

Included within the borough's multi-agency huddles are another One Croydon initiative – the addition of Personal Independence Coordinators (PICs) with Age UK Croydon.

The PICs team will visit patients in their own homes and provide the link between various health and care agencies, as well as give isolated people access to community groups and volunteering opportunities.

The aim is keep the person well which avoids them needing hospital care and helps them maintain their own independence and wellbeing.

The PICs offer dedicated support over a 12-week-period to find new activities or support services to improve a person’s quality of life, health and wellbeing.

To be referred to the network, patients need to have two long-term health conditions and have had at least two hospital admissions in the previous 12 months.

Once a patient has been referred, the team meet weekly or fortnightly at a GP surgery to discuss the person’s needs and next steps. This is more frequently than in the past, when often “multi-disciplinary teams” would only meet monthly, so is much more responsive and is more of a team approach.

Our Personal Independence Coordinators have helped hundreds of older people in our community stay well, by taking into account all of the factors that can affect their health – including housing, lifestyle, family and social connections.