GPs in south west London can now get digital access to adult social care data from local councils, helping them offer better support to their most vulnerable patients.
The data is being made available to GPs whose patients receive proactive care. This type of care supports people aged 18+ with the most complex health needs – they may be very frail, or have multiple long-term conditions, for example – and who have frequent hospital admissions and visits to A&E.
Delivered by teams of different healthcare professionals, including GPs, community nurses, social care workers and staff from the voluntary sector, proactive care offers are tailored to each person.
Proactive care supports social needs as well as physical and mental health, helping people stay well and independent at home for as long as possible, reducing avoidable emergency care and hospital admissions. A proactive care pilot in Kingston and Richmond saw a 49% reduction in unplanned urgent care visits over a four-month period.
GPs and other healthcare professionals use the data to identify people who would benefit most from the service, alongside their own expert knowledge of the people they care for.
Dr Annette Pautz, clinical lead for proactive care in Kingston and Richmond, and a Kingston GP, explained: “Accurate, up-to-date information from a variety of sources is vital for us to successfully identify people who could benefit from proactive care.
“The addition of adult social care data means that, for the first-time, GPs can view the patients’ interactions with health and social care organisations.
“Access to this data means we can quickly identify any gaps in care and, working with our colleagues from social care, more easily put in place any additional support that patients need.”
Dr Maryem George, Sutton GP, said: “Social care information plays a pivotal role in avoiding any unnecessary hospital admissions. I am really looking forward to this exciting development and being able to access social information in a timely manner.”
NHS South West London’s data teams worked with Croydon, Merton, Richmond, Sutton and Wandsworth councils to ensure appropriate use of this data. This work has also been supported by NHS England Data Services.
Busayo Akinyemi, director of integrated care at NHS South West London, said: “One of our aims for transforming care is to use data and information more proactively to help deliver better care and improve patients’ outcomes.
“We have been working with partners in our local authorities for several months on the adult social care data project. It is an excellent example of how the whole system can work together to develop the tools that will help us achieve real, co-ordinated improvements in care for our residents.”
For more information, contact Anca Costinas, lead transformation manager for the project.
