Building on the progress made in collaborative working during the pandemic, our teams in Central & North West London NHS Foundation Trust, Central London Community Healthcare NHS Trust, Hounslow & Richmond Community NHS Trust and West London NHS Trust have developed an integrated governance structure. 

This involves an informal joint Collaborative Board and an Operational Delivery Group, overseeing a range of workstreams to deliver improvements in the care we provide for residents of North West London.

By working together with the North West London Integrated Care Board, health leaders are focused on delivering improvements in all of the key community service areas.

Improvement Initiatives:

One of our most important projects is to ensure the availability of community beds in all boroughs for patients most in need of care.  By delivering a range of high quality support services to patients in need we expect to reduce demand on beds - thus enabling patients who are more able, to continue to enjoy their independence and for those who need beds to be accommodated.

In NWL, we work towards supporting patients to go home wherever, and as soon as, possible. We only move patients from the acute hospital setting to a community based inpatient bed where there is a clear reason that the patient cannot be discharged home and needs a period of recovery or rehabilitation. 

We always aim to place patients as near to home as possible.

We have agreed a clinical core offer that all of the designated community based inpatient units should deliver, and have been working on the resources or other changes required to ensure standardisation in the delivery of care. We continue to review the number of community inpatient beds needed compared to the level of support in the community services that will enable patients to reach home sooner.

Our decision making is based on clinical safety, long term outcomes as well as ensuring best value for money.  

Our community nurses support patients and families in managing difficulties on a day-to-day basis and patients are encouraged to take control of their own care by learning about how best to manage their condition. 

We have agreed a clinical core offer based on our collective expertise in delivering community nursing services and national best practice, and we’re working with the North West London Integrated Care Board to implement this when resources can be identified.

Going forward our focus will be on recruiting and retaining more nurses to ensure we are able to continue to deliver a high level of care both in people’s homes and in the local community.

The Community Collaborative has innovated pathways to improve access to our Urgent Community Response service across the eight boroughs of North West London through an integrated Community Referral Hub which supports referrers from 111, 999 and the Ambulance Service. This hub is run by West London NHS Trust on behalf of the four Trusts.

The hub ensures that all patients in North West London are able to access services rapidly to support a range of conditions where, otherwise, there would be a risk of a patient needing attendance at, or admission to hospital.

Urgent Community Response (UCR) teams operate in all boroughs with core hours of operation from 8am to 10pm.  The core service provides a clinically relevant contact (usually face to face) within 2 hours of referral for all accepted referrals that are triaged as needing a 2 hour response. 

The following 9 conditions/clinical areas can be covered by UCR services:

•  Falls - with no apparent serious injury (including to the head, back, hip / able to rule out a fracture & loss of consciousness).

•  Urgent catheter care - blocked catheter and/or pain from a catheter related issue with a risk of harm/very high risk of admission.

•  Decompensation of frailty - frailty related conditions which may result in loss of strength, speed, energy, activity, muscle mass, resilience to minor health strains and loss of independence. Other problems, such as decompensation caused by a minor stressor event, such as a urinary tract infection (UTI), that can cause a sudden or disproportionate decline in function are also accepted.

•  Reduced function/deconditioning/reduced mobility - mobility loss can be sudden or gradual, leading to a sudden presentation and an acute need. The person may have a change in functional ability or ability to manage at home and with activities of daily living.

•  Palliative/end of life crisis support – breakdown in core palliative/end of life care services who may wish to receive crisis treatment at home/usual place of residence as part of a pre agreed treatment escalation plan, rather than a hospital admission.

•  Urgent equipment provision - including assessment to make the person safe and optimise functional ability.

•  Confusion/delirium - increased, or new, confusion, acute worsening of dementia and/or delirium (excluding sepsis).

•  Urgent support for diabetes – post hypoglycaemic episode (now resolved) or blood sugar management (excluding sepsis requiring hospital admission, hyperglycaemia/ketoacidosis).

•  Unpaid carer breakdown - breakdown of existing unpaid carer arrangements causing immediate health risk.

This is not an exhaustive list - these are aspects of common clinical conditions, or needs, that may lead to a patient requiring a two-hour response in a crisis.

We are working hard to ensure that good care is available within the community so that patients leaving hospital are well supported both short term, as soon as they leave, and longer term to prevent future hospital admissions.

In collaboration with Imperial College Health Partners, we have undertaken a review of the services offered in the community for neuro rehab provision across the eight NWL boroughs, which will help to drive how any future investment is best made. We have employed two neuro navigators to support the outer NWL boroughs (Brent, Hillingdon, Ealing and Harrow) which is a welcome new resource alongside the neuro navigators already working in inner NWL.

These neuro navigators help people with complex neurological conditions to avoid lengthy stays in hospital or care settings. They work with patients, families and clinicians to “navigate” their rehabilitation journey to the most appropriate destination. We have also agreed to appoint a clinical lead for NWL community neuro services.

Having standardised the information we use to make decisions across the four community providers, our business intelligence leads are working together to improve how data is captured, ensuring good data quality and literacy amongst the community workforce and shared visibility of information between clinicians, operational and corporate teams.  By embedding these approaches, we can make better insights with data being captured at the right time and in the right way.