Communities of Practice

Communities of Practice page

NHS High Weald Lewes Havens CCG is working with partner organisations from health, social care, housing and community services, as well as with local people to improve the delivery of health, care and support services and to improve the health and wellbeing of local people.

We are initially building a Community of Practice (CoP) for the Havens which means that we want local partner organisations to work together to plan, design and deliver more integrated services that better meet local needs.

The partners involved in this work comprise the four local GP practices, Sussex Community Foundation NHS Trust, Sussex Partnership Foundation NHS Trust (SCFT) , Health in Mind, Adult Social Care, the Joint Community Rehabilitation Service, Age UK, SCDA, Care for the Carers, Health and Social Care Connect, and Integrated Housing Solutions, to name a few.

The Havens CoP will build upon work previously progressed as part of the ‘Healthy Havens’ project a few years ago. This project introduced a range of new local services that provide a solid foundation for future developments. These are described on the subsequent page.  

The Havens CoP will also benefit from the fact that Multi-Agency Team meetings have been established at all four local GP practices. These meetings bring together a range of local partners including the voluntary sector to jointly review the care and support needs of patients who are identified as most at risk of decline and in need of support.

The Havens Community of Practice was launched at an event in Newhaven on 6 December 2017, and a steering group of partners will take responsibility from January 2018 for agreeing and implementing actions to improve local services. 

Initially, in line with CCG priorities, the group will focus on improving the delivery of services for frail people and for improving services that avoid unnecessary hospital care, but over time the steering group will identify and respond to their own priorities based on analysis of local needs.   

Following on from the initial work in the Havens we will look to develop Communities of Practice in Lewes (building on existing plans for development of a primary care home), Uckfield and Crowborough. 

.The following summarises the services and initiatives introduced by the Healthy Havens project that will be built upon by the Havens Community of Practice.   

This specialist role is commissioned from Brighton and Sussex University Hospitals NHS Foundation Trust and provides access within the community to direct patient care and/or advice and guidance for GPs for their most complex patients. The aim of the service is to manage the care of these most complex patients outside of the hospital environment, and it has achieved positive outcomes and received excellent feedback from patients and GPs.

A pharmacy team has been recruited to work within each of the four local GP practices with the aim of ensuring patient safety and improving patient compliance with regard to medication taken, and releasing GP time dealing with medication reviews. The feedback received from GPs regarding this service is very positive.     

Initially a Practice Connect Worker was recruited to support local GP practices with the management of people with or at risk of developing long term conditions, with the aim of improving self-management of conditions and lifestyles, and also linking patients with local voluntary and community services that could be of benefit to them.    

This role has now been replaced by a Community Navigator service from Age UK, which is indirectly commissioned by the CCG, and which works on a similar one to one basis with people to support them to manage their health and access local services.

There is also now a Locality Link Worker in place for the Havens who specifically works with local health and social care professionals to improve their awareness and understanding of voluntary and community services, and improve the use of these services for the benefit of people.     

Following a review of local services the CCG has decided that it is no longer able to continue funding the CTLA NHS Transport for the Havens service beyond the 30 September 2018. 

This decision has been made because the NHS, both locally and nationally, is currently facing a significant challenge to meet rising demand on services within restricted finances, and as a consequence the CCG needs to prioritise funding for services that deliver direct clinical benefit for patients. 

The decision to cease funding does not reflect the quality of the service provide by CTLA and it is not one we take lightly. We have reviewed the impact that stopping the service will have on local people and have contacted service users with advice on alternative options. 

Collaborative working between East Sussex Fire and Rescue Service (ESFR) and GP practices now means that vulnerable people can be referred by GPs for a home safety visit by ESFR, where trained staff will assess any risks and put in place measures to address these e.g. installation of fire safety equipment or referrals to other services.   

Find out more

To find out more about the Feel Good brand visit our Feel Good toolkit and resources page.

 If you would like to find out more about the Havens Community of Practice please contact Keith Hoare, CCG Cluster Lead for the Havens, on 01273 403610 or at keith.hoare@nhs.net.