All practices in north Southwark have signed up to being a large PCN, with the support of Quay Health Solutions, in set up and implementation. (QHS) was established in 2011 as a Community Interest Company (CIC). QHS work with the GP practice in the PCN and other health and social care services, to provide care for over 190 thousand patients across north Southwark. The current interim clinical directors in the north Southwark (QHS) PCN are Olufemi Osonuga, Louisa Dove, Anita Banerjee and Stefan Lipinski.

COVID-19 Vaccination & Boosters

North Southwark PCN Covid-19 vaccination centre

If you are a patient registered with a north Southwark GP please contact your GP practice for queries relating to the vaccination centre.

Contact for professionals or patients not registered with Southwark

GP: Qhs.covidvaccination@nhs.net 

Location: Artesian Health Centre, 138 Grange Road, SE1 3GF, London 

Further information 

Please visit the NHS South East London Clinical Commissioning Group website for further information and guidance on Covid-19 vaccinations.

Social Prescribing

Overview of social prescribing

Our social prescribing team work across north Southwark and comprises of 10 social prescribing link workers, including two team leaders. Each link worker is assigned to a group of GP surgeries within one of our five neighbourhoods. Link worker support offers patients an additional, personalised route to improving their health over the longer-term by utilising the rich and diverse range of community services and voluntary sector organisations in our area. You can meet the social prescribing team here!

The purpose of social prescribing

Social prescribing recognises that health is determined by an array of influences and social determinants. Addressing people’s needs and tackling health inequalities will therefore benefit from a holistic and self-directed approach. Many of the issues with which people present at their GP stem from these wider social factors. Treatment solely focusing on clinical health can be short-term and ineffective towards tackling the root causes of ill health. Difficulties with a person’s housing situation, finance, mental health, diet, physical activity or social isolation need to be addressed if we want to improve wellbeing in the long-term. Social prescribing is a means of giving people choice and control over the way their care is planned and delivered, based on what matters to them, their individual strengths and their needs. It makes the most of the expertise and potential of people, families and their surrounding communities, whilst delivering better outcomes and patient experience.

Meet the team!

Meet our team of social prescribers working across north Southwark.

Patient Story
Practice feedback

What are the plans for the future?

The social prescribing team will continue to build our knowledge and links with the community sector. A closer integration in our ways of working will free up clinical capacity, reduce duplication and ensure better care for all. We hope that the rapid response enforced by the Covid-19 crisis can have a positive legacy in bringing people and organisations together to coordinate our efforts towards tackling health inequalities and improving the health and wellbeing of our population.

Further information

Anyone working in a GP practice can refer a patient into the social prescribing service by completing the ‘Elemental Form’ in EMIS.

Please watch ‘Social Prescribing: Transforming Health for London ‘by the Healthy London Partnership to see more fantastic social prescribing work across London.

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Local Extended Access Service

GP practices in north Southwark are working together to deliver the extra appointments so you may not see your usual doctor but they will work regularly in Southwark and have the same skills. With your consent, any doctor or nurse you see can access your healthcare record to ensure they can offer the right treatment.

Our Friends and Family Test feedback for both 2018 and 2019 highlighted that over 90% of patients surveyed were likely or extremely likely to recommend the service.

What do we offer?

The EPCS currently offers three services:

• GP appointments
• Nurse appointments
• Contraception appointments

How do I get an appointment?

If you would like a GP or nurse appointment, simply contact your GP practice in the usual way and ask them to book you in at the EPCS.

Opening Times

Contact details

Spa Medical Centre
50 Old Jamaica Rd
London
SE16 4BL

If you have booked an appointment at the EPCS via your GP practice or NHS 111 and need to change or cancel your appointment, please contact the EPCS reception on 020 3883 1620. Please note, we cannot book an initial appointment for you via the EPCS reception, only your GP or NHS 111 can do this.

You can download our leaflet, with a map here!

 Further information

• If you would like to know more about access to your health records, please read this this document.
• Find out more about our EPCS achievements in the QHS 2018/ 2019 annual report.
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GP Pharmacists

Overview of GP pharmacist’s programme

In 2018 QHS was successful in an NHS England bid to recruit clinical pharmacists to become part of the general practice team.

QHS has employed eight clinical pharmacists who have been posted across 14 GP practices in north Southwark. The roles have been established in partnership with NHSE‘s education and training partners, providing pathways to support the pharmacists to develop as primary care clinicians and independent prescribers within practices across IHL.

Purpose of programme

Clinical pharmacists are highly trained experts in medicines and as part of the GP Forward View will be helping to reduce demand on GP practices and supporting the management of patients with long term conditions.

The aim is to reduce demand on GPs and more importantly improve the quality and safety of prescribing for patients by providing medicines reviews for patients. The clinical pharmacists will also be trained to become prescribers to run clinics for people with long term conditions such as asthma.

This programme of work also aims to improve links with community pharmacists and improve communication and ensure a more seamless transfer between the hospital and community.

The clinical pharmacists will be working within the four neighbourhoods in north Southwark (Borough, Walworth, Bermondsey and Rotherhithe).

What have we done so far?

• Pharmacists have had a thorough induction in general practice so that they were able to integrate with their practice teams and across QHS. Their focus is currently to support practices with medicines reviews for patients.
• We have embedded eight clinical pharmacists who are now working across all five of our neighbourhoods (Bermondsey, Rotherhite, South Walworth, Walworth Triangle and Borough).
• Clinical pharmacists are working within our care home service.
• Clinical pharmacists have delivered high level medication reviews in patient facing clinics in GP practices.
• Developed a QHS Medication Review Template on EMIS, enabling NHS England KPI data collection
• Supported GP practices with prescribing policy work and CQC inspections.

What difference has this made?

Positive feedback has been received from GP practices regarding GP Pharmacists.

What are our plans for the future?

QHS are exploring plans to increase the number of GP pharmacists in 2019/ 2020. We are developing plans for Primary Care Network (PCN).

All pharmacists will be qualified to prescribe independently with the aim of running long-term condition clinics.

Pharmacists will be upskilled to deliver more services within practices such as annual flu vaccinations and home visits.

Pharmacists are building a series of high quality QHS prescribing policies to support member practices.

To find your local pharmacy, please visit NHS: Find a pharmacy.

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Care Navigation

Overview of the programme of work

It is recognised that the needs of some patients are social rather than clinical in nature but they are still at risk of being admitted to hospital or being in crisis. Evidence shows that providing additional support focused on social needs (e.g. social isolation) would reduce this risk or provide a more appropriate management response should a crisis arise.

Quay Health Solutions is working with Age UK Lewisham and Southwark, the CCG and other local partners within the Local Care Network to deliver a Care Navigation Pilot.

 The purpose of the programme of work

We aim to ensure care is designed and delivered around the needs of the individual, through partnership working. This area of work is part of our coordinated care programme, supporting people with multiple long-term conditions and frailty. Services should be joined-up to promote improved outcomes for individuals in need of health and social support, enabling them to live not just longer, but better lives.

What has been done so far?

 Primary Care Navigation (PCN)

Practices in north Southwark have paired with local pharmacies and have identified reception, health care assistant and counter staff to attend a primary care navigation training programme.

The role of the PCN is designed to release clinical capacity and provide better outcomes for patients where their needs would be better met through a social intervention. The PCNs are trained to identify support and signpost patients to local services. The PCNs are supported by the SAIL Care Navigator for more complex cases.

Patient Story

John was 97 years old and kept getting nuisance calls when he was trying to sleep. He found them very distressing and was calling the GP practice to ask his GP to help. He wanted the GP to call the estate manager to make the calls stop. The primary care navigator explained that it might be better to speak to a SAIL Navigator rather than a GP since the problem was not medical. The SAIL Navigator called John to reassure him and then referred him to Trading Standards who have agreed to visit John and put blocks on his phone so he doesn’t get cold callers anymore. John has stopped calling the GP for help about this now, and feels confident that the issue will be resolved soon.

Case study

Please see this PCN case study from Old Kent Road Surgery which highlights the impact of PCN on the practice.

SAIL Care Navigation

A SAIL Care Navigator from Age UK Lewisham and Southwark works across a number of host GP practices supporting patients identified as needing additional non clinical support.

SAIL Care Navigators support people to stay healthy and independent by assessing their needs and co-ordinating an appropriate package of support. The service is for patients with high levels of social need, so the agreed plan might include supporting people to access new social groups and activities, learn new skills, access benefits advice or practical adaptations in the home.

The Age UK Lewisham and Southwark SAIL Care Navigator works closely with GP practices across a number of sites and takes referrals via the SAIL checklist. The SAIL Navigator has close links with the wider voluntary and community sector and social care colleagues.

Practice feedback

“Thank you so much for your efforts with Sarah. She left a message for me on Wednesday saying how thrilled she was with the help you have given her. I am truly grateful; you are making a big difference to her wellbeing” Ranya (Dr Zeineldine Aylesbury Medical Centre)

“Thank you so much for this and updating me – it’s really useful – you’ve done a great assessment of actually what she wants and needs! Your plan sounds perfect – I’m really grateful for this and I think all below would really benefit Georgina.”  Vicky (Dr Burt Manor Place)

Patient story

Rose had become very isolated and saw no one except her daughter. She told her nurse during a holistic health assessment that she loved sewing. It turned out she was an incredibly skilled seamstress who made all her own clothes, but had nothing to sew for and was giving away all her material. The navigator told Rose about Blackfriars Sewing Club and took her on the bus. She was welcomed into the group and was thrilled at the idea of sewing bags and cushions for the club to sell and raise money for a sewing machine. She told her son she had been wasting her life all this time, and has now joined the group every Thursday for seated exercise and lunch as well as sewing.

 What are the plans for the future?

Via neighbourhood working we are planning to up skill more practice staff. We will also aim to work more closely with our settlements (Time and Talents, Pembroke House, Bede House and Blackfriars) to ensure that more patients are referred to these services and receive the support they need.

Further information

See what our PCNs and SAIL Navigators think of the programme here!

Anyone working in a practice can access support for patients from a SAIL Navigator by completing a SAIL checklist.  Patients can also self-refer.

Earlier this year we attended the International Forum on Quality and Safety in Healthcare to present our PCN work. You can see the poster we presented here.

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Multidisciplinary Team (MDT) working

Overview of MDT working

The main focus of MDT working is to bring together health professionals from primary care (GP practices), secondary care (hospitals), carers, social workers and the community and voluntary sector to work together to discuss patient care. By working together, health professionals are able to use their collective expertise to discuss the best interventions for patients and put them in place quickly.

MDT working is part of a wider programme of work to improve coordinated care for patients with three or more long-term conditions in north Southwark.

 MDT working in north Southwark 

MDT working has built relationships between local health and social care organisations and people. GP practices already connect with a range of health professionals to discuss patient care, however QHS now coordinate an additional monthly Community Multidisciplinary Team (CMDT) meeting.

The CMDT meeting provides a forum for health professionals to discuss patients with complex health needs, share best practice and identify solutions. They are an educational environment and have enabled shared learning and greater knowledge between health and social care providers about local services and support available for patients.

 What have we done so far?

• QHS currently run one MDT meeting per month at a convenient location and time for health professionals to allow full participation.
• We have two neighbourhood facilitators who support these meetings.
• In 2018/ 2019 we reviewed 80 north southwark patients in these meetings.

What are our plans for the future?

In the future we plan to have MDT meetings in each north Southwark neighbourhood (Borough, Walworth south, Walworth triangle Bermondsey and Rotherhithe) as part of our neighbourhood working programme. We are working on enabling dialling in so that practice staff can attend meetings virtually.

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Neighbourhood working

Overview of the programme of work

QHS member practices are divided into five geographical areas called neighbourhoods in Southwark, which are; Bermondsey, Rotherhithe, Borough and Walworth triangle and south Walworth. Our neighbourhoods support delivery of our Partnership Southwark which aims to join up care between GP practices, hospitals, Southwark Council and voluntary and community organisations ensuring coordinated and improved quality of care for our population.

The purpose of the programme of work

Working in neighbourhoods ensures a focus on the local needs and priorities of our member practices and their local patients. It means local connections and relationships can be established across GP practices and sectors such as healthcare and the voluntary sector in a meaningful way. It means having a shared purpose and shared resources to deliver quality care and outcomes for our patients living in these neighbourhoods.

GP practices are working more closely than ever with our partners including  Guy’s and St Thomas’ NHS Foundation Trust, South London and Maudsley, Southwark Council, Community Pharmacy and voluntary and community services including our local settlements; Bede House, (Bermondsey), Time and Talents,(Rotherhithe), Blackfriars Settlement (Borough) and Pembroke House (Walworth).

What has been done so far?

• We have recruited two neighbourhood coordinators and a neighbourhood manager to support GP practices with this new way of working. One coordinator will work across Borough and Walworth and one coordinator will work across Bermondsey and Rotherhithe.
• A neighbourhood programme was launched in November 2018, bringing together over 100 people from primary care, secondary care and the voluntary and community sector to explore areas of common challenge and scope improvement projects.
• Our Care Navigators, based in GP practices have been trained at their local settlement and will refer patients who would benefit from services provided by the settlements.
• Neighbourhood Champions including a GP, practice manager and practice nurse have been recruited to progress neighbourhood projects in Rotherhithe and the Walworth triangle.
• Pilots were launched in the Walworth triangle and Bermondsey and Rotherhithe neighbourhoods to look at solutions for people with mental health issues. You can read more about this in our Year in Review 2018 – 2019.

What are the plans for the future?

• We will continue to provide training, share best practice and support and develop new ways of working across practices.
• We will continue to work on pilot projects and share learning with other neighbourhoods.
• Our neighbourhood development work will support the work of our Primary Care Network and Partnership Southwark.

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Our Contracts

Quay Health Solutions (QHS) is a group of 20 GP practices (member practices) in north Southwark. QHS has been given funding by NHS Southwark Clinical Commissioning Group (CCG) to improve the quality of care in general practice and improve the health outcomes of local patients. As part of this, we support our member practices to deliver the Population Health Management Service contract, the Personal Medical Service contract, the Extended Primary Care Service and the Care Home Service.

Population Health Management Service (PHMS)

The PHMS contract began in April 2015. All member practices support the delivery of the PHMS contract. The services we offer as part of this contract include:

• Coordinated care for people with three or more long term conditions
• NHS Health Checks
• Annually reviewing people who have pre-diabetes
• Providing asthma and COPD inhaler reviews
• Ambulatory blood pressure monitoring

Personal Medical Service (PMS)

The PMS is a locally agreed contract between the CCG and individual GP practices. The PMS contract includes: providing flu vaccinations, supporting people who; have suffered from a stroke, have hypertension, have chronic heart disease or have diabetes. It also includes supporting people who are at the end of their lives. In north Southwark, QHS support our member practices with the delivery of the PMS primary care services for our population.

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Click the link below to find out more about your local PCN: https://www.quayhealthsolutions.co.uk/our-primary-care-network/