South West London CCG Annual Report and Accounts 2020/21

programme, our engagement team has worked with GPs and pharmacists and the local councils to talk to different groups and communities online, through virtual meetings and events, answering questions to help address the concerns of many people about this new vaccine. Kingston and Richmond have some of the highest vaccine uptake rates in South West London and we are already working on messaging, events and materials for younger people as the programme moves down the age cohorts. Preventing and supporting the management of long-term ill-health Across Kingston and Richmond, we have been working to develop a model of care that supports the development of healthy behaviours within our population and enables people to make healthy choices about their lifestyle. The model of care focuses on empowering people to be able to self-manage any long-term health conditions, maintaining independence (within the parameters of their disease) and preventing the progression of disease into complexity and frailty. The prevention element of the model brings together NHS, council and partner services to focus on issues such weight management, mental health and wellbeing and risky behaviours such as smoking and drug use. Working together, we will also support people to manage long-term health issues such as diabetes and cardiovascular disease themselves using a range of options – from simple information to regular monitoring and management. Two anticipatory care pilot practices started work looking to proactively support a cohort whose health and social needs, while not currently at the top of the pyramid of need now, are likely to escalate to that in the near future. The objective is to sustain this population with care in or near to their homes, rather than having to escalate to acute sites of care. Journey recovery hubs Two hubs – one in each borough – provide support for people to prevent imminent mental health crisis. With no need for a referral, the aim of the hubs is to prevent escalation, reduce isolation, increase independence and self-management and improve wellbeing by drawing on strengths, resilience, and coping mechanisms. Both hubs kept going throughout the pandemic offering local people socially distanced, phone and online support. Establishing a GP in-reach pilot at Kingston Hospital The NHS long term plan describes the need for more joined up and coordinated care, breaking down barriers between health and care organisations and teams to support people with long-term health conditions. Acute hospital medical teams aren’t always sighted on the breadth of skill of the primary care team, or the admission avoidance services that can be used to facilitate rapid 52 | NHS South West London Clinical Commissioning Group