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  • NHS Southwark Clinical Commissioning Group (CCG) worked in partnership with Quay Health Solutions, Improving Health Limited, Health Innovation Network, Healthwatch, King’s College London, King’s Health Partners and Queen Mary University London.
  • The project scaled up a clinical effectiveness model to 38 GP practices and their 320,000 patients in Southwark.
  • Clinical Effectiveness Southwark (CES) focused on improving outcomes for patients with long-term conditions and ensuring consistency of approach.
  • Project ran from November 2017 to November 2020.

CES is an approach designed to put the information primary care professionals need at their fingertips; making the right thing to do the easy thing to do.

The project was based on an approach adopted in East London, which played a major role in improving health care delivery in three of the UK’s most deprived boroughs.

As a similarly deprived area of London, with a high disease burden and wide health inequalities, CES tapped into the experiences of East London, and adapted and delivered a local model.

The model is based on: ‘belief’ (guidelines, education and awareness-raising); ‘act’ (using trusted templates to support evidence-based practice, regular feedback through analytics and making understanding real-time data core to the daily work of clinicians); and ‘motivation’ (cross-practice learning and aligning incentives to clinical effectiveness areas).

The CES team produced a package of support for practice teams across eight clinical areas that are seen and treated frequently in Southwark: atrial fibrillation, diabetes, hypertension, asthma, breathlessness, chronic obstructive pulmonary disease, heart failure, and depression and anxiety.

Guides were produced for each condition, summarising national advice, highlighting messages relevant to Southwark’s population, and listing local referral or advice services. Clinical templates and data searches and reports were produced, and education sessions and practice visits held.  

A number of improvements in clinical practice have been identified. Southwark had the highest overall Quality and Outcomes Framework improvement across London in 2018/19, with continued improvement in all CES condition areas.

CES’s multi-professional team was also able to draw on its experiences to rapidly produce guidance to support practices during the COVID-19 pandemic, for example guides on proactive long-term condition management during COVID-19 and long-COVID.

The CES programme has been further scaled up across South East London.

Contact information

For more information about this project, please contact Nick Harris, CES Programme Manager.

About this programme

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