Neighbourhood and Wellbeing Delivery Alliance Progress Report 2021-22

Strategic Priority: Living with long term conditions

Our priority outcome: Help people to manage multiple long-term health conditions and help people with chronic pain to get the support they need

We aim to provide patient centred care by removing the need for patients to ‘tell their story’ multiple times to different services. We also aim to improve the experience of people who need to use multiple services by working more effectively together and using appointments and consultations to address a range of needs at the same time rather than one by one. Lastly, we work to reduce inappropriate medicines use and to reduce reliance on multiple medicines.

Diabetic man testing his blood sugar in blue heart frame

Context and key challenges

Covid-19 left a backlog of unaddressed needs among people with multiple long term health conditions, and long waiting lists across healthcare providers.

The challenge which the local healthcare system set out to address was to work together across GP practices and hospitals to identify, reach and address the health needs of this vulnerable population in a joined-up way that would improve patient experience and outcomes and also relieve pressure on services.

What we have offered

Our Multiple Long-term conditions test project focused on patients with multiple long term health conditions, aiming to reduce fragmented care and to improve both the quality of care and the experience of patients accessing multiple services. The North Lambeth test project targeted a primary care network (PCN) population, covering six GP practices to create sufficient scale for a series of medical clinics to be undertaken with a multi-agency team.

The project scheduled multidisciplinary team clinics between March and July 2022 to assess patients who had several long term health conditions such as diabetes, heart issues or other issues and who were booked to be seen by several specialist health hospital clinics. Patients were identified from hospital data and included those who needed specialist active care or who were on a waiting list.

Staff attending included a GP, a primary care coordinator and three hospital specialists, who varied dependent on the patients being discussed. From each clinic, a proposed plan and lead clinician was identified who was responsible for linking with the patient and other relevant clinicians, for amending medication, arranging appointments and recommending any additional approach to care.

Our impact

Six clinics were undertaken with 66 patients reviewed. As a result of this more joined up approach, 14 fewer appointments were required by patients, giving them more time to focus on self-management and day-to-day living. We also reduced inappropriate medication use in five patients and completed five new referrals to services including the community matron and psychological therapy.

Additional follow up actions were recommended to be undertaken in primary care.

Our next steps

The Alliance will continue to work with health and care system leaders to improve timely identification of patients with multiple long term health conditions who could benefit from this approach, and to further enable effective communication between clinicians across organisational boundaries. In this way, we will support the continuing development of more personalised services and more effective resource management across the health and care system.

We will continue support the system to provide holistic patient centred approaches to reduce unnecessary patient appointments across and between organisations and support improved collaboration at system level. Additionally, we will continue to explore how we can improve our services locally for our health and care workforce to cope with the increase in demand for health and care services.

Case study: Chronic pain support

Chronic pain is defined as pain that lasts for more than three months. It is the second most common reason for claiming disability benefits, and significantly increases the risk of depression, and sleep disruption. It can lead to social isolation, reduced quality of life and in some cases a reduction in life expectancy.

Chronic pain is the second most common long term condition in Lambeth, where 47% of residents are from Black and multi ethnic backgrounds, 20% live in poverty, and 46% are social care users. We know that ethnic minorities, women, and those from disadvantaged backgrounds are more likely to suffer from chronic pain, with black females in Lambeth having twice the prevalence rate as the general population.

Photo of young black woman grabbing neck in pain

We have invited a small group of residents with chronic pain to help design new care pathways and community services to support those who live with chronic pain to maintain access work and improve or manage their day to day activity independently.

Additionally, we have started a chronic pain register to make it easier for general practice staff in Lambeth to support patients through the development of personalised support plans, medication reviews and annual reviews.