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Improving health care pathways for patients with chronic conditions

Posted on April 5th 2018

PenCLAHRC Senior Research Fellow, Dr Helen Lloyd, has spoken to the BBC about the impacts of a new health care system on GP services in south Somerset.

Rising patient numbers, and the number of patients with multiple chronic health needs, places significant pressure on existing healthcare resources.

The Taunton Deane Symphony Service aims to develop more efficient ways of providing care for people with multiple long-term conditions who frequently visit their GP. It considers what individuals would like to happen with regards to their future care, and works with patients to develop care packages to help health providers better meet those needs. In doing so, the project has encouraged patients to use medical services more appropriately, and to find other sources of support when necessary.

The service has recruited wellbeing advisors from the community to help people with long-term issues develop their own personalised health care support plan. Patients are encouraged to take their personal plan to all GP and hospital appointments, to help health and care providers to meet their individual needs.

This has been shown to help patients to better understand their conditions, the medications they’re taking, and how to effectively self-manage them. It also teaches them to acknowledge the physical, psychological and social impacts their conditions have upon their life, and what they can do to minimise them.

In conversation with Claire Carter at BBC Somerset, Helen suggests that:

“Older people who are isolated may be going to their GP for a problem that is around isolation. That might be driving some of the physical symptoms that they present, but in actual fact the root cause can be dealt with by a more socially orientated intervention.”

The personal care plan helps to address such issues, encouraging patients to consider the root cause of their symptoms and to seek the appropriate support.

Helen and her team have been working with the Symphony project since 2015, collecting data from patients and health care staff in order to measure the impact the new model has had on services.  In many cases, unnecessary patient contact with GP services has been reduced. Over six months, the first 60 patients to benefit reduced their contact with their GP by more than 60 % and contact with the local nurse by nearly 50%. One participant reported 29 fewer exchanges with medical staff.

Helen suggests that this is due to the service’s more holistic and patient-inclusive approach to health care provision:

“If you feel like you matter, and you’re being worked with as a partner in care, then you’re more likely to be engaged, want to help and be supported to look after your own health and wellbeing.”

You can listen to Helen discussing the project on BBC Somerset here, and being interviewed for BBC Spotlight here.

For more information about the Person-Centred Coordinated Care project, of which this forms a part, visit the webpage.

The Taunton Deane Symphony Service is a joint venture between Taunton Deane GP Federation, Somerset Partnership NHS Foundation Trust and Taunton and Somerset NHS Foundation Trust.