New evidence proves collaborative working is improving care for patients with long term conditions

A new partnership project between hospitals and GP practices in north west London is already helping to improve care for many patients with long term conditions, evidence shows.

The project, Connecting care for adults, launched in September 2017. The medical notes of more than 500 patients under the care of their GP for a long term condition have been reviewed by hospital experts from Imperial College Healthcare NHS Trust.

It was found that, in more than half of the cases of patients with lung problems, strong steroid medication could be reduced or stopped altogether. For patients with chronic kidney disease, it was possible to reduce the amount of different medication each patient was taking. 

It is hoped that a reduction in their medication will help prevent unnecessary side effects of strong medication, allowing better management of the patient’s condition in the community, preventing unnecessary hospital visits. 87 per cent of GPs involved in the project said that it had improved their overall knowledge of the specialist conditions.

Connecting care for adults is initially focusing on patients with chronic kidney disease, lung disease (chronic obstructive pulmonary disease and asthma) and heart failure. The project involves specialist clinicians the Trust going out to local GP practices to provide practical support in three key areas:

  • case reviews
  • patient self-management
  • education and training

Professor Jeremy Levy, consultant nephrologist at Imperial College Healthcare NHS Trust, said: "Taking part in this programme has been an amazing experience; as hospital consultants we are definitely not fully aware of the challenges facing GPs, and I have learned huge amounts which will improve my interactions both with GPs and patients. It has become one of the highlights of my week."

Dr Yasmin Razak, GP principal at Goldborne Medical Centre, said: “By putting our heads together for a population health approach to managing our patients, the reviews promoted better partnership between generalists and specialists. It optimised and actually reduced extraneous activity cutting our workload. 

“The practical learning gems gleaned from discussions are being used time and time again in consults, increasing my confidence and capability in managing complexity.”

The project, supported with funding from Health Education England, aims to help forge and consolidate mutually supportive clinical relationships. It is part of a wider strategy to move towards more integrated care which puts the individual at the centre of their management of their condition, irrespective of the care provider.

The Connecting care for adults team have been shortlisted for Education Team of the Year at this year’s BMJ awards. The winner will be announced on 10 May 2018.

The Connecting care for adults team will be organising events and sharing news throughout the project’s lifetime. Email to find out how you can get involved.