WIREDGOV

The first 12 month report into three demonstration areas – Carmarthenshire, Cardiff and North Wales – set up to try out and test new ways of managing care for people with chronic conditions, identified major benefits to patient care.

The aim is to ensure that individuals living with chronic conditions such as arthritis, chronic obstructive pulmonary disease, diabetes and chronic heart conditions can access the right service, at the right time, in the right place and delivered by the right person.

In Carmarthenshire, emergency medical admissions have been reduced by almost 40 per cent for chronic bronchitis or emphysema, 30 per cent for heart failure, and 10 per cent for diabetes as part of their wider programme of improvements.  

Mrs Hart said that the approach of health, social services, voluntary and third sector, working much closer together and providing more support to allow patients to receive help closer to home is a model that will need to be replicated in other parts of the new NHS as the new structure will encourage greater collaboration between organisations.

The report into the delivery of the Chronic Conditions Management Model found:

• Better integrated care is evident, with better communication between organisations with responsibility for caring for patients;
• Patients have identified feeling more confident and engaged in making decisions about their care and services they would like to receive;
• Consultants have been involved in reviewing the management of complex cases with other professionals, such as GPs, specialist nurses or physiotherapists; and
• Development of better training and support for staff caring for people with chronic conditions.

Mrs Hart said:

“The report outlines improvements in care for patients with chronic conditions following a demonstration programme set up last year.

“The report charts the progress of the three national demonstrator sites to explore how staff can work across organisational and professional boundaries to improve services for people living with chronic conditions and those at risk of developing a chronic condition in future.  

“The way in which some services to patients most in need of care and support has already started to change and already delivering major improvements in care and reducing pressure on services.

“The results are impressive. In Carmarthenshire, for example, emergency medical admissions have been significantly reduced as part of their wider programme of improvements.  

“In North Wales, GPs, community nurses and social services staff have been brought together at a local level.  These teams have been able to improve the way in which care is planned and delivered for individuals.  

“The project in North Wales has also been working to help people better understand how their medicines work and offering new services in community pharmacies such as smoking cessation, weight loss programmes and blood pressure monitoring.

“The first phase of the project in Cardiff has focussed on services for people who have epilepsy and diabetes. The demonstrator has brought together a team of health and social care professionals to help bring about changes, which are having a practical and positive impact on the experiences of people living with chronic conditions. The project is also looking at how services can be designed to meet the needs of all of the diverse population groups who live in Cardiff.

“The successful work undertaken in joining up health and social care services in the demonstrator sites exemplifies the kind of joined-up working between agencies resulting in benefits to patients that should, in time, become standard in the new NHS structure.

“I look forward to seeing the lessons and learning from the demonstrators taken up across Wales as part of our All Wales programme to drive service improvements so that all patients living with chronic conditions can benefit from these new ways of working.”

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NHS Wales

Some 3 million people live in Wales and use the services of the NHS.