A new project to increase collaborative working between hospital and primary care teams in NW London is improving care for many patients with long term conditions according to the new findings from a project run by a team of expert clinicians at Imperial College Healthcare NHS Trust.
The project, Connecting Care for Adults, was launched in September 2017. The team has reviewed the medical notes of more than 500 patients under the care of their GPs for some long term conditions and the project has begun to show the benefits to patients.
The team has 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 patients’ medication will help prevent unnecessary side effects of strong medication, allowing better management of their condition in the community which could mean hospital visits are avoided.
The project is also improving information of specialist conditions among GPs with 87% of those involved in the project saying that it had enhanced their overall knowledge. There is also much for the team to learn from their GP and pharmacy colleagues too. The project aims to encourage sharing of each other’s knowledge and experience to provide care tailored to the needs of each patient.
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, a local GP 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 aims to help further facilitate more commonly supportive relationships between the GPs and specialist hospital clinicians. This is part of the Imperial College Healthcare NHS Trust’s wider strategy to move towards more integrated care which is person-centred, coordinated, and tailored to the needs and preferences of the individual, their carer and family. It means moving away from episodic care to a more holistic approach to health, care and support needs, that puts the needs and experience of patients at the centre of how services are organised and delivered.
GP practices in the Brent will be the next to benefit from this initiative.
Cllr Ketan Sheth is Brent Council’s Chair of the Community and Wellbeing Scrutiny Committee
