Imperial College Healthcare NHS Trust is working closely with GPs in the community to improve the care of adults with long term conditions. Analysis found that there had been inconsistent referrals, inaccuracies of diagnosis and incorrect management of adults living with chronic obstructive pulmonary disease, chronic kidney disease and heart failure.
Working with GPs, together they reviewed GP registry data to identify patients that needed the most support. Hospital consultants conduct virtual reviews of the patients with GPs and their teams in their practice, to enhance management and facilitate learning.
Over 1,000 patients have now been reviewed. Early results have been impressive and include: 12 per cent of patients avoiding being referred into hospital; a reduction in the use of steroid inhalers by 70 per cent; improved diagnosis and treatment of patients with heart failure by 30 per cent; prevention of acute presentations with end stage kidney disease; and significantly enhanced learning and understanding of GPs around these long term conditions. GP feedback has been extremely positive. The programme is now expanding across the region.