• Run by First Contact Clinical, in partnership with NHS South Tyneside Clinical Commissioning Group
  • Aimed to encourage self-care and improve quality of life for people in South Tyneside with long-term conditions
  • Redesigned primary care long-term condition management, incorporating psycho-social interventions for those patients who needed the most support to achieve self-care and had the most to gain from it
  • The project ran from January 2017 to April 2018

This project from the social enterprise First Contact Clinical was designed to improve quality of life for people in South Tyneside living with a long-term condition, by helping them to self-care.

People with chronic obstructive pulmonary disease entered the project as part of their long-term condition review or following a new diagnosis in primary care. Their ‘Patient Activation Measure’ (PAM) score, which indicates their ability to self-care, was used to determine which people needed the most support to achieve self-care and who had the most to gain from it.

Patients were offered psycho-social interventions in a stepped care approach, ensuring those with the lowest PAM scores were offered the most intensive intervention. These ranged from sessions with a trainee health psychologist or psycho-social practitioner to receiving information from a social prescribing navigator or attending a community-based mutual aid group.

The project recruited 410 patients across two GP practices and achieved its aim of increasing PAM scores overall for those with the lowest initial ratings. The latest data analysis shows a 24% reduction in unplanned appointments for the people who engaged with the team.

This successful implementation was strongly influenced by the enthusiasm of practice teams to change care pathways and resulted in positive and motivating feedback from patients.

The project team is now measuring the impact on secondary care in order to obtain mainstream funding to extend the intervention to all patients in the borough with long-term conditions. Funding has already been secured for expansion into a further three GP practices and to patients recently diagnosed with diabetes.

Contact information

For more information about this project, please contact Susan Gill, Director of Operations, First Contact Clinical.

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