Over a quarter of the population of England have a long-term condition – including asthma, diabetes or depression – and an increasing number of these have multiple conditions. Research shows that people with long-term conditions use a significant proportion of health care services – 50% of all GP appointments and 70% of days spent in hospital beds.

The NHS has been working hard in recent years to reduce avoidable hospital admissions. This both improves patients’ quality of life and reduces pressure on beds.  People who live with a long-term condition need support to be as independent and healthy as possible, so preventing complications and the need to be admitted to hospital. 

At East Barnwell Health Centre in Cambridge the team recognised a rising trend in long-term conditions and co-morbidities in younger patients – plus these individuals were lacking support from the established care services that are available locally to the over-65s, such as the community matron.

Debbie Parsons, practice manager at East Barnwell, explains,

“We felt that we could make an impact on avoidable admissions by offering more support and advice to patients with long-term conditions, particularly adults under 65, but we recognised that we didn’t have the resource to tackle this. We are very grateful to the Evelyn Trust for the funding we secured early in 2015 for a long-term conditions nurse to work at our practice on a pilot scheme.”

Jo Baines, East Barnwell’s dedicated long-term conditions nurse, now works with patients three days each week, offering medical checks, advice on medication, signposting and support for healthier lifestyles. One of the keys to Jo’s success has been that she offers longer appointments to give people the opportunity to discuss concerns in detail and improve their understanding of their illness. Jo is an experienced nurse practitioner with expertise in long-term conditions, including diabetes and COPD – Chronic Obstructive Pulmonary Disorder.

An interim evaluation of Jo’s work in Summer 2015 showed that she had already made a real difference to a range of patients, particularly those with multiple conditions who are facing other challenges to their health such as low incomes, unemployment or poor housing. East Barnwell is part of Abbey Ward, a district of Cambridge with a diverse population and a relatively high number of people suffering from poverty or disadvantage.

“We’re very hopeful that, at the end of the pilot, the data will show an improvement in the patients' understanding of their conditions, better symptom control and reduction in complications, and so fewer avoidable admissions. Our objective is to demonstrate a lower level of admissions, combined with improved patient outcomes, so our one-year project can secure mainstream NHS funding and continue to support the people of East Barnwell,” adds Debbie.

www.eastbarnwellhealthcentre.co.uk