Managing long term care sponsored by Sanofi Aventis

The growing number of community matrons working across and covering just about every GP practice in the Cornwall and Isles of Scilly Primary Care trust patch – there are now 39 – is just one indicator of the success of the county’s approach to tackling long-term conditions by putting the emphasis on prevention.

It was as long ago as 2003 that the increase in community services capacity saw the first cohort of 12 community matron posts being piloted, alongside new inter-agency rapid assessment teams of nurses, therapists, social workers and case coordinators.

"Within its fist year the success of this predictive model for identifying patients at risk was starting to reverse the trend for rates in emergency admissions for people with chronic obstructive pulmonary disease and other chronic conditions," says Carol Williams, director of service improvement.

A partnership board for older people followed, responsible for joint commissioning and performance monitoring, and has enabled adult social care and the PCT to increase investment in the integrated service improvement plans. Last year this culminated in the trusts selection as a whole system demonstrator site for telehealth supporting the monitoring of people with long-term conditions at home.

"Now that we have the external validation of the HSJ Award," says Ms Williams, "there is a feeling that we are on a much stronger footing when it comes to negotiating business or making the case for practise based commissioning."

"We have also been able to grow the COPD exercise programme," she continues, "and in the operating plan this year we have secured funding to provide courses across six key areas in the county."

What judges want:

  • Action in response to specific NHS and public service agreement targets
  • Partnership working (such as multi-disciplinary, patient involvement, public-private sector or working with local government)
  • Good use of information
  • Effective working across the primary and secondary care interface to reduce emergency admissions
  • An imaginative approach to new staff roles and workforce planning
  • Evidence of action which reflects the Choosing Health white paper

Acute and primary care innovation sponsored by BT

When you have put a lot of time and effort turning an idea or a vision into a working project that responds to an unmet need, is starting to achieve excellent outcomes and makes patients feel cared for where they didn’t before, you want people to know about it.

For the team at Bradford and Airedale Teaching Primary Care trust who devised and helped deliver the self-injury service one very direct way of doing that was to enter the HSJ awards 2007.

"As with the planning and forethought you put into the service itself, the opportunities the awards provide make this worth spending time over," says Gillian Proctor, clinical psychologist. "You want to read the criteria closely, be sure what it is you are being asked to demonstrate and allow yourself plenty of time to prepare your final submission."

The trouble the Bradford team took to clearly explain their groundbreaking work paid dividends. They were winners of last year’s Primary Care Innovation award with a service the judges described as a “trailblazer”. Their work was also highly commended by the Secretary of State, whose award is open only to the very best of the category winners.

"There is something very special and very motivating about getting that level of recognition, both at a prestigious national event and from such eminent judges," says Dr Proctor. "Just being short-listed was good news and an ideal opportunity to reward the dedication and belief of a lot of people – from executives to frontline clinical staff – with a fantastic and what turned into a very celebratory night out."

What judges want:

  • Excellence in implementation of policy and guidance
  • Improved patient outcomes and services
  • Improved access: not only reduced waiting times, but also access to appropriate therapies and practitioners
  • Improvements in the health of part of the local population, such as by targeting those with the greatest health needs
  • working in meeting public service agreement targets