Winner Cornwall & Isles of Scilly Primary Care Trust with Cornwall County Council Department of Adult Social Care

The Pathway to Improving Health andIndependence

In an area with a large population of older persons, high indices of deprivation and long journey times to acute services, an inclusive strategy has seen a former national outlier for unplanned admissions become a whole system demonstrator for long-term conditions.

The judges were particularly praiseworthy of what they described as the immense potential in the partnership approach for promoting and impacting on population health and well-being.

Cornwall’s vision has been to support early diagnosis and the delivery of integrated services with equality of access that promote and maintain self-management and optimise quality of life.

The strategy for health and well being of people with long term conditions, developed in tandem with the joint commissioning strategy for older people, has mainstreamed preventative and predictive initiatives for care, informs intermediate care services and has brought about a system for the delivery of community health and social care services that is responsive and integrated.

Since it began in 2003 the ambitious programme of work has scored a number of considerable achievements – a community matron’s team that contributes to reduced hospital admissions, GP workloads and length of stay; multi-agency rapid assessment teams providing intervention and rehabilitation services; acute care at home teams; a COPD service review with work areas including a nationally recognised pulmonary rehab programme; an all services single point of access.

Following the introduction of these initiatives, from an emergency admissions growth of 9 per cent in 2003/04 the figure has now dropped to negative growth, with an associated 17 per cent reduction in emergency bed days. Local people have taken part in Strategic Review discussions and shown their continued approval of providing more integrated care at home.

Whole system demonstrator status will bring the addition of innovative technology such as biometric testing to support principles of independent living.

Contact - Carol Williams, Director of Service Improvement, Cornwall & Isles of Scilly PCT

Highly Commended Hampshire PCT

Orthopaedic Choice

This joint initiative between primary and secondary care provides a managed care pathway for patients referred with musculoskeletal conditions. It filters, assesses and refers the ‘musculoskeletal’ patient to an appropriate primary care service, and where needed, a “doorway” into Orthopaedics.

Orthopaedic Choice was launched in response to increasingly poor and confusing circumstances for access to diagnosis and treatment – waits for outpatient appointments were running at 18 months and having been seen, 60% were sent for other therapies, or back to their GPs.

The new service ensures fast access to 24 weekly sessions at eleven sites providing expert opinion from: a multi-professional triage team offering clinical assessment; a fit for surgery team; consultant clinics where patients requiring surgery can be listed; pain services and discharge management teams. Routine appointments have a maximum six weeks wait while urgent referrals are seen within two weeks.

Since first opening in 2001 the service has been rolled out to PCTs, acute trusts and independent treatment centres across a wide geographical area and this year is expected to offer over 20,000 appointments.

The quality of service has contributed to the meeting of national waiting times targets and has delivered savings within the health economy.

Judges commended the quality of the implementation of a pathway redesign involving primary and secondary care clinicians that is easily transferable to other long-term conditions.

Dr Sarah Schofield, Clinical Development Lead Orthopaedic Choice,

Highly commended Norfolk PCT


A joint initiative between Norfolk PCT and Health DialogUK, Norfolk Healthline offers a free telephone health coaching service for patients across five targeted long-term conditions - diabetes, asthma, COPD, CHF and CHD.

Based on a whole-person approach supported by predictive modelling the project helps patients to navigate healthcare services and improve their self-care management. This includes working with patients to prepare them for consultations and clinical visits and help them have more realistic expectations.

Norfolk Healthline was commended by the judges for its innovative chronic disease management scheme and drew special attention to the inclusivity of an approach that is also tailored to individual need.

As a complement to conventional services, specially trained registered nurses – Health Coaches - support patients with an identified emerging risk to manage their condition using Shared Decision Making techniques. Patients more actively engaged in managing their care with health professionals can be shown to have improved outcomes.

Health Coaches have been able to reach 8 per cent of the targeted populations, successfully engaging with 82 per cent.

The resulting reductions in hospital admissions within the identified high-risk groups have helped to drive down medical costs within the overall PCT population. Long-term condition patients using Shared Decision Making Techniques are also seeking fewer surgical treatments. High levels of patient and clinician satisfaction with the programme have been reported.

Dr John Sampson, PEC Chair and GP,NorfolkPCT

Sandwell PCT

CVD Risk Project

The majority of GP practices in Sandwell were failing to develop registers to identify and treat patients without CVD but with a greater than 10 per cent risk of CHD events in the next ten years.

The PCT worked initially in six practices, using a 3-stage methodology to identify and offer treatment – pharmacological and/or referral to lifestyle services - to those at most risk.

It is estimated that across Sandwell 260 deaths could be prevented over a 10-year period.

Contact - Mary Fairfield, Choosing health Manager

BirminghamEast andNorth PCT

Partners in Health

With a focus on community collaboration, locally targeted services and an ethos of self-care and health education The Partners in Health Centre provides individualised care to the local population. The Centre hosts a wide array of services and activities, with a strong self-care management message.

Care management programs include cardiac rehab, smoking cessation and pain management sessions. It also runs a number of targeted patient education sessions such as diabetes education sessions in Urdu and English and women only exercise classes.

Contact - Assistant Director for Long Term Conditions, Janine Ginn