Supported by Sanofi-Aventis


  • David Pink, chief executive, Long-Term Medical Conditions Alliance
  • Dr Mashkur Khan, consultant, Epsom and St Helier trust
  • Carole Nossiter, assistant director, policy and development, Sanofi-Aventis

Winner South Sefton PCT

The judges praised the project for its robustness and positive vision, building clinical leadership in primary care for the management of long-term conditions as the patients want it and in line with national policy

The South Sefton clinical champion team model was established in 2003 as a means of empowering clinicians to lead change, redesigning care pathways for the community setting in line with national service framework and National Institute for Health and Clinical Excellence guidance. The model offered the further benefits of improved collaboration with secondary care colleagues and increased engagement with service users.

A multi-directorate team of senior managers supported the development of GPs with an interest in diabetes, coronary heart disease and chronic obstructive pulmonary disease through leadership training, co-opted specialist nurses and secondary care professionals, backfill for weekly team sessions.

The clinical champion team leads the delivery of the local development plan in its clinical area through service re-designs across the whole system. They are also charged with producing investment proposals for monies identified in the LDP for the professional executive commitee to consider.

Managers are pleased with the increased levels of confidence and credibility the scheme has earned from secondary care. On the clinical side there is early evidence of practices embracing quality initiatives beyond the quality outcomes framework and addressing inequality through improved access and the targeting of marginalised groups.

All three specialties have raised standards of care by devising new system pathways, staff roles and referral protocols. New services include: palliative care guidelines for heart failure and end-stage COPD patients; a nursing home diabetes training programme and a heart failure diagnostic and treatment optimisation service. The 'joined-up' model represents a change in approach to diseases traditionally managed in hospital but experienced by patients in the community.

GP clinical champions for diabetes, CH and COPD, contact

Highly commended Walsall teaching PCT

It originates from the Local Implementation Team in 2003, itself formed following the publication of the national service framework for diabetes.

Prevalence of diabetes in Walsall is higher than the national average and the figure is set to rise steeply by 2010. The borough also has significant numbers of smokers, people with poor diet and exercise regimes, obesity. There are also low levels of educational attainment, pockets of high ethnic minority population and a wider background of social deprivation.

Emulating the approach taken in the NSF for coronary heart disease the overall aim is to respond to demand 'doing the important, simple things, right, all of the time'.

Some of the key objectives in the strategy include improved glucose, blood pressure and cholesterol monitoring, practice-based pharmacists to improve prescribing and new roles such as a specialist diabetes nurse. The Local Implementation Team helped practises with direct support, facilitated training and education.

A successful pilot scheme in a small number of practices was extended across the borough. Performance is measured against agreed objectives using prescribing data, run charts and other monitoring systems.

Improvements have been achieved in all QOF diabetes indicators. Prescribing performance has seen a sustained improvement across a range of drugs. More patients are now on disease registers and accessing systematic care. The approach is also demonstrating its ability to tackle health inequalities, with the greatest improvements achieved in areas of high deprivation and ethnic minority populations.

Diabetes: doing the important simple things right, contact

Finalist North East Lincolnshire PCT

Psychological barriers to exercise exist for people who suffer or fear shortness of breath but in this project, expert patients help overcome those anxieties and establish pulmonary rehabilitation as an important feature in the management of a long-term condition

Working alongside the COPD clinical co-ordinator at community-based services, 'buddies' offer peer support and motivation, assist with exercises and lead some of the educational activities.

Dramatic physical and psychological improvements have been recorded using standardised assessment tools. The PCT uses the project as an example of best practice that could be replicated across the country.

Pulmonary rehabilitation buddies, contact

Finalist Exeter PCT

This whole-systems model has changed the way patients with long-term conditions and complex needs are cared for in the community and reflects the desire of service users, carers, and public sector providers to create a sustainable multi-disciplinary approach

Joint training has fostered close working relationships and joined-up support to individual patients. Process mapping has improved co-ordination while the use of the single assessment process supports planning.

The new care culture has shown improvements in quality of life indicators and reduced emergency hospital admissions. A domiciliary pharmacist service has simplified medicine regimes and improved compliance. The option of keeping records at home is highly valued by patients and carers.

Whole-systems model, contact

Finalist Peterborough and Stamford Hospitals Foundation Trust

This glaucoma screening service has been set up as part of the DoH's chronic eye disease pilot scheme and allows greater flexibility to those patients transferred by the ophthalmology department

Hospital doctors train community optometrists across a range of glaucoma management skills, both theoretical and practical. The nursing and orthoptic departments help with training in intraocular pressures measurements. Pilot evaluation includes internal audit, and patient and optometrist satisfaction questionnaires.

Waiting times for first assessment have been reduced from eight to 10 months to as little as two weeks. The community optometrists have seen over 900 patients.

Community specialist optometrists in glaucoma, contact jason.hill