Lisa Smith
Practice Nurse Manager
St Peters Street Medical Practice
The Challenge
Patients with multiple Long-Term Conditions (LTCs) often struggle to attend annual reviews and the clinical focus can lead to duplication of work while leaving other needs unmet.
reduction in total GP demand estimated from the improved LTC reviews process
The Innovation
Lisa set up a system of personalised multimorbidity reviews, consolidating all LTCs into one appointment.
She set up a triage process to provide longer reviews for patients with poor control or greater risk and shorter appointments for well-managed patients.
She also utilised new roles, such as care coordination and social prescribing, to tailor support, address underlying needs and reduce GP workload.
The Impact
- Practitioner: Lisa is continuing to develop in her role and seniority while rolling out this model across other PCNs.
- Patients: 44% increase in patients attending reviews, fewer appointments, enhanced self-management and improved health outcomes.
- System: 2% reduction (856 hours annually) in total GP demand estimated along with reduced duplication of work like blood tests.
