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.
2%
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.
44%
increase in patients attending reviews
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 leading to 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.
