Alex Kent
Hi, my name’s Alex Kent. I’m medical director for North East and North Cumbria ICB and I cover long term conditions as part of my portfolio. I also work part time as a GP in North Tyneside.
I’m joined today by Dr James Crick, who is the clinical director for East Riding and Hull at Humber and North Yorkshire ICB; Barry Todd, who is a clinical champion for Health Innovation North East and North Cumbria for cardiovascular disease prevention and primary care; and Dr Indira Kasibhalta, who is clinical director at Dewsbury and Thornhill Primary Care Network for Kirklees, place lead for chronic kidney disease project.
So today we are going to be talking about managing long term health conditions within primary care. And in this episode, we are looking to explore new ways of working that enable patients living with long term conditions to get the health care that they need. So these conditions range from cardiovascular disease and chronic liver disease to diabetes, dementia, frailty and respiratory conditions such as asthma and COPD.
Cardiovascular kidney metabolic disease is a term which basically describes where heart disease, kidney disease, diabetes and obesity co-exist and can exacerbate one another. It’s rising in quite alarming rates in the UK and is imposing a major burden on NHS and it is costing the UK economy quite significant amounts of money, as well as having a huge impact on the lives of patients living with these conditions.
So in the UK, chronic kidney disease alone affects 7.2 million people. Diabetes 6,000,000 and cardiovascular disease 7.2 million. And this costs the NHS 6.4 billion, 10 billion and 7.4 billion respectively. So we’re spending huge amounts of money on supporting people with these conditions and actually what we want to do is make sure that we can where possible prevent these conditions and certainly manage them optimally to try to give patients the best quality of life possible.
So in this episode, we’re going to be exploring exactly what’s meant by long term conditions. Some of the initiatives that are making it easier for people to get specific care and how to manage their health in primary care.
So first of all, let’s go right back to basics and could I ask somebody to explain to our audience what we mean by long term health conditions, please? James.
James Crick
Thanks, Alex. I suppose, I mean there’s probably a whole series of definitions, but if I’m thinking about how am I trying to explain this to a patient, for me it’s a condition that once that disease process starts is likely to remain for the rest of that person’s life. And it’s going to have an impact on both quality of life and on quantity of life. And I guess if you think about in those terms, that’s why we need to do what we can to either prevent it occurring in the first place, or once a disease has started, how we can manage it to reduce the chance of it getting worse over the course of that person’s life?
Alex Kent
Thank you. And that that prevention aspect is key, isn’t it? Barry, did you want to come in on that?
Barry Todd
Yeah, I think what James is saying is very important in that one of the challenges in primary care is that we manage our patients well and part of the problem is that good outcomes rely on early intervention, good medicines optimisation and other measures. And if we don’t get that right, then the impact on the patient can be quite significant. The patient’s family and carers and also on the NHS economy.
Bad management versus good management. It can be a wide gap.
Alex Kent
Absolutely. So the starting point for managing any of these conditions is, first of all diagnosing them so would anybody like to sort of talk about how we can help to support the initial diagnosis – Indira?
Indira Kasibhatla
I would say as part of NHS England’s five year forward view, which has concentrated heavily on long term conditions where living well project concentrates on a lot of long-term conditions where – which wasn’t there 10 years ago, is working together.
Pharmacies have started doing hypertension opportunistic identification then councils across various areas have started doing opportunistic NHS health checks, where patients can just walk in to get their health checks done and then in general practice as well, it’s been heavily promoted to have health checks to be done on a regular basis and opportunistic checks as well. Whereas coming to it with my primary care network hat on, we have conducted lots of workshops which actually promote health and also create many more opportunities to identify long term conditions.
Alex Kent
Thank you. So I suppose with all of these new kind of points of access, these new places where people can get care, the challenge is now becoming actually how do we tie all of this together to actually make sure that regardless of which access point a patient hits, we manage that patient holistically and bring in the relevant people at the right times. James, would you like to come in?
James Crick
Yeah. Thanks, Alex. And I think Indira, you’re absolutely right that if I think back to my early days of being a GP, 20 odd years ago now, general practice did everything and we talked about primary care, but what we meant was general practice. I think now when we talk about primary care, we need to be thinking about the much broader primary care family and recognise the value and I think we do recognise the value and bring our skilled colleagues in community pharmacy into the conversations.
I know we’ve had, certainly my bit of the world, we’ve been doing some work with optometrists and dentists in identification of hypertension. And so there is something about, I guess, moving away from what the old world was to what the new world’s going to become, in particular relation to whatever the neighbourhood health service model looks like and how we create a truly integrated approach that makes it easy for people to access.
Alex Kent
Yeah, and I suppose actually it makes sense. You know, people are being seen, let’s make that contact count. And actually, let’s think, you know, if you are an optician and you’re looking at somebody’s eyes and you can see evidence of hypertension and they’ve not got a diagnosis, it would make sense to be able to take their blood pressure, wouldn’t they? Is that the sort of initiative that you’ve got running at the moment?
James Crick
So there’s a few things that that we’ve got going on. There’s the, the kind of opportunistic identification as you describe as of kind of the consequences sort of the damage that unmanaged undiagnosed and unmanaged high blood pressure can bring. That’s a bit late to be honest.
We probably – it’s great that we identify those people, but actually we want to be identifying people much earlier in their life, so that it doesn’t get to the point where there’s evidence of that kind of end organ damage that – any damage to the eyes so we’ve also got some, a lot of community based work – community workers supporting people in public sector settings.
So libraries, in supermarkets with blood pressure stations with a clear protocol about what to do depending on your results and as you said, part of the challenge in all of this is making the diagnosis and if we don’t have a system that allows people to make it or to be allowed to make a diagnosis or receive a diagnosis, it’s really difficult for them to then receive the kind of gold standard care that we want them to receive.
So there’s almost a whole life course approaching all this from the primary prevention opportunities that are… that we need to signpost to, that our local authority colleagues deliver through their public health services, through to, as Indira said, the risk stratification. So the identification of people at risk of heart disease and early identification of heart disease. So diagnosing people as early as we can, so that we can then get them on to the appropriate treatment – if we’re using heart disease as an example, get them on to the appropriate treatment, to reduce the risk of things getting any worse and to maximise the period of life that they’ve lived in good health.
Alex Kent
And so what sort of tools have you got for that risk stratification? Are these being used in the real world, is there evidence that these are working and that they’re helping people?
James Crick
I think if you’re talking specifically about cardiovascular risk, Q risks been out there, continues to be out there and is being updated almost annually at the minute and is a fundamental part of the NHS health check.
There are challenges with the NHS Health check in that how do we reach the people who we need to reach – often the people who come forward and not necessarily the ones that we consider to be a greatest risk and then that falls into the whole conversation around ‘how do we maximise access for our core 20 plus populations, our deprived and marginalised, our excluded groups, our inclusion health groups who we know experience poorer outcomes’, particularly from again using heart disease or cardiometabolic disease, as an example, rather than continue to achieve better outcomes for our more affluent communities, our less deprived communities – we can’t leave anybody behind.
Alex Kent
This is the challenge, isn’t it? Often the people who you really would like to come forward, don’t come forward, and I suppose it’s actually thinking about different approaches to deliver healthcare. Barry, have you got any thoughts on that?
Barry Todd
I think first of all, we’ve got to get away from the idea of silo working and being sort of swimming around in our own goldfish bowls. There’s an ocean out there, we should all be swimming together in it. So, I thoroughly agree with what James is saying. I think we need to utilise community pharmacy because it is that point- most people are on at least one prescription – will utilise their community pharmacy and that is a real key area to concentrate on first.
My personal experience is that when I was working in practice with hypertension, we ran out of blood pressure machines to enter patients to do the seven-day blood pressure checks by community pharmacists – actually was offering ambulatory blood pressure checks and that was really good – needs to be careful with interpretation. But I could go to them and say, look, we’re swamped out here, can you help us?
We need to strength our links with community pharmacy – community pharmacy in my opinion it doesn’t advertise itself as well as it could. You know, the whole Pharmacy First agenda and as you say, James, if we could be doing NHS health checks within community pharmacy for instance, that’s not beyond our ken I don’t think. Other things that we’ve done as Health Innovation North East, we’ve had buses going out and offering the health checks into communities. A roving bus, so various communities, but we’ll have specifically gone to ethnic minority groups in mosques and in churches, and that has really made a big impact.
People who wouldn’t normally engage particularly well, were really, you know, were flying with it. So there are ways of doing it, but are you aware of what each other’s doing? Are we aware of what our local authorities are doing and so on and so forth? We need to have that big picture and work together.
Alex Kent
I think that’s absolutely it, isn’t it? And I suppose actually, if we’re working within a system and we’re not sure exactly what’s happening, then how can we expect patients to know? So I suppose it’s about making that offer really, really clear. So that actually, you know, it’s advertised and people know that there’s a need to come forward and actually where they can, where they can present. Indira, did you want to come in?
Indira Kasibhatla
Yes, regarding the risk stratification of these individuals, who could be at risk comes into picture only when they have got diagnosed conditions on electronic system. There’s new system on like the electronic systems we use, have got a place where we could identify high risk individuals by EFI2 coding, it’s a coding which we can use through our electronic systems. And this identifies people with multiple long term conditions like they have got asthma, they’ve got diabetes and they’ve got any other long term condition and then they it puts them at a higher risk where practices have got facility to identify them and give more attention to them.
But main problem is, as Barry pointed out, with deprived communities I work in one and it’s so difficult to engage them with health service. In places where the more affluent areas, you could get patient to come for their health check with one text message, whereas it needs a lot of time investment from practices on deprived areas like we probably wouldn’t get any response to text messages. So we call them, using our admin staff and then when we call them, book an appointment – then there is no guarantee they’ll turn up for that appointment. So there’s a lot of educational aspects. Investment need to go into educational aspect in perhaps, maybe as Barry suggested, into places of worship, libraries and community communal areas where you expect more crowd to gather.
Alex Kent
Yes, I think actually, you know we’ve discussed a number of initiatives here where we are actually going out into the community as opposed to waiting for the community to come to us, which definitely sounds like it’s the right way to work going forwards. James, did you want to come back in on that?
James Crick
Yes thanks, Alex and Indira, yes I agree you’re absolutely right, it sounds like we’re all probably working in relatively deprived communities actually then from a clinical perspective I mean, I think one of the things I suppose if I put my public health hat on, one of my concerns is not the people who are on the register, but actually the people who aren’t – the people who don’t access our services. And I guess that kind of speaks to your point of if you think back to how we’ve previously tried to maximise a health offer to deprived communities.
If we use vaccination as an example, there was a period not that long ago where we asked people to come in to be vaccinated and then there was a cohort, a group of people who we really struggled to engage with. So we took the vaccine to them and actually I think it’s the same with almost every other health intervention that we’re thinking about now, that we have a core offer that is always available, it’s always been available that people come to, but that then provides some capacity or some space, some time to be able to take the service out to the people who can’t, who won’t, who don’t for whatever reason.
And there’s something about better understanding what those barriers to access are. I mean, we talk about it from a, we just need to deliver this service – well, we absolutely do, and as a jobbing GP, it’s really easy to fall into the trap of just thinking, ‘well, they haven’t come forward and therefore it’s fine.’ But actually how do we engage critically with that understanding? Why haven’t people come forward? What do we need to do differently? Is this something about the way we configure our services or the way we arrange things? Or actually is this something different? Is this about working with the community to build up trust and understanding of a condition, whether it’s diabetes, cardiovascular disease, chronic renal disease, where does it all sit? But actually how do we move, how do we kind of shift the population’s thinking and our thinking as the deliverers of the service?
Alex Kent
Yeah, and I suppose actually some of the some of the ways in which funding streams work actually don’t incentivise that because you know it’s based on getting a percentage of your practice population through the doors. It’s not about getting that really key cohort through the door, say where you know that you’ve got a met need. You know that there’s pathology, but you, you know you haven’t been able to make that diagnosis because you’ve not seen them for 10 years. And is there anything that anyone has been working on to try to tackle that?
Barry Todd
I just wanted to sort of come in with what Indira was saying about – the thing is communication and AccuRX and similar pieces of software are excellent, but I think we over-rely on them, so we send an AccuRX message, there’s no response, why is there no response? Because the patient doesn’t understand English, perhaps t the patient doesn’t have the technology to be able to respond to that – maybe more elderly population -so we really do need to, you know, follow up, follow up and follow up. So follow up with a letter, follow up with a phone call and make every effort. And I think the problem is in primary care, have we got the time to do that or are we just ticking boxes?
Alex Kent
Thank you. And yeah, and AccuRX – is that a text messaging system?
Barry Todd
That’s right, yes. I don’t know what you have on SystemOne there, Alex, but probably something similar.
Alex Kent
Brilliant. OK. So, yeah, are there any other examples of that?
Indira Kasibhatla
Basically, what we do need to do because in our community there are several, we talked about the holistic care and how to kind of join up all these people having their reviews done at different places, which is mainly to identify these patients. There is a IT system where it pulls reports across from various resources and puts them under one heading called case finders. What that means is, let you take me as an example, I probably went into hospital a few years ago or last year, had some bloods done, and those bloods are abnormal and I could be diabetic. And that says to you, well, this patient could be diabetic. Do you want to have a look into their record?
So we invested as a primary care network into this piece with case finders last year, with additional funding, which we had some potlift in our primary care network, and looked into all those patients, in the population of 42K in deprived area of mine and looked into all those patients who could have long term condition and allocated them after reviewing the records into either have got that condition or not got that condition. As a consequence, they all got opportunity to participate in health checks and had an opportunity to look after their own health and they’ve been made aware they’ve got this condition.
Alex Kent
And I think actually more and more that is becoming the future. We’ve got so much data in the system that actually you know we’ve got the genomic screening projects, but actually even with what we’ve got at the moment, we can make a pretty good guess about people’s risk level and do much more targeted approaches to detection and prevention there can’t we. James?
James Crick
Exactly. Yeah, I think we’ve kind of got three things that we’re broadly looking at in the Humber and North Yorkshire footprint. So we recognise that we’ve got some real challenges, particularly in relation to cardiovascular disease, but actually almost certainly in relation to diabetes, obesity and renal disease, particularly in our coastal and port communities, and trying to understand why people don’t take up the health check offer, why we struggle to achieve the treatment targets that the NHS England have previously set out and what the evidence based targets that NICE provides. And so we’ve got some behavioural insights work being undertaken.
So, working with our voluntary community sector organisations to work with communities, to better understand what those barriers and drivers into services might be. So, I think there’s something about in our bit of the world trying to understand what the problem is, why we think it’s a great idea, but it’s just not being taken up. So, this kind of that aspect and the other two things, I think we’re certainly starting to look at off the back of the last couple of months have been the – we have our local pharmaceutical committees.
So, the representatives of our community pharmacy providers as part of our CVD prevention network and we’re working with them on potential opportunities that the new community pharmacy contract that NHS England has negotiated might bring and the flip side of that is the general practice contract and the incredible focus that’s being given now to cardiovascular disease and cardiovascular disease prevention and how we can, how we can support practices and PCNs to I guess achieve those targets because they’re the right thing to do, but in a way that reflects the new skill mix in practices, so it doesn’t have to be a GP doing this, it could be a clinical pharmacist, it could be a nurse practitioner, it might be a healthcare assistant doing some of the monitoring side of things.
We’ve got some toolkits that one of our clinical leads has developed to try to – using high blood pressure as an example – to try to reduce the number of appointments needed to titrate somebody to target so that we’re getting a patient – a person – better-protected in a shorter space of time without having a massive impact or having a slightly smaller impact on the practice.
Alex Kent
And actually that’s important for the patient because I suppose every appointment has a risk that they’ll, they’ll forget it, they’ll be ill or something will come up and so once you, you know, once you’re out of the system, it’s harder to get back into it, isn’t it? So actually getting there quicker has advantages for practices and for patients. So just you mentioned there the changes to the GP contract, what sort of changes have we seen in the GP contract?
James Crick
Specifically in relation to cardiovascular disease, which I have to say is kind of a bit that I’m interested and excited about, it’s the much greater focus on cardiovascular disease prevention within the quality and outcomes framework, which is part of how practices are funded. And an increase in the thresholds to the maximum achievement that the practices need to get to.
If I use an example, in previous years you might have said, or the target might have been 70%, so 7 out of 10 patients with high blood pressure are needed to be treated to target. That leaves three out of 10 who aren’t, and the chances are those 3 out of 10 are probably from our inclusion health groups, or our core 20 population— our 20% most deprived nationally – and they may also feature in the group who don’t achieve the diabetes target who also don’t achieve any targets around chronic kidney disease.
So by moving that target up, hopefully we’re reducing the proportion of the population, the number of people who are not going to reach that target and maybe even create a bit of space and capacity to think about how we, how we might reach those groups. Again, coming back to the point about how do we take this out to the people who don’t access services, acknowledging that it’s just not incentivised in that way at the minute – that doesn’t mean it won’t in the future.
Alex Kent
So those targets are quite stretching for practices, aren’t they? Do you think we’ll make it?
James Crick
I’m positive. I mean, I think there, there is always something about, from my point of view in the Humber and North Yorkshire footprint, it’s about working with practices to understand what they’re doing well and what their gap, what their challenges and their barriers are. You know, we recognise that the challenges that coastal and port communities bring that that Chris Whitty described back in 2021 in relation to workforce and recruitment. But we’re not seeing lower levels of quality in those communities, those coastal communities. We’re seeing high levels of quality. So those practices, those communities are using their skill mix differently. We need to capitalise on that.
Alex Kent
And you know, for any of the panel today, what sort of advice would you have for practices who are now thinking actually our last year’s results did not get us up to those thresholds? What can we do differently? Barry:
Barry Todd
So I think we need to be using all the intelligence that’s available to us. So CVD Prevent is a series of indicators or measures by which we can see how each practice is doing, or each primary care network is doing, that does provide a big incentive but could be a bit of an eye opener as to what we need to do.
We also need to – it’s the beginning of the financial year, we need to get in early in order to achieve the targets by the end of the financial year. You can’t just achieve those targets overnight, but the earlier you make a start, the better. And also, as James has alluded to, we need to use, we need to upskill our non-medical clinical staff in order to manage these patients. To have confidence in them and to actually encourage their growth in terms of what they can do and to trust them to be able to do it well and my experience has been if you can do that, you actually promote a sense of ownership, a sense of excitement and enthusiasm within the practice to achieve those targets and do the best they possibly can for the patient because it’s the patient at the end of the day that really does matter.
Alex Kent
Absolutely, James, any other thoughts?
James Crick
Yes, thank you. I agree with Barry around that kind of data-driven approach. And I guess in my bit of the world the clinical leads that work with me are already using data packs to go back out using CVD Prevent which is a great tool that NHS England, have published online. It’s a little bit out of date, the data’s the start of a conversation and it doesn’t have to be perfect, it just it’s a start of a discussion. So they’re not waiting to be contacted about how we’re going to do this. We’re actively going out to try and support practices and primary care networks to have those conversations and make the offer to support them as best we can. So, we think it’s really important.
Alex Kent
And just a sort of final kind of question, I think we’ve talked about some really great initiatives and some changes to the contract that you know will help to support to improve our outcomes around CVD, cardiovascular disease. Is there going to be an impact on practice though, because I think you know there are workforce challenges, people are all working very, very hard. Actually have we got the capacity to do this? James.
James Crick
I think it’s a really important question and there was something in in one of the medical journals a couple of weeks ago around that focus on prevention and are we trying to do too much with a limited workforce. I guess the point is, if you think to, to paraphrase the CMO, he’s talked about trying to push the development of long term conditions in a person’s life as far down that life course as possible to maximise the number of years lived in good health and therefore reduce the burden for that individual, for their family and for the health service.
The challenge with any prevention activities, it’s rarely a short-term solution. So I think the challenge is how we how we work with our primary care family, not just general practice but the breadth of primary care and community organisations to think about how we can, I guess, maximise the opportunity. So increase identification, increase support, look at the non-medical bits – so the lifestyle stuff that would sit around some of the prevention conversations that don’t need to come anywhere near the health service really that actually we could be doing differently.
And I guess shift the work within general practice and other parts of primary care to appropriate who can work to top of their licence- so to work as well as they possibly can, being supported, feeling confident to do so. But the context that this is all sitting in is there’s also the reactive piece that needs to sit around -so the kind of the acute. So we’re talking about long term conditions, but actually people get sick and it’s how we how we as a system manage all of that. So I’m positive, but it’s not going to be straightforward.
Alex Kent
It never is, is it? I think if it was then we’d have done it already. Indira?
Indira Kasibhatla
What we have actually done in our area is to kind of share that responsibility between our neighbourhood teams. Basically working together regarding chronic kidney disease, we had this Healthy.io project, which is an ICB initiative where we had this company who will promote doing urine ACRs and then that is a part of work which we have actually promoted widely across PCN as well as well as beyond PCN, where patients who attend for long term condition review with cardiometabolic syndrome will get a urine sample to be done to check for CKD, and we held few workshops for clinicians to have to have more insight into chronic kidney disease, Because as we are aware the emphasis has not been given to chronic kidney disease, either in the quality improvement within primary care or through any other local enhanced services in primary care.
So as a part of this education, we worked along with the leads, the nephrology team and we held a lot of educational sessions across Kirklees to improve understanding among not just young practitioners but lead health professionals. As you’re aware, the workforce, the clinical workforce, is not just GPs at the moment. We’ve got lots of other allied health professionals who will be seeing majority of our patients who could screen these patients as opportunity arises, so this has led to increase in identification of existing CKD patients.
Which again, we could educate them ’cause obviously patients through plus NHS App. They could see on NHS App, they’ve been coded as chronic kidney disease so they got back to general practice saying, ‘oh, what is this, are my kidneys ok?’ which we took as a good opportunity to explain to them what it is and why it is important to focus on. And also this gave us a lot of opportunity to educate them about the primary causes for CKD, like uncontrolled diabetes, uncontrolled hypertension, non-compliance with medication and then the consequence of it could be dialysis. This has actually shown – I mean I can say from my first-hand experience that a lot of patients agreed to start on some of the medication which we call SGLT-2, you probably heard the names like Dapagliflozin. These are disease modifying and have shown huge control over CKD progression and also heart failure, progression and stuff like that.
So yeah, patients who are resistant to starting this treatment in the past, once we mentioned kidneys they have agreed and gone on to them so it’s perhaps sometimes a straightforward conversation in some of the communities would be a lot more helpful than you know, subtle signals, of saying, oh, you probably could have progression in few years’ time. So that worked really well.
Another initiative is working with cancer alliance, as you might have seen, 70% of patient population are identified in later stages of the cancer because of the prefixed ideation scare to approach health services and most of them are identified in A & Es as well. So we took initiative and we worked with Cancer Alliance where we had an additional breast cancer screening van kept in supermarkets. Cancer Alliance staff came over and worked with us, which massively, massively helped us with not eating into our own admin time and burdening us with a lot of administrative chores.
So I think the future would be working together and neighbourhood teaming and utilising every single opportunity to educate patients and not to forget we have a training hub within our area, who are really, really good with putting all these long-term conditions, stratifying them and putting the workshops for various health professionals like Nurse Associates, general practice assistants, care coordinators who are the workforce which we are using at the moment to educate patients. My dad – he was diabetic, but no one told him how important it is for diabetes control. It is very important for it to halt other conditions.
So he was very hard-working engineer. He’s been trying his best as per his knowledge goes to control his diabetes. But there was no insight into what diabetes can cause as a silent disease. People should understand it’s not just about your sugars being high, the amount of food you eat will also affect your sugars, and the sugars are not just gonna sit there in your blood. They’re gonna go into your eyes. They are going to go into your kidneys and also they can go into your legs and heart – your blood vessels will become smaller in the volume. leading to reduced blood supply to your brain as well as your heart. And please do not think not eating sweets is enough- that’s what exactly happened with my dad, and he was not obese or very thin. He was just diabetic, working hard, not had much time to concentrate on his diet, didn’t know what it can do. So he ended up with CKD and when he ended up with CKD, he ended up in a in a very bad shape with total shutdown of his kidneys with one episode of chest infection at the age of 58.
I just started my Med school then. He didn’t have much time to see my success, so he quickly progressed to lined-on dialysis, which wasn’t very easy for us especially we are me and my dad are very much emotionally connected and very close, so he used to say anything but dialysis, but there was no other option. And he was needle phobic and every time we get to that dialysis centre he used to panic, I used to attend with him, hold his hand and I kind of learned to kind of calm him down for his dialysis.
That is the very reason why I would want to promote CKD because if people understand that it’s not just diabetes, it’s not just diabetes. It’s a disease, if not controlled, could take your life. Fair enough. If you go at once, but no. If you take your life slowly bit by bit and it can be quite traumatic. Not just yourself, but to family around you, which that is the main reason why I took up the CKD project and wanted to lead on it purely because I want people to understand, especially people from my own background That’s all I can say.
Alex Kent
Thank you. Lots there, I think that’s really helpful to have that personal story that brings it home, and actually this is why we do this, isn’t it? It’s to, you know, to try to support patients. You know, as much as the data is important. it’s actually about that individual at the end with that story. Thank you. Any final words from you, Barry?
Barry Todd
Yeah, I think going back to what Indira was saying about chronic kidney disease, we’re actually in a national emergency. The kidney units are stowed out and our secondary care colleagues, the renal physicians, are reaching out to us to help them to stem the flow. So early identification and proper medicines management right at the beginning is essential.
In order to do that, because as you quite rightly say we, we don’t get incentivised to do it, we need to find money from elsewhere. And I mentioned the P word ‘pharmaceutical industry’. I think we need to move away from being suspicious of pharmaceutical industry now and to work with them and secondary care in order to get initiatives to be able to tackle this major problem.
So for instance, in Sunderland and Tees Valley, we’re working with health innovations and the ICB are working with one of the pharmaceutical industrial partners to reach out to the community in the ‘spot programme’ which identifies patients so that they can be optimised by clinical teams. But the tricky ones actually are seen, the renal physician comes out to the GP surgery and actually has a consultation with the patients in primary care.
There’s all sorts of things that are going on exciting projects, but we need to widen our vision and engage with with our partners out there.
Alex Kent
Thank you. So I mean, I think, you know we’ve heard about lots of different initiatives here and different ways of approaching long term condition care. Just to try to improve our outcomes for patients. I mean, I think obviously it all starts with the diagnosis. I think we’ve got some tools which are really helpful, in terms of stratifying risk and understanding where to look for those diagnosis. I think actually we’ve now got medications and treatment options that are available to us that work really well.
So there’s a real reason now to actually look for some of these conditions early, identify them early, manage them early and hopefully try to prevent that, you know, end outcome of heart attacks, strokes, dialysis, amputations, which none of us want to see. And actually, you know, in the future, if we get all of this right, do the partnership working, do the joined up approach, then hopefully we’ll start to see a reduction in those numbers. So thank you all for all of your contributions today. I think that’s been a really interesting conversation and I appreciate all your time.