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Information and public services for the Island of Jersey

L'înformâtion et les sèrvices publyis pouor I'Île dé Jèrri

New schemes help treat long-term conditions

09 January 2018

Islanders who live with diabetes or chronic obstructive pulmonary disease (COPD) are helping to trial two new pilot schemes which will benefit their health, better manage their long-term conditions and be more involved in how their care is planned.

The schemes are part of the Sustainable Primary Care Strategy, which was launched in December 2015; both began in late 2017 and will run for a trial period of one year.

The diabetes pilot scheme is being trialled with GP practices HealthPlus and Cleveland Clinic, and is open to patients of those practices who live with Type 2 Diabetes, are over 18, and not pregnant. It is estimated this is around 800 people, around a quarter of adult diabetics in Jersey.

The GP practices will, through a partnership with the Diabetes Centre, run dedicated clinics with specialist diabetes nurses from the Diabetes Centre and their own practice nurses so that expert knowledge can be shared. Through the new trial scheme, patients will be able to set their own health objectives.

Patients will continue to pay for the service, which consists of three appointments. The total package of care is at a slightly lower rate than what they would normally pay for their annual GP checks.  The appointments include diabetes checks, a care planning appointment and a GP follow-up appointment. Patients will be able to access specialist diabetes care in a convenient and familiar setting.

Blood glucose monitoring strips will be available at the practice on the same terms as the Diabetes Centre.

Enhanced care

It is hoped that if the pilot scheme is successful, individuals and their GP practice team will become more confident in managing their diabetes, leading to more diabetes care being successfully delivered without visits to the Diabetes Centre. This will in turn allow staff at the Diabetes Centre to deliver enhanced care to complex patients.

The pilot scheme has been designed in partnership by clinicians and service users. These include GPs, nurses and consultants from general practice, HSSD Diabetes Centre and FNHC. Diabetes Jersey has represented service users in the pilot design. Understanding how the pilot is working will help to redesign services that manage other long-term conditions in Jersey.

A ‘call for ideas’ for pilot schemes was circulated, HealthPlus and Cleveland Clinic came forward and were selected following an evaluation process.

Dr Philippa Venn from Cleveland Clinic said “We are delighted to be taking part in this pilot scheme which allows our diabetic patients to have care for their condition in a familiar setting. We believe this is a great concept for this important group of patients, and allows our expert nurses to talk with and reassure patients.

“We know that individuals living with diabetes visit their doctor more often than the average person, at least four times a year for regular checks, blood tests and prescriptions (we know that some visit the GP many more times, sometimes for diabetes-related complications). The pilot aims to provide annual diabetes checks in general practice with specialist support at a marginally lower cost: the service has been designed on the principle that patients in the pilot should not be financially disadvantaged. To support this, the pilot is part-funded by Health and Social Services. Charges for other monitoring and prescription appointments will remain the same as they are now.

“Many individuals living with diabetes will also visit the Diabetes Centre several times per year. By adding a Diabetes Centre specialist service to a General Practice service at no extra cost and by involving individuals more in their diabetes care, we hope that some people may need to visit the Diabetes Centre and/or their GP less for Diabetes-related complications.”

The second pilot scheme, in partnership with Cooperative Medical, involves around 100 COPD patients who are either already diagnosed with COPD or who are thought to be at risk from it.

Screening and assessment for all patients

Free basic screening and assessment will be offered to all patients. All patients will be managed by the COPD Care Manager and depending on their severity, this will be alongside their GP or the Respiratory Team based at health and Social Services.  The Care Manager will help to coordinate access to services and deliver some interventions.

The Care Manager is a free service funded by HSSD, but GP appointments will be paid for in the normal way. The patients will also be offered a Medicines Use Review, either in one of the Co-op pharmacies or, if considered necessary, at home.

Patients who need additional support will also be quickly advised which services can help them if needed, such as Jersey Talking Therapies, Help2Quit, Pulmonary Rehabilitation or other support services by the Care Manager.

Sara Kynicos from Cooperative Medical said “For a primary care provider to work so closely with patients who have COPD is a great opportunity. We hope that the pilot scheme will allow patients to be empowered to better understand their condition and feel that they can be confident in their self-care, while if they have greater need, services can be better co-ordinated for them. In addition, to have access to a multi-disciplinary team when needed is a great boon, and we hope that the pilot will reduce Emergency Department attendances and hospital admissions for issues related to COPD.”

The Minister for Health and Social Services, Senator Andrew Green, added “I am very grateful to everyone involved in these two worthwhile pilot schemes which will help islanders who need extra help and support with their conditions. There has been a lot of detailed work behind the scenes to ensure that the pilot schemes work and are of real benefit. I very much look forward to seeing the results and I hope both are a success, giving patients confidence in the excellent health care services they can expect from Jersey, whether that is from their known and trusted GP, a specialist nurse, or my team at Health and Social Services. It’s great to see true partnership at work which is at the heart of the re-design of services which is ongoing to make them as accessible as possible for patients. We need to treat and care for everyone, and I’m pleased to see this happening, with patients who have long-term conditions.”

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