Case studies


Our annual Carers Week campaign brings together carers, community organisations, GPs, and colleagues from Adult Social Care, London Borough of Newham

Our annual Carers Week campaign brings together carers, community organisations, GPs, and colleagues from Adult Social Care, London Borough of Newham

This page gives details of a number of other recent initiatives designed to empower patients to take control of their own care.

The diabetes prevention programme: 

The diabetes prevention programme is designed to help people at high risk of developing diabetes type 2 to change their lifestyles. We are leading the implementation of the programme across east London, together with Newham Council, and were one of 27 areas across the country to be chosen to be part of the first stage of the Healthier You: NHS Diabetes Prevention Programme. GPs will invite people they know to be at high risk to enrol and they will receive tailored help including education on healthy eating and lifestyle and bespoke physical exercise programmes to lose weight, which will be delivered as part of our community prescription programme. This will help to challenge health inequalities by supporting people living in East London to take control over their health outcomes.

The Self-management Support Programme (SMSP): 

As part of the Self-management Support Programme, people with two or more identified long term conditions (controlled diabetes, cardiovascular disease, coronary heart disease, asthma, atrial fibrillation, hypertension, COPD) will be invited to take part in the scheme which consists of three one-to-one sessions with a trained local pharmacist over the course of 12 weeks, where they will have the opportunity to talk about the issues that are most important to them – whether that’s increasing their personal understanding of their condition, working on their confidence in managing their medication or improving their general health and wellbeing.

Together with their pharmacist, patients living with a long term condition and their carers will develop a personalised ‘My Wellbeing Plan’ that identifies their health goals and focuses on how these goals can be achieved.  These might include making positive changes to their lifestyle by being more active, eating healthier or getting involved in their local community, with pharmacists helping to connect people to local services and community groups that can provide on-going support and encouragement using online signposting tools. 

The Patient Activation Measure (PAM) tool will be used to personalise and target interventions, evaluate the effectiveness of interventions and the overall performance of the project.

Diabetes care plans: 

Diabetes care plans are part of the Extended Primary Care Diabetes Service. Healthcare professionals are expected to write an annual diabetes care plan in conjunction with patients using consultation skills based on motivational interviewing techniques.  98% of practices have at least one healthcare professional that has attended a Motivational Interviewing skills course.

Key Outcomes: during 2015/16, 84% of patients with type 2 diabetes received a diabetes care plan as part of their annual diabetes care.

Diabetes Community Champions: 

Our Diabetes Community Champions have actively been delivering outreach activities in community centres, places of workshop, Schools as well at community events. The Champions have also set up a Diabetes Support Group that is hosted by the London Borough of Newham. The group meets at Manor Park Library on the third Friday of every month. Led by and for people living with diabetes, the support group provides information about NHS diabetes services as well as lifestyle tips and advice to help people self manage.

Multi-disciplinary meetings:

These multi-disciplinary team (MDT) meetings, introduced as part of the integrated care programme, bring together staff from different disciplines who can contribute their knowledge, skills and experience into developing coordinated care plans for and with patients with complex healthcare needs. These MDT meetings bring together staff from across all local healthcare providers so that the needs of the patient can be met across traditional healthcare boundaries ensuring continuity of care and an improved patient experience. 

Carers training on GP access:

NHS Newham CCG, in collaboration with Newham Carers Network, held a training session for carers focused on improving carers’ knowledge of primary care services.

Participants attended the session in Stratford library led by the Primary Care team which covered topics including GP access, alternative ways to improve health and care, supporting self-management and the future of primary care such as video consultations. The project is sponsored by NHS Health Education England as part of the CEPN Transformation Fund and a second module, to be held soon, will look at diabetes care. A guide for carers was also developed and given to participants following the training.

Following the workshop the majority of carers who attended the training session said they now felt more confident and comfortable about accessing all the different services offered by their practice, one participant told us, “through today’s session I have been made aware of other ways to seek help”.

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