What is the challenge your project is going to address and how does it connect to the theme of 'How can improvement be used to reduce delays accessing health and care services'?

Patients who have multiple long term conditions (LTCs) often find that that traditional care pathways result in each condition being treated in isolation. This is costly for them from a time and appointment attendance perspective. It is also costly for healthcare systems as there is a missed opportunity to optimise the care and medications that are provided via holistic reviews for ‘all’ of the patient’s LTCs, in contrast to isolated interventions.

Traditional care pathways make it difficult for Clinicians to work in a greater integrated way. There are few opportunities that they can easily come together from Primary, Community and Secondary care, to pool their knowledge and expertise around holistic patient reviews. This results in frustration for Clinicians, as much as patients, as often while they are aware that other Clinical colleagues with different LTC expertise could have helped them provide an even more robust care plan for the patient.