University Hospital Bristol NHS Foundation Trust 1

Patient led service. Through a direct access system (DAS), regular rheumatologist – initiated reviews were replaced by patient initiated reviews, accessed through a telephone helpline run by the rheumatology nurse specialists.

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University Hospitals Bristol NHS Foundation Trust 2

Set up as an admission avoidance service with the aim to support GPs with patients with chronic lung disease.

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University Hospital Bristol NHS Foundation Trust 3

Facilitating discharge from admission wards and HOT clinics A joint collaboration between BRI and Bristol Community Physiotherapy services for respiratory patients

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University Hospital Bristol NHS Foundation Trust 4

Early supported discharge for stroke patients. Providing intensive rehabilitation in the home outreaching from the acute unit. Also accept referrals from the TIA clinic

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Royal National Hospital for Rheumatic Diseases NHS Trust 1

The RNHRD has been developing a Falls and Fracture Liaison Service at the Royal United Hospital (RUH) Bath. This is a partnership between the RNHRD, RUH, BANES PCT and Wiltshire PCT.

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Royal National Hospital for Rheumatic Diseases NHS Trust 2

Using alternative media to support adults with Chronic Fatigue Syndrome (CFS). The RNHRD provides an alternative media service (telephone, email, and texting) to support adults with Chronic Fatigue Syndrome

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Royal National Hospital for Rheumatic Diseases NHS Trust 3

Mindfulness and Acceptance based therapies. This unit is the national leader in this area and the service model is fully in line with the CMO’s recommendations, being a good example of a level 3 service, in his terms.

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Royal National Hospital for Rheumatic Diseases NHS Trust 4

This unit is the national leader in this area and the service model is fully in line with the CMO’s recommendations, being a good example of a level 3 service, in his terms.

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Royal National Hospital for Rheumatic Diseases NHS Trust 5

The education programme is provided separately for Lupus patients and Scleroderma patients as three education/ information sessions of half a day each and is repeated annually.

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NHS Dorset PCT 3

Community service model with particular benefit to patients with glaucoma.

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NHS Dorset PCT 2

Improves the communication of a patient’s key clinical information and care preference to all clinicians likely to be involved in the patient’s care.

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NHS Dorset PCT 1

Self Management in Local Environment (SMILE) team service.

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NHS Cornwall & Isles of Scilly PCT 9

The Whole System Demonstrator Programme is a DoH trial of the use of preventative technology to support people with heart disease, diabetes and COPD.

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NHS Cornwall & Isles of Scilly PCT 1

A model of primary care based dementia community service which enabled a GP-led Memory service to be set up.

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NHS Cornwall & Isles of Scilly PCT 7

Self contained mobile eye screening unit. Integrated team delivering a co-ordinated programme to fast track patients. This test uses specialist ophthalmic cameras to recall images of the retina.

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NHS Cornwall & Isles of Scilly PCT 6

The Director of Public Health is leading this piece of work, which is being developed in partnership with the local authority.

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NHS Cornwall & Isles of Scilly PCT 5

There are a great number of information sources but some require time-consuming searching and may not be accessible for some users.

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NHS Cornwall & Isles of Scilly PCT 4

The next generation tool for risk prediction is the Combined Predictive Model. This combines information from primary care information systems and hospital activity

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NHS Cornwall & Isles of Scilly PCT 3

Better understanding and management of their LTC. Supported to stay in their own home.

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NHS Cornwall & Isles of Scilly PCT 2

PCP offers an approach to the care of people with long term conditions/ complex needs that will help us to drive a shift from the organisation of services around professional groups to patient centred holistic care.

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NHS Cornwall & Isles of Scilly PCT 8

Through technology empowers patients, users and carers to have more responsibility and control

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Royal Devon & Exeter NHS Foundation Trust

Established to look at the processes for admission, discharge and effective care of patient’s with a range of disabilities.

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Royal Cornwall Hospitals NHS Trust

Cardiac rehabilitation in Cornwall provides exercise and educational programmes across Cornwall and is available to people who have had heart surgery

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Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust

Type I diabetes educational programme and treatment programme which allows patients to eat and drink whatever and whenever they like

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North Bristol NHS Trust

An admission avoidance clinic for adult respiratory patients. It is recognised that a large number of patients with respiratory disease are admitted to hospital

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Great Western Hospitals NHS Foundation Trust 1

Shared primary and secondary care electronic patient record for End of Life Care in the first instance

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Great Western Hospitals NHS Foundation Trust 2

NHSI Pathway for patients with diabetes is being implemented at the Trust

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Gloucestershire Hospitals NHS Foundation Trust 3

The purpose of UTOPIA is to deliver a step-change in the quality, safety and efficiency of the Trust’s Unscheduled Care Pathway, including those with long-term conditions

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Gloucestershire Hospitals NHS Foundation Trust 2

A locally responsive service for people with multiple sclerosis (MS). Accelerated access to care for people with Multiple Sclerosis

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Gloucestershire Hospitals NHS Foundation Trust 1

Exercise DVD to help patients maintain exercise routine

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Devon Partnership NHS Trust

A proactive preventative approach that focuses on promoting mental well being through a workshop programmes

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