Using technology, data and evidence of what works well to provide more tailored care to people with a long-term condition

To get the conversation started, here is one of our ideas for how we can better support people with long-term conditions - we'd like to know what you think of it. 

New technology is making it easier for health and care services to provide care to people that have, or are at risk of developing, a long-term condition. We are going to use this technology, data and evidence of what works well, to provide more tailored care. 

We will do this by looking at all the patients with a particular condition at a GP surgery, to see whether they are getting the care and treatment that we know works best, and to look at what we could do differently to care for them. 

For example we could explore the care being provided to people with breathing problems such as Chronic Obstructive Pulmonary Disease (COPD). This is a complex group of people with huge variation in their health and they can visit the GP and/or hospital many times a year. 

We could use technology to look at anonymised data for this group of patients to better understand the severity of their disease, how many were smokers, how many admissions they had to hospital in a year, how many other illnesses they had, how many came for routine checks, how many infective exacerbations they had suffered, and their medications.

We could then segment patients according to the severity of their disease, and design new service models to look after them according to their need. 

Why the contribution is important

We already do this to some extent, but new technology is making it easier to do. We want to provide more proactive care and support people to manage their long-term condition, rather than wait for people to go to their GP surgery or A&E when their health is worse and they need urgent or emergency care. We want people to stay well for longer or prevent them developing long-term conditions, where possible. 

by Chris_admin on July 25, 2019 at 10:13AM

Current Rating

Average rating: 4.3
Based on: 3 votes


  • Posted by HelenNku July 25, 2019 at 15:37

    I think this is a great idea & could be expanded further to include remote monitoring of patients via technology to manage conditions using apps etc to self report general obs, use IT to feedback to GP/Practice Nurse & flag up any concerns. This could reduce necessary GP appointments.
  • Posted by Chris_admin July 26, 2019 at 09:51

    Thanks HelenNku - we completely agree. There are some great Apps out there that can make a real difference to people's lives.

    For example MyCOPD is for people with breathing problems ( People can use it to monitor trends in their lung function over time and view how their symptoms change over the weeks, months and years.

    What other Apps are people using to monitor and manage their long-term condition?
  • Posted by Dan_K July 26, 2019 at 11:26

    The NHS could use technology so much more. You would save lots of money and make mine and other people’s lives much easier.
  • Posted by ChairWNCCG July 30, 2019 at 12:00

    Th epropblem here is one of infrastructiure and investment. We are very digitally immature in N&W and funds are very tight. It is however a great idea.
  • Posted by Crowea August 13, 2019 at 18:04

    Standardised Inhaler technique training workshops and literature available for staff in both secondary and primary care, to assist patients with inhaler technique. Additionally, primary care updating secondary care with support groups post discharge by linking directly with the respiratory wards. This would assist in the self management of COPD
  • Posted by ironlady August 18, 2019 at 15:09

    It is important to bear in mind that a lot of people, particularly the elderly, are not tech savvy and would be excluded from some of the suggestions being made.
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