Chronic Disease Stories

The work that the practice team does in the Chronic Disease topic areas can make significant improvements to patient outcomes. Here, practices generously share their stories of change.

Click on the links to be taken to each practice's story.

Database Tidying and Data Extraction

"I must say we did embrace the concept and greatly appreciated being led along the path of tidying our databases and being able to extract accurate informative data...read more

Acute Cases Management

"We have made lots of changes to update our Chronic Disease registers and to keep them accurate by coding correctly...read more

Data Cleansing

"In the last month, we have inactivated all patients who have not attended the surgery within the past two years...read more

The Rise and Rise of the Chronic Care Coordinator

“We have made quite a few changes but I believe the most significant change was brought about by employing a Registered Nurse to co-ordinate chronic disease management....read more

CHD Reminder System

"We needed to find a reminder system for the doctors, when consulting patients who are on the CHD register (these patients are identified very easily, they are coded blue on the doctor’s appointment screen) to check that patients are up-to-date with recommended readings, levels and medications...read more

Increase in Annual Diabetes Checks

"We at Woodside Surgery have increased the rate of annual diabetes checks from a low 12% in 2005 to 73% in 2009...read more

Tracking GP Management Plans and Team Care Arrangements

"I think these days a CCC is a must...read more