>>Dr Dan Alton: Increasingly we are realising
that our lifestyles are crucial to our long term health. We know the health inequality
gap is increasing. But despite all of our best efforts in certain cases, some patients
are still slipping through the net. Finding and supporting these patients can help them
improve their lifestyle and their overall health for years to come.>>Steve Bryan: I’ve got type 2 diabetes
and I was diagnosed with it around ten years ago.>>Michele Bryan: I’ve also got type 2 diabetes.
I was diagnosed probably about 8 years ago.>>Dr Dan Alton: Some groups of patients aren’t
responding to our standard, one-size fits all approach to support them to improve their
health and lifestyles. And in Berkshire West integrated care system we are working very
closely with partners in health, social and the voluntary sector to bring data together
in a new way>>Dr Jennifer Singh: There are quite devastating
consequences of type 2 diabetes which can cause premature death. These are things like
heart disease and strokes. So it’s really important to intervene early so we can prevent
these complications from happening.>>Steve Bryan: We used to have to go to the
GP surgery once a year for a review meeting. We were told when we needed to go in. We’d
get our medication assessed and our blood sugars assessed and we would be prescribed
new medication. We were told what was the right thing for us, what was the right medication,
and how we should behave and what we should and shouldn’t eat. And there wasn’t a
lot of two-way dialogue>>Michele Bryan: If I’m honest, I would
say our approach to it – well mine definitely was – I’ve got this but I can take some
tablets. So I’ll take the pills and crack on.>>Steve Bryan: We were gradually deteriorating.
Every year the medication would be stepped up a little bit and I could gradually see
the blood sugars rising.>>Matthias Winker: The key to this is data.
Coming together as a system provides us with the opportunity to join up data from health
and social care, to support and help GPs with hard evidence to proactively design interventions
for patients who really need their care.>>Dr Dan Alton:
We identified a group of patients with Type 2 diabetes that did seem to be slipping through
the net. And we went out and asked them why this was the case.>>Steve Bryan: Dr Alton called us and had
a long conversation with us about a potential group session.It was really great to have
that personalised approach where he was keen to understand what would work for us rather
than just being the medical profession telling us what the right answer was.>>Dr Singh: So we had a one and a half your
group session. It was quite a casual setting. We were able to divulge lots of information
in a detailed fashion to a large number of people.>>Michele Bryan: We felt like we were having
a conversation with somebody that was interested in getting a plan together involving all of
our things, not just what we ate and what our sugar levels were.
Steve BryanI think we both walked away from that with a much better understanding of why
things happen, how they worked and how we could work in tune with them.>>Dr Dan Alton: So the beauty of this approach
is it offers local solutions to local problems. We have the analysts support to be able to
interrogate the data we now have available, to really pin down which groups we need to
support better.>>Steve Bryan: We’ve taken dairy largely
out of our diet. We’ve cut back on bread. We’re eating a lot more fish, salad and
a lot of nuts and porridge. We’ve also upped our exercise, so we’re doing a lot more
walking.>>Michele Bryan: The change in the bloods
was immediate, almost. From our finger testing we could see like really within three days
how quickly that had started to show results which was very encouraging.>>Steve Bryan: We’re less reliant on the
medication to keep them low. It’s controlled as much by the diet as the medication.>>Dr Dan Alton: For me as a GP, this offers
a way of providing a different service that is tailored to our patients that we know will
work.>>Dr Jennifer Singh: It’s effective because
it’s a personalised treatment plan for a patient. It’s completely tailored to them.>>Matthias Winker: I think the long-term benefit
of population health management is the predictive element. The analysis of the data today allows
us to predict the future health needs and demands of future patients>>Dr Dan Alton:
Population health has been around for a very long time. But what we have now is much greater
integration within systems that we can utilize to adopt this very logical approach to how
we improve the health and wellbeing of our population health

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Methew Wade

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