Chief Investigator: Simon Fraser, Professor of Public Health, University of Southampton

Team:

Nisreen Alwan, Professor of Public Health, University of Southampton, Lead for the Healthy Communities theme (from 1st Oct 2024), NIHR ARC Wessex.

Robin Poole, Consultant in Public Health, Southampton City Council.

Michael Boniface, Professorial Fellow of Information Technology, Director of the IT Innovation Centre, University of Southampton, and lead for the Workforce and Health Systems theme, NIHR ARC Wessex.

Kelly Cheung, PPI lead, NIHR ARC Wessex and University Hospitals Southampton.

Emilia Holland, Public Health Registrar, University of Southampton.

 Seb Stannard, Research Fellow, MELD-B project, University of Southampton.

 Claire Sheikh, Senior Pharmacist, Living Well Partnership, Southampton.

 Kelly Hislop Lennie, Principal Academic in Adult Nursing, Bournemouth University.

 Lynn Laidlaw, Patient and public contributor and researcher, PPI contributor MELD-B

 Sally Dace, PPI contributor MELD-B and Wessex ARC

James McMahon, PPI contributor MELD-B, School of Primary Care Research UoS, South West Genomic Medicine Service. Lead PPIE for DIALOR, a digital intervention addressing frailty in Bournemouth University

Partners: Hampshire and Isle of Wight Integrated Care Board, University Hospital Southampton NHS Foundation Trust, Bournemouth University, Southampton City Council, Living Well Partnership.

Start: 1 October 2024

End: 31 March 2026

Summary

This project is about taking knowledge that has been learned from two ongoing research studies about living with multiple long-term health conditions to see if we can apply it in a ‘real life’ setting in a large general practice in Southampton.

Two research projects called ‘MELD-B’ and ‘the ARC Treatment Burden study’ have identified many aspects that make living with multiple long-term conditions challenging for people. This ‘workload’ might make it more likely that people feel overwhelmed by their health conditions. If people have a high workload, and particularly if they are frail, this can end up with them needing to be admitted to hospital. We have also identified that some aspects of people’s early life can make it more likely that they are admitted to hospital in middle age. If such challenges are recognised in advance and appropriate help provided, such unplanned admissions might be avoided.

Care coordinators are people working in NHS settings, including GP surgeries, to identify and support people at risk of such admissions. They have a lot of people on their books and it can be challenging to know who needs what help, and who needs it most urgently.

We want to see if the things we have learned from our previous research study can help the care coordinator make these decisions. In this short project we plan to do this in a large practice in Southampton, the Living Well Partnership, which looks after about 45,000 people.

We plan to:

·       collate all the aspects identified in these studies that might make people more vulnerable

·       make sure we understand the current way care coordinators identify and engage with patients

·       work with all the relevant people in the practice to make sure we take people on this journey with us

·       undertake some workshops, co-led by PPI contributors, to co-develop the strategy for adding new aspects (such as the ‘workload’ and early life aspects mentioned above) to current approaches

·       test the addition of adding these in Living Well Partnership and evaluate the process

We will share our findings at an event involving as many of the team from the Living Well Partnership as we can and get their feedback. This event will also include other relevant interested parties, such as those from the Integrated Care Board.

PPI contributors have been deeply involved in the work of MELD-B, have helped to shape this proposal and will continue as co-investigators. They will be reimbursed for their contributions according to NIHR guidance.