Patient and Service User Survey

HELP IMPROVE ISLINGTON'S SELF-MANAGEMENT SERVICES

If you are an Islington resident living with a long-term condition, please complete the following survey to help us better understand your support needs.

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* 1. What is your age?

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* 2. What is your gender?

Male

Female

Transgender

Gender neutral

Non-binary

Other (please specify)

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* 3. How would you describe your ethnicity?

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* 4. Which of the following long-term conditions do you have and how many years have you been living with each? (please select all those that are relevant for you)

	1-5 years	+5 years	+10 years
Cancer	Cancer 1-5 years	Cancer +5 years	Cancer +10 years
Cardiovascular (e.g. Angina, Hypertension)	Cardiovascular (e.g. Angina, Hypertension) 1-5 years	Cardiovascular (e.g. Angina, Hypertension) +5 years	Cardiovascular (e.g. Angina, Hypertension) +10 years
Chronic Respiratory (e.g. Asthma, COPD)	Chronic Respiratory (e.g. Asthma, COPD) 1-5 years	Chronic Respiratory (e.g. Asthma, COPD) +5 years	Chronic Respiratory (e.g. Asthma, COPD) +10 years
Chronic Neurological (e.g. Multiple Sclerosis)	Chronic Neurological (e.g. Multiple Sclerosis) 1-5 years	Chronic Neurological (e.g. Multiple Sclerosis) +5 years	Chronic Neurological (e.g. Multiple Sclerosis) +10 years
Chronic Pain (e.g. Arthritis)	Chronic Pain (e.g. Arthritis) 1-5 years	Chronic Pain (e.g. Arthritis) +5 years	Chronic Pain (e.g. Arthritis) +10 years
Diabetes	Diabetes 1-5 years	Diabetes +5 years	Diabetes +10 years
HIV	HIV 1-5 years	HIV +5 years	HIV +10 years
Irritable Bowel Syndrome (IBS)	Irritable Bowel Syndrome (IBS) 1-5 years	Irritable Bowel Syndrome (IBS) +5 years	Irritable Bowel Syndrome (IBS) +10 years
Mental disorder (e.g. schizophrenia, depression)	Mental disorder (e.g. schizophrenia, depression) 1-5 years	Mental disorder (e.g. schizophrenia, depression) +5 years	Mental disorder (e.g. schizophrenia, depression) +10 years
Any other long-term condition(s) (specify below)	Any other long-term condition(s) (specify below) 1-5 years	Any other long-term condition(s) (specify below) +5 years	Any other long-term condition(s) (specify below) +10 years

Please specify any other long-term condition(s)

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* 5. Have you ever taken part in any of the following self-care or self-management support services?

Diabetes Education and Self-Management for Ongoing and Diagnosed (DESMOND)

Diabetes Self-Management Programme

Expert Patients Programme (EPP)

Healthier You - Diabetes

HeLP – Diabetes (online tool)

Help On Your Doorstep Service

Islington Choice and Control Peer Coaching Service

Islington Navigation service

Long-term Exercise Programme

MacMillan HOPE Self-Management Programme

Phase 4 Cardiac Rehabilitation Programme

Positive Self-Management Programme (PSMP)

Pulmonary Rehabilitation Programme

Recently Diagnosed Programme (HIV)

X-PERT Diabetes Programme

Other (please specify)

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* 6. If you have attended a self-care or self-management support service, what about it was beneficial and what could be improved?

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* 7. What do you think are the barriers that prevent people living with long-term conditions from attending self-care or self-management support services? And what could be done to better support them?

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* 8. If you were designing the perfect support service to help you live better with your long-term condition(s) what would it look like and how would it work? e.g. venue, structure, format, timing (day, evening, weekends), who would facilitate it etc.

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* 9. Anything else you’d like to say about existing or future self-care and self-management support services in Islington?

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* 10. If you would you be interested in taking part in a one-to-one interview and/or a focus group please provide your details below and one of our team will be in contact:

Name

Email Address

Phone Number