Public Health Minister, Caroline Flint, recently worked for two days alongside community matrons based at West End Lane Clinic, Rossington.

This is her diary.

DAY ONE

Arrive at West End Lane Clinic greeted by Mandy Holgate and Eileen Gasgoigne, the Community Matrons I'll be spending the next two days with. Mandy says we'll start with me putting on some gloves and an apron which I am pleased to say was a friendly wind up.

I met Eileen and Mandy a few months ago when I was asked to open an extension to the clinic which also houses them, GPs, district nurses and space for a variety of clinics. In the big scheme of NHS building development pretty small fry, but a really important resource for community based health staff and the people of Rossington - a mining community south of Doncaster.

Over coffee Mandy and Eileen tell me about their patients, who will have two or more long term conditions and two or more unplanned hospital admissions in the last year. I say hello to the drug staff at the weekly clinic before hitting the road with Eileen and her small suitcase on wheels, not standard NHS issue but it does the job.

First stop is Jim* who has respiratory problems amongst other things. We have a look round to admire the tidy job that's been made of installing the piped oxygen which Jim needs for up to 15 hours a day. Jim's daughter has an inhaler for her problems too and has been great in training him to use his properly. He shows me his care plan which he keeps at home. It means any person, a specialist respiratory nurse or social services worker, can know how he's doing and what is being done. As Eileen says it can be frustrating when you have done a full assessment and another agency insists on doing their own from scratch. Not much fun for the Jim's of this world either. Routine checks are done blood pressure, temperature, oxygen levels, medicine supplies and the care plan updated. There's a lot of talking. It shows how personal Eileen's relationship is, but she's checking in a friendly but probing way that everything is okay.

Eileen gets a call from a local GP practice who want to refer a case so we head over there.

At the practice Eileen introduces me and before long a doctor appears with a camera and photos follow. An occupational hazard for all MPs, but happy to oblige. One of the GP's is a mentor for Eileen. Pop into have a chat with the practice sister on some cases and Eileen gets some medication for some massive midge bites from an evening in the garden. Before we leave we talk to the Practice Manager about the referral case and arrange for Eileen to visit him the next week.

Quick stop at Cooplands. Return to base for lunch. Eileen checks her emails and I return calls to DH..

Next stop is Beryl who is in her 50's and has developed diabetes. She's working really hard to improve her diet and activity with great support from husband and daughter who, also it's fair to say, are overweight too. They're making steady progress. Swimming at the local baths has become regular for them and Beryl has learnt to swim. I am not allowed to leave without a bag of home grown tomatoes - Jamie Oliver would be proud.

Obviously, all the patients have been forewarned of that I am with Eileen and Mandy
and I have met some of them before which is a nice surprise.

Our final visit today is a medical miracle. Rose has defied all the doctors and survived major illness' to still be with us in her 90's. Eileen warns me she can be very strong willed and vocal about what she will and won't do. Living with her family, Eileen touches base with daughter Deirdre first. What has become clear to me today is that Eileen is not just a lifesaver for her patients but for other family members too. Rose joins us and says she has given up smoking. I ask her when and she says yesterday. Does that mean she's starting again today I ask and she laughs while Deirdre rolls her eyes. Stopping Mum smoking is a job and a half.

DAY TWO

Monthly meeting of Doncaster's Community Matrons. Ian from the PCT arrives for photos to which we all pose completely naturally en masse.

After dealing with the business and a few questions from me, it's my turn to answer a few questions about my job and what's happening in the NHS.

After lunch, I'm off with Mandy. Her first visit is to Sarah who is from a traveller family. Sarah, like other patients hoards medicines. Mandy always checks for unused medicines and as on previous visits, leaves with a bag to dispose of safely. Both Mandy and Eileen are training to be allowed to extend their prescribing powers which will make matters a lot easier and probably save the NHS money too. Sarah tells me when she feels okay she won't take them. Sarah has chronic respiratory disease but still smokes despite her daughters' best efforts. They say she has cut down though!

Next call is Jessie. She has only recently moved into her flat in a residential centre for older people. She has access to in-house carers but maintains her own independence too. Looking at Jessie, she doesn't appear that sick sitting in her cosy, tidy flat. But her respiratory problems mean that it doesn't take much exertion for her to feel exhausted. Mandy has been key to sorting out an electric scooter for her to use. All the paperwork has been done so fingers crossed for delivery.

Off we go to George and Marjorie. George's conditions have been made worse by a stroke. Marjorie suffers from back problems and is usually lying on the sofa but today is in an armchair propped up by lots of pillows. I have the feeling that all the patients I have seen have made a special effort for me which is very humbling considering all they have to deal with. She is very organised and tells me that the pile of papers she keeps close at hand may look like chaos but provides everything she needs day to day to run their lives. They pay for delivery of 14 frozen meals weekly, dinner and pudding. I have a look at the catalogue and it is a very good choice and they have no complaints about this private service. Before we leave Mandy arranges for a prescription to be sorted at the GP.

Our final stop is Eddy who lives on his own and whilst talkative and alert, he is painfully thin, weighing not much over six stone. He has actually put on some weight and Mandy has tried to get him to take some supplement drinks. The problem isn't that there aren't services there for him but he won't use them. Mandy is one of the few people he'll allow to visit and slowly she tries to make some progress.

We check in at a local GP practice for Mandy to hot desk and update the practice's records for the patients she's seen. Trying to develop a seamless service so that patients get the best possible joined up care. Chat to the GP about his speciality in sexual health before Mandy calls time and we head back to the office.

What have I learnt over the last two days?

First, how complicated the needs of Mandy and Eileen's patients are but their treatment is still manageable outside of hospital.

Secondly, it has focussed my mind on the challenge of more of us living longer. Clearly some patients have contributed to their conditions through poor diet, lack of exercise and smoking but others haven't, it's just the way it is. Prevention for me still needs more priority in the NHS but treatment will always be necessary; the question is what form that treatment takes, by whom and where. As Mandy and Eileen sum up their work: we can't keep all our patients out of hospital all the time, but we can give them more confidence to call us rather than 999 most of the time and get them out quicker when hospital treatment is necessary. What is clear from their patients and their families is how well received the community matron service is and how it has given some renewed confidence and welcome relief to them all.

The key to their success is how well they work in partnership with other health and care agencies. The theory is one thing but how they work in practice is the test. Overcoming bureaucracy and different working cultures is paramount but sometimes it is like walking through treacle.

Finally, what the patient wants has to come first. Not all want the same things or are prepared to do what may be in their best interest. That can be very tough and frustrating.

It's been great and I have agreed to Mandy and Eileen's request to shadow me at the Department of Health. Hopefully they'll get as much out of the experience as I have with them. It'll be different.

*All patients' names have been changed to protect their privacy.