Long-Term Conditions


Long-Term Conditions

This service has been developed in recognition of the increasing number of patients who have more than one long-term condition (LTC), and the need to manage patients with a holistic approach to health and wellbeing. It seeks to improve care for people with co-morbidities so that patients receive their care as efficiently and holistically as possible.

The service aims to provide better care for patients by treating one or more conditions at the same time, with patient need being the driver rather than individual conditions. Patients will be covered by the same LCS from the moment of being flagged at risk of developing an LTC through diagnosis, treatment and long-term management.

The LCS objectives are to:

  • support patients to identify their own personal objectives in order to improve their overall health and well-being
  • encourage a preventative and pre-emptive approach to care through systematic offer of lifestyle advice and support (e.g. lifestyle behaviour change, seasonal health advice, etc.)
  • reduce the prevalence gap for long term conditions
  • tackle health inequalities by offering equitable access to pro-active care for all patients with long-term conditions, while being mindful of the issues relating to difficult to engage patients, low levels of activation, patients with learning disabilities and poor mental health, etc.
  • provide clear processes for practices
  • support primary care workforce development
  • achieve better management and outcomes for people with long-term conditions
  • allow more flexible implementation/delivery, ensuring that practices have autonomy to implement certain aspects of the LCS according to their capacity and expertise
  • ensure outcomes are deliverable, manageable and measurable
  • encourage collaborative working with key local agencies including health, social care and the third sector.