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  4. Complex Long Term Conditions Service 

Complex Long Term Conditions Service 

Introduction 

Patients with long term conditions (LTCs) and co-morbidities currently often experience fragmented and inefficiently co-ordinated care. ​ Some 70% of healthcare spend is on managing patients with LTCs. ​By tackling these issues, we have a significant opportunity to improve patient experience and outcomes. 

The Complex Long Term Conditions programme seeks to address this. The programme is testing new models of care to improve management of LTCs, including fewer appointments, better decision making and easier access to services. 

The programme is being delivered by the NCL Health Alliance (all-in provider collaborative) working as part of the NCL ICS. This is part of the work to drive partnership working to improve outcomes and experience for the population we serve.​ 

One of the key objectives for provider collaboratives is to reduce unwarranted variation and inequality in health outcomes. 

Two older people sitting on a bench in park on a sunny day. Photo is taken from the back so you are looking at the view with them.

The challenge

Long term conditions present a wide range of challenges that lead to poor patient experience, outcomes, and inefficiencies.  

  • 1 in 4 adults in England have at least two health conditions, with over 26 million living with a diagnosed long-term condition and 10 million adults having two or more.  
  • Life expectancy is 10-15 years earlier for those in deprived populations. The intersectionality between deprivation, multimorbidity and complexity drives further health inequalities where services are disjointed and ineffective.   
  • Managing patients with long term conditions equates to 70% of the total healthcare spend, accounting for 50% of all GP appointments, 64% of all hospital appointments and 70% of hospital bed days.  

In North Central London (Barnet, Camden, Enfield, Haringey, and Islington), where our programme is focused, the number of people with Long Term Conditions is growing and continues to grow. 

  • 430,000 people in NCL are living with at least one long term condition. Metabolic and Respiratory conditions make up 72% of LTCs in NCL. 
  • The number of people with LTC is expected to grow to 8% by 2030. .  
  • Since March 2020 there has been a 21% increase in people with three or more LTCs ​ 

Multiple appointments across different specialist teams can be confusing, time-consuming to navigate and it’s too easy to lose sight of the issues that matter to the patient.​ 

  • The average number of GP appointments increases with each LTC, reaching an average of 13 attendances per year for someone with 3 or more LTCs ​.

The solution

With a test and learn approach, the programme aims to design  improved models of care to bring changes across the system in the management of long-term conditions​. These will be tested at two primary care networks (PCNs) from November 2024, with two further PCNs joining in early 2025.  

Patients will be managed into a new clinical model where secondary care consultants provide coordination of clinical opinions across specialties and work directly at the interface with primary care.​   

Key principles of this approach include strong links to community services, a holistic approach to care and a long-term conditions team with a specialist/generalist skillset. 

As the programme develops, opportunities for a multi-speciality clinic approach for patients requiring in-person assessment and treatment, with access to innovation and research, will also be explored.  

As a result of the new model we hope to achieve  the following benefits:​ 

  • Fewer overall clinical appointments (hospital, community, mental health, GP) ​ 
  • Improvement in clinical outcomes 
  • More co-ordinated and timely decision making and planning ​ 
  • Timely and easier access to appropriate clinical services and treatments  

Lived Experience Advisory Group 

We’re forming a group of people with first-hand experience to share their thoughts and help inform the design and delivery of this service.   

If you have lived experience of two or more long-term health conditions (including but not limited to diabetes, heart problems, respiratory conditions (such as COPD) or high blood pressure and currently live in one of the following London boroughs: Barnet, Camden, Islington, Haringey or Enfield, we’d love to hear from you.  

For more information about being part of the Lived Experience Advisory Group, please get in touch with the team: nclha@uclpartners.com 

Find out more 

Contact the Complex Long Term Conditions programme team: nclha@uclpartners.com