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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 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. 

In the video below you can hear more from the patient’s perspective about navigating the system.

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. 
  • The number of people with complex long-term conditions is rising 7% faster than overall population growth.
  • Each year, approximately 150,000 people in NCL experience more than 10 acute care encounters
  • The number of people with LTC is expected to grow to 8% by 2030. 

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.​ 

Feedback from our lived experience advisory group reflects the human cost of this fragmentation—patients and carers described feeling like they were “in a plane with no pilot,” with their personal needs often overlooked or lost between services

The solution

In response, system leaders across NCL have come together through the Provider Collaborative to develop and test a new coordinated care model for people with complex long-term conditions. This model was co-designed by clinicians, operational leaders, and patients through dedicated design workshops, drawing on learning from existing integrated care initiatives.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​ by   

  • Appointing early adopter primary care network (PCN) test sites 
  • Creating bespoke, risk-stratified patient lists using both primary and secondary care data 
  • Establishing a clinical team of link consultants aligned to each PCN, supported by a central coordination team 
  • Conducting in-depth patient reviews using full access to all EPR systems  
  • Building a network of specialist advisors who support care planning without requiring new referrals 
  • Holding joint case discussion meetings to create and implement shared care plans, fully documented and visible across primary, acute, and community systems 

This approach enables consultants to shift from reactive, siloed care to proactive, joined-up support, with strong links to community services – improving patient outcomes, experience, and the overall value of care delivery. 

Impact

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

  • Fewer overall clinical appointments across hospitals, community services, mental health and GP practices ​ 
  • Improved health outcomes for patients 
  • More joined-up decision making and care planning 
  • Faster and easier access to the right treatments and services  

To date, findings include: 

  • Many patients reviewed were ‘under the radar’ – not able to access care in the way it has been provided 
  • In many cases the team have been able to reduce duplication, improve the timing and coordination of appointments  
  • Of over 200 patients reviewed, only 3 new secondary care referrals have been made 
  • Out of the first 177 patients discussed, 69 medications were changed, specialist advice was gathered in 95 cases 
  • Clinicians have reported stronger collaboration between GPs and secondary care teams, and increasing confidence in managing complex, multi-morbid patients. 
  • Behaviour change is emerging as a key driver of success, suggesting potential for broader adoption across the Integrated Care System (ICS). 

Since the programme started, we have head from patients that:  

  • They’re grateful to have access to a service that can help co-ordinate systems 
  • It’s really good to know that people are checking in on me and my care 
  • It’s reassuring to know that the help is there if it’s needed 

Learning 

Responding to multi-morbidity is a national issue and the programme has shared learning with other provider collaboratives in the London region, on national webinars including NHS Providers and with colleagues in neighbouring systems. The programme is featured in the Kings Fund report on approaches towards complex long term conditions. We have documented early learning with publications in the HSJ and through LinkedIn blogs and presented a session at NHS Confederation Expo. 

Scaling success 

Based on our promising results in 2024/25 the NCL Health Alliance secured funding to continue and expand the programme for 25/26. We are therefore scaling our approach from individual PCNs to delivering at a neighbourhood footprint in 2 of our boroughs. By operating at a Neighbourhood level we will explore the opportunities to create a seamless service for patients with long term conditions embedded alongside the development Integrated Neighbourhood Teams. 

Through the programme we are exploring the development and use of machine learning to create a more predictive and accurate way to identify patients suitable for the CLTCS approach. The NCL HA is now working closely with the London Centre for AI and the NCL ICB analytics team to develop a machine learning tool using both primary and secondary care data to improve the efficiency and efficacy of cohort selection. 

Patient Involvement 

To share their thoughts and help inform the design and delivery of the service we set up a lived experience advisory group to work alongside us. The group brings together individuals living with or caring for someone with multiple long-term conditions and had invaluable insights to share. Read more about how the group helped shape the programme.  

Find out more