Long term conditions Archives - Here https://hereweare.org.uk/blog/category/long-term-conditions/ Rated Outstanding by the CQC Fri, 29 Aug 2025 10:09:05 +0000 en-GB hourly 1 https://wordpress.org/?v=6.5.5 https://hereweare.org.uk/app/uploads/2024/03/cropped-Here_favicon-32x32.png Long term conditions Archives - Here https://hereweare.org.uk/blog/category/long-term-conditions/ 32 32 Rethinking Our Health: Why it matters https://hereweare.org.uk/blog/rethinking-our-health-why-it-matters/ https://hereweare.org.uk/blog/rethinking-our-health-why-it-matters/#respond Fri, 29 Aug 2025 09:32:50 +0000 https://hereweare.org.uk/?p=17118 Introducing Rethinking Our Health – a new way of working with communities to support people living with long-term conditions.

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Rethinking Our Health: Why it matters

A Rethinking Our Health workshop space featuring flipcharts and whiteboards covered in colourful sticky notes. One flipchart is labelled "SOLUTIONS" with a hand-drawn lightbulb in the centre, surrounded by ideas on post-it notes. In the background, posters titled "YOUR HEALTH" and "BARRIERS" are visible, with more sticky notes and diagrams. The image is framed by an abstract teal shape.

Our CEO explores why rethinking health matters now more than ever and how community-powered approaches can reshape the future of healthcare.

The moment that sparked a quiet revolution

In the summer of 2022, we were deeply inspired by a document from New Local – A Community-Powered NHS co-authored by Adam Lent, Grace Pollard and Jessica Studdert. The principles of community powered health were a clarion call for Here, triggering a quiet revolution in how we delivered our services.

A series of conversations in our clinical teams led to a series of startling innovations across our services, that New Local helped us to take to a wider audience. Our Community Appointment Days approach pioneered in the spring of 2023 is now unquestionably one of our most impactful innovations in delivering healthcare services. More than 120 providers across the UK have now engaged with Community Appointment Days – either adopting the model or actively exploring how to replicate it, changing our expectations of where and how healthcare should be delivered. So, when Adam says what he has written now is the most important thing since then, it’s time for us to take a look.

A healthcare approach based on traditional telling, doing, treating needs a radical rethink

Doing with, not doing to

Doing With: Reinventing Public Services In A Time Of Crisis | The King’s Fund speaks clearly to the challenge of our time – and today we are already in lock step with the approach outlined. Since the earliest days of our services for people with long term conditions we have built in patient leadership. Our staff now known as ‘Health Builders’ are a critical part of our infrastructure – people with lived experience who design and deliver services with the community, enabling the ‘do with’ approach that is so critical to our wider public service reform.

Why healthcare needs a rethink

Nowhere is this more critical than in healthcare. Given 80% of the determinants of health are not related to access to healthcare, a healthcare approach based on traditional telling, doing, treating needs a radical rethink – particularly when it comes to the upstream shift to prevention set out in the ten-year plan. Now, compared to when the NHS was founded, 65% of NHS spending is on long term health conditions.

A group of people of various ages sit around a table in a bright, community-style room, engaged in lively discussion. Papers, pens, coffee cups, and post-it notes are spread out on the table. A colourful mural and more participants are visible in the background, contributing to a collaborative and inclusive atmosphere

From treatment to management

What this means is the treatment paradigm needs to shift. For at least 65% of the time, we need to be focused on and enabling ‘management’ over treatment. That means a deep collaboration – led by the citizen, to understand how they want to manage their health condition and integrate this management approach into their daily life, to make sure they have the life that matters to them.

The language of healthcare: time for a rewrite

This frame does not feel shocking to me, and yet the implicit rules that underpin how we deliver healthcare suggest that this approach will be deeply radical. Nowhere is this more present than in the language we use to describe healthcare interactions. We ‘consult, prescribe, treat, review, discharge’. Patients ‘wait, present, comply, disengage or DNA’. We talk in acronyms and euphemisms, about CVD, COPD, CVA, about activation levels, health literacy, risk factors and the ‘hard to reach’.

We treat episodically, with little view of the whole person or their whole lifespan.

Listening with curiosity, humility, and a willingness to let go of assumptions is a radical act, one that can unlock different outcomes.

From patient to person

We ask if they are taking their prescribed medication daily, not if they are walking, talking to others, living in a place they can call home with good work, good friends and a good life.

Only rarely do we connect as humans, acknowledge what matters most, and work together to enable it to happen.  Joy, connection, quality of life do not show up in our lists of key performance indicators or our measures of productivity.

Listening is a radical act

Part of what gets in the way is the rigorous training, expertise and experience that sits in the hands of our health professionals. With so much hard-won knowledge and skill, it is challenging to adopt a listening approach, to acknowledge that what we care so passionately about may be of secondary importance to the patient in the room.

Listening with curiosity, humility, and a willingness to let go of assumptions is a radical act, one that can unlock different outcomes.

Charting a new course, Rethinking Our Health project

We know a different approach can work. In the pockets around the country that Adam highlights, new types of conversations are happening, and communities are uniting with new purpose. We’re excited to be exploring how to ‘rethink our health’ in a project at Here. We hope to both design and test new ways of connecting healthcare to communities – to map how healthcare services best ‘dock’ to places and the people they serve is our primary focus.

Alongside this, we want to track how change happens, what makes it possible and sustainable, and to share our learning as widely as we can.

We’re still early in this journey, but we believe this is where the most important work lies, and we’re not alone.

If you’re rethinking health too, we’d love to connect.

We’ll be sharing our learning as the project developspublishing regular reflections on what works and what doesn’t.

Sign up to updates direct to your inbox  

Also of interest

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Ingredients for community codesign: a venue, some flipcharts, a bowl of soup and a lot of trust https://hereweare.org.uk/blog/ingredients-for-community-codesign/ https://hereweare.org.uk/blog/ingredients-for-community-codesign/#respond Tue, 12 Aug 2025 09:46:54 +0000 https://hereweare.org.uk/?p=17092 Introducing Rethinking Our Health – a new way of working with communities to support people living with long-term conditions.

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Ingredients for community codesign: a venue, some flipcharts, a bowl of soup and a lot of trust

A Rethinking Our Health workshop space featuring flipcharts and whiteboards covered in colourful sticky notes. One flipchart is labelled "SOLUTIONS" with a hand-drawn lightbulb in the centre, surrounded by ideas on post-it notes. In the background, posters titled "YOUR HEALTH" and "BARRIERS" are visible, with more sticky notes and diagrams. The image is framed by an abstract teal shape.

Reflections from our first Rethinking Our Health codesign workshops.

Codesign events with communities and partners 

July saw an important milestone in Rethinking Our Health, with our test site partners we held community codesign events to share back the findings of the engagement phase, and to discuss practical ideas to take forward in the autumn. These will be focused on our goal of community-designed, clinically backed support for people with or at risk of osteo-arthritis, cardiovascular disease and diabetes.

A mix of lived and professional experience

People seated around a table in a community codesign workshop. One woman speaks while others listen, with printed materials, post-it notes, and paper coffee cups on the table. A colourful mural is visible on the back wall.

At both events we had a half and half mixture of community members and people who work in health, local government, and the voluntary community and social enterprise (VCSE) sector.   

Designing the events with the community 

Both events were planned with our test site partners and community members, and this is key to how they went. This meant focusing on the biggest things people told us about in the engagement phase – there were pain, access to services, understanding and confidence around your condition, practical social and financial barriers.   

Two areas, two approaches 

In one test site there has been a history of (and a funded infrastructure for) conversations and partnership working. Over the last ten years, many issues have been discussed, the progress both desired and created by all, the codesign event felt natural. It felt like we could ask things of each other.   

In our other area leadership is more dispersed, local government takes a bigger role in leading and encouraging community health and engagement partnership working. Test site partners took a participatory appraisal approach to developing community engagement in our big question, and the pre-event work was important to building interest and confidence to take part.   

Shared energy and commitment 

One thing in common was that both events were buzzing with enthusiasm and commitment to neighbourhoods was clear. There is a real appetite for building on existing or previous work, ambition for better solutions and understanding that so much of this is built on relationships.   

A group of people participating in a roundtable discussion during a community codesign event. The table is covered with printed worksheets, post-it notes, and drinks. The setting is a bright room with murals on the walls and multiple groups in conversation

What we heard: Key themes from the codesigns 

Key themes that came out of both events were  

  • desire for local, early, holistic support  
  • positive and ambitious views on the role of community and VCSE in this  
  • community engagement and mobilisation, patient leadership and voice is critical  
  • importance of being heard, and *feeling* heard – both in individual situations as well as a community  

We heard a range of views about what kind of support could be given by clinicians versus non-clinicians, and creating different configurations of how community and clinician support could be offered together. 

Clinical risk and collaboration 

There’s an important discussion to be had about understanding and managing any clinical risk, which Here as a clinical and community-rooted organisation is well-placed to host.   

Looking ahead 

This way of working is how health care will be developed over the next ten years and beyond.

Dr Rowan

For now, sign up to receive an update when we publish the next blog. Want to get in touch about Rethinking Our Health? Email us: Collab@HereWeAre.org

Also of interest

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Rethinking Our Health: co-designing better support for long-term health conditions in Sussex https://hereweare.org.uk/blog/rethinking-our-health-co-designing-better-health-long-term-conditions-sussex/ https://hereweare.org.uk/blog/rethinking-our-health-co-designing-better-health-long-term-conditions-sussex/#respond Wed, 16 Jul 2025 15:56:33 +0000 https://hereweare.org.uk/?p=16827 Introducing Rethinking Our Health – a new way of working with communities to support people living with long-term conditions.

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Rethinking Our Health: co-designing better support for long-term health conditions in Sussex

A Rethinking Our Health workshop space featuring flipcharts and whiteboards covered in colourful sticky notes. One flipchart is labelled "SOLUTIONS" with a hand-drawn lightbulb in the centre, surrounded by ideas on post-it notes. In the background, posters titled "YOUR HEALTH" and "BARRIERS" are visible, with more sticky notes and diagrams. The image is framed by an abstract teal shape.

Introducing Rethinking Our Health – a new way of working with communities to support people living with long-term conditions. 

Rethinking Our Health is a new collaboration between Here and The King’s Fund, bringing together communities and organisations across Sussex to explore new ways of supporting people living with multiple long-term conditions. 

Together with partners in the voluntary, community and social enterprise sector, primary care, and local government, we’ll be focusing on two neighbourhood test sites: 

 

  • Wick in Littlehampton, supported by the Arun Integrated Community Team (ICT), and 
  • Hangleton & Knoll in Brighton & Hove, supported by the West Brighton & Hove ICT. 

Why is this needed? 

Long-term conditions (LTCs) are among the most pressing issues in health and social care in the UK. These chronic illnesses require sustained, ongoing management, and an increasing number of people are living with more than one condition. 

This rise in multiple long-term conditions is having a serious and growing impact on individuals, families, communities, the economy, and our health and care services. 

However, formal healthcare only accounts for around 20 per cent of a person’s health outcomes. The remaining 80 per cent are influenced by social factors, health behaviours and the physical environment. This means we need to look beyond traditional ways of working and rethink how people, communities, and professionals across health and other sectors come together to design solutions.

Supporting the ambitions of the NHS 10-Year Plan 

This project directly supports the aims of the new NHS 10-Year Plan, which prioritises prevention, neighbourhood-level care, personalised support, and tackling the root causes of health inequality. 

Rethinking Our Health aligns closely with the plan’s ambition to strengthen the role of communities and the voluntary sector in health improvement, and to give people more control over managing their own conditions. It also helps test practical approaches to joined-up, place-based care, delivered through integrated neighbourhood teams. 

Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.

Who we’re working with 

Wick test site partners 
Voluntary Action Arun & Chichester, Arun District Council, West Sussex County Council, Arun ICT 

West Brighton & Hove test site partners 
The Hangleton & Knoll Project, Portslade Health Centre 

What we’re aiming to do 

People with more than one long-term condition often face a tangled web of barriers to managing their health, not only clinical symptoms, but also housing pressures, transport issues, isolation, work stress, or caring responsibilities. 

Rethinking Our Health is about working with communities to design and test new ways of offering support that will: 

  • be rooted in the community and built around people’s real lives 
  • be clinically backed and co-designed with local professionals 
  • recognise and respond to the social and environmental barriers people face 
  • help prevent the development of additional conditions 

Initially, we will focus on supporting people living with osteoarthritis, diabetes and cardiovascular disease, which are often experienced together. We expect pain and mental health to be important factors in this work, although persistent pain will not be included in the project. 

What we know 

We know that people face a wide range of barriers when it comes to managing their health. These include: 

  • social factors such as housing, work, transport and caring responsibilities 
  • the combined impact of multiple conditions 
  • fragmented services which treat conditions in isolation 
  • isolation or a lack of local support 
  • limited knowledge, confidence or skills to manage their health 

How we’ll work 

The project will unfold over four phases: 

  • Community engagement (May–June 2025): Listening to local voices and experiences 
  • Co-design sessions (July 2025): Shaping the new approach together 
  • Delivery of the new Rethinking Our Health offer (autumn 2025 onwards) 
  • Evaluation of the impact and process (autumn 2025 onwards) 

Our principles 

Everything we do will be underpinned by a shared set of values and principles: 

  • Asset-based and community-led: starting with strengths, not just needs 
  • Clinically backed, co-delivered: health professionals and communities working together 
  • Personalised care: support tailored to each person’s life and goals 
  • Equal weight to social and clinical factors 
  • Addressing health inequalities head-on 
  • Trauma-informed ways of working 
  • Generous leadership and open sharing of what we learn 

Stay connected 

 If you would like to know more or get involved, please contact jo.crease@nhs.net.

We will be sharing our learning and progress as the project develops on our blog.

Also of interest

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The Health Builder difference: Redefining patient involvement https://hereweare.org.uk/blog/health-builder-difference-redefining-patient-involvement/ https://hereweare.org.uk/blog/health-builder-difference-redefining-patient-involvement/#respond Mon, 09 Jun 2025 17:02:18 +0000 https://hereweare.org.uk/?p=16668 At Here, we believe that designing exceptional care means working in true partnership with the people who use our services. In this blog, Health Builder Norman Webster shares how our unique approach puts lived experience at the heart of service design and delivery.

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The Health Builder difference: Redefining patient involvement

South Asian man sat talking to a care navigator in a medial consultation room

At Here, we believe that designing exceptional care means working in true partnership with the people who use our services. In this blog, Health Builder Norman Webster shares how our unique approach puts lived experience at the heart of service design and delivery. 

Designing and delivering exceptional care surely has to include those for whom the care is being designed and delivered? “Do with” rather than “Do to” has to be the way forward to improve outcomes and shift responsibility from clinicians to a shared responsibility with patients. 

Patients and carers are involved as Health Builders in this design and delivery journey at Here.

What is a Health Builder? 

What is a Health Builder, I hear you ask.  

We are a small team of people with various long-term health conditions who work across services at Here, including Sussex MSK Health: Brighton & Hove and West Sussex. We are involved in patient empowerment initiatives like Shared Decision Making and Personalised Care. Our work spans advising on policy documents and public-facing communications, observing clinics to provide feedback for clinicians’ Continuing Professional Development, and helping improve pathways in areas such as stroke aftercare. One of our team members has even provided the voice-over for our informative patient videos.

The Health Builder team is unique in that we are paid according to NHS guidelines for honoraria and we are involved in areas of work as true partners in creating exceptional care.

Holding space in service design 

We are confident in holding our space at the table when important, exceptional care service design conversations happen. We know one another and can speak up for each other in these spaces. We hold regular “Big Conversations” in community settings to gather the views and feelings of our communities. We explore current themes in health care delivery in local communities.  We explore how people currently access our services and what could make the experience smoother and more accessible for everyone. We do this so that we can represent them in the policy and governance decisions as they are made. 

Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.
Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.

Building accountability into new governance structures 

There is a formal route of reporting our work through the Clinical Quality Oversight Group. This is a new group set up following the creation of the Sussex MSK Health: Brighton & Hove and West Sussex in December 2024. It is vital that, during this period of change within our service, we put patient experience at the heart of building this new MSK service with colleagues from across Brighton & Hove and West Sussex. 

More than a tick-box: meaningful involvement 

The Health Builder team is unique in that we are paid according to NHS guidelines for honoraria and we are involved in areas of work as true partners in creating exceptional care.  We are also unafraid to point out inadequacies in service creation and delivery. We are not simply a group of people with lived experience, wheeled out when “consultation” is required, as part of a tick box exercise. 

Our priority is providing community health and networking events to build long-term and meaningful relationships where those communities feel safe in expressing their health interactions with NHS services.

Valuing local and cultural connections 

We value community connections and are active members of groups such as Crawley Community Action, Community People, West Area Health Forum and Voluntary Action Adur and Chichester.  

The delivery of services to marginalised groups is important to us. We have facilitated health events with the Gurjar Hindu Indian community, Crawley Islamic Centre and Masjid, West Hove Health Forum and others. Apart from providing on-site health care, we are keen to hear the views of local communities. We provide feedback information via the Clinical Quality Oversight Group. 

Listening, acting and learning through feedback 

Our priority is providing community health and networking events to build long-term and meaningful relationships where those communities feel safe in expressing their health interactions with NHS services. Sometimes these conversations can be difficult, but we value and act upon all feedback through our community engagement efforts. 

One example of this in action is our work to improve stroke pathways. Health Builders collaborated with clinicians and service leads to gather and reflect the real experiences of people who had accessed stroke aftercare services. Through community conversations and targeted engagement, we identified areas where patients and carers felt unsupported, particularly in transitions between acute care and community rehabilitation. Our insights helped to shape clearer signposting, better continuity of care, and more personalised support for stroke survivors and their families.  

Our ultimate aim is to seek out marginalised groups and ensure members of those groups begin to feel that care is accessible and safe for them. 

Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.

Why Health Builders matter more than ever 

The NHS has been under immense financial pressure for years. Rising staffing, medicines, energy and fuel costs, a growing maintenance and estates backlog and the post-pandemic situation have tightened the NHS’s purse strings. The people in charge are forced to make tough decisions to balance the books. It is ever more important that patients derive maximum benefit from each interaction with the NHS and that they are treated in the most cost-effective ways possible. 

Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.

Making every contact count 

Health Builders provide wrap-around care to people who access our service by welcoming them at CAD and Hub events, supporting them at Peer Support Groups and ensuring that all services and communications are delivered in the most appropriate ways. 

By knowing our communities and understanding their needs through our “Big Conversations” and other activities, we can identify marginalised groups. We make every effort to engage with them to understand their specific needs. We try to make care feel accessible and safe for them. 

The bottom line is that we need to make every contact count in the current health economy. 

By Norman Webster – Health Builder.  

Also of interest

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Beyond the Diagnosis: What better care looks like for people with multiple conditions https://hereweare.org.uk/blog/beyond-diagnosis-better-care-multiple-conditions/ https://hereweare.org.uk/blog/beyond-diagnosis-better-care-multiple-conditions/#respond Mon, 02 Jun 2025 07:42:26 +0000 https://hereweare.org.uk/?p=16629 People living with multiple long-term conditions often experience fragmented care. In this blog, we reflect on The King's Fund’s latest report and share what we’ve learned about building services that support the whole person, not just a list of diagnoses.

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Beyond the Diagnosis: What better care looks like for people with multiple conditions

South Asian man sat talking to a care navigator in a medial consultation room

We know people living with multiple long-term conditions is fast becoming one of the defining challenges of modern healthcare.

Despite the prevalence of complex health needs, care systems are still largely designed around single conditions with separate appointments, professionals, and pathways that rarely speak to each other. For the individual, this can feel like navigating a maze of services with no map.

The King’s Fund’s recent piece on clinical coordination puts this issue into sharp focus. It calls for a shift from fragmented models of care to those built around the person as a whole recognising that people don’t live in silos, and neither should their care.

At Here, we’ve been working to build what this looks like in practice. Whether through integrated musculoskeletal services, faster and more compassionate dementia assessments, or data tools that support local systems to act more holistically, we’ve seen the difference it makes when care is designed for real life, not just clinical pathways.

This blog reflects on the themes raised by The King’s Fund and shares some of what we’ve learned as we try to build care around people, not problems.

Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.
Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.

 

1: From care pathways to life pathways 

Care that works well for a single condition can quickly become burdensome for a person managing several. Our MSK services in Sussex take a whole-person view—connecting people to physiotherapy, mental health support, community groups, and social prescribing, depending on what matters most to them. 

Crucially, this joined-up approach doesn’t just feel better for patients—it’s more efficient for the system. Avoiding duplication, reducing unnecessary referrals, and helping people access the right support first time leads to better outcomes and lower overall costs. Supporting someone to live well with multiple conditions is not just good care—it’s smart use of resources. 

Care built around complexity doesn’t have to be more complicated. When we design for real life, we find simpler, more sustainable solutionsfor people and for the system.

2. Design with, not for

One of the clearest lessons from our work is that services should be co-designed with the people who use them.

When we partnered with Age UK to deliver a new dementia assessment service, we built it around what people told us they needed: faster answers, fewer handoffs, more clarity and kindness. That feedback shaped everything from the clinical model to the language we use in our leaflets.

The result is a service that feels more personal, more efficient, and more trustworthy.

 

3. Make the tech work for people, not the other way round

As The King’s Fund rightly notes, good coordination relies on systems that talk to each other—and to the people using them. But all too often, technology ends up serving organisational or system demands rather than patient needs.

We’ve invested in data and analytics platforms that help different parts of the system understand population health and work together. The aim isn’t just efficiency, it’s insight that leads to better, more joined-up decisions.

Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.

4. Equity must be built in, not bolted on

People in more deprived areas are more likely to experience multiple long-term conditions—and to face greater barriers in accessing support. Reviewing data with people on the ground tells you where to focus.

By working alongside VCSE collaborators, we’ve created community health days in parts of Sussex where need is high and engagement is low, bringing services directly to people and reducing the friction of navigating formal systems. It’s a small step, but it reflects our belief that access and equity must be considered from the start, not retrofitted later.

 

5. Relationships matter more than structures

Changing systems is complex. But often, it’s the quality of relationships – between professionals, teams, and organisations – that determines whether care feels joined-up.

In our work, we’ve seen integrated teams flourish when they’re built on trust, mutual understanding, and shared purpose. Creating time and space for professionals to learn from each other and build those connections is just as important as any formal process redesign.

Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.

6: Measure what matters – to people and the systems

We’re still too focused on activity and throughput. While these metrics have their place, they don’t capture whether someone feels better, more supported, or more able to manage their health.

At the same time, understanding what matters to people gives us a clearer picture of what works and what doesn’t. That leads to better decision-making, better commissioning, and better value. It means investing in what genuinely helps and scaling back what doesn’t. True efficiency starts with understanding the person, not just the pathway.

 

Looking ahead

Supporting people with multiple long-term conditions is one of the most complex tasks in modern healthcare but it’s also where some of the greatest gains lie.

When we design care that reflects real life rather than idealised pathways, we unlock better outcomes and better use of resources. Coordinated, whole-person care doesn’t just improve people’s experiences; it reduces duplication, lowers demand on stretched services, and allows professionals to work more effectively.

Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.

At Here, we’re learning that care built around complexity doesn’t have to be more complicated. In fact, when we listen to people and work collaboratively across the system, we often find simpler, more sustainable solutions. 

We’re excited to be embarking on a new project with The King’s Fund to explore how a deeper understanding of multiple long-term conditions – and more intentional co-creation with the people living with them – can help shape healthcare that works better for both individuals and the system as a whole. 

Integrated, person-centred care is not a luxury – it’s essential to delivering quality and value in the NHS of the future. 

We’re looking forward to sharing what we learn through our collaboration with The King’s Fund, follow along for open and honest reflections, challenges, and learning as we go. 

Also of interest

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Dementia Action Week 2025: With the Alzheimer’s Society https://hereweare.org.uk/blog/dementia-action-week-2025-alzheimers-society/ https://hereweare.org.uk/blog/dementia-action-week-2025-alzheimers-society/#respond Fri, 23 May 2025 14:51:51 +0000 https://hereweare.org.uk/?p=16557 This Dementia Action Week, the spotlight is on diagnosis — helping people recognise the signs of dementia and take that all-important first step.

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Dementia Action Week 2025: With the Alzheimer’s Society

South Asian man sat talking to a care navigator in a medial consultation room

This Dementia Action Week, the spotlight is on diagnosis, helping people recognise the signs of dementia and take that all-important first step. At Here, we know how important it is that people feel supported not just after diagnosis, but from the moment they’re referred.

Photo of two white women outside with trees in the background. stood next to each other and smiling towards the camera. The woman on the left has long hair and the woman on the right has a short bobbed hair cut.

 

That’s why we’ve deepened our partnership with Alzheimer’s Society as part of our work to improve the Memory Assessment Service (MAS) in Brighton & Hove.

Together, we’ve worked to expand our support offer and connect more people to vital support services. From the point of referral, Alzheimer’s Society provides support, practical advice and signposting for people with memory concerns or a diagnosis of dementia and their families.

This partnership complements the work of our MAS team, who continue to offer regular check-ins and What Matters to You conversations. With increasing demand for memory assessments, this joined-up approach has helped us deliver care that is timely, person-centred and grounded in dignity.

We’re proud of what we’ve achieved together so far and committed to building on it, so that no one has to face the waiting period alone and everyone accessing our service feels informed, supported and seen.

We are delighted to be working in partnership with Here. Together we can help many more people to get the right support, at the right time.

 

Carrie Holmes
South East England Regional Manger at Alzheimer’s Society

Also of interest

The post Dementia Action Week 2025: With the Alzheimer’s Society appeared first on Here.

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Celebrating Social Prescribing Day: How Care Navigators are supporting our community https://hereweare.org.uk/blog/care-navigators-supporting-community/ https://hereweare.org.uk/blog/care-navigators-supporting-community/#respond Wed, 19 Mar 2025 08:02:32 +0000 https://hereweare.org.uk/?p=16318 Care Navigation/Social Prescribing is a model that enables health and social care professionals to refer people to a range of non-medical services within their community to improve social, mental and physical health and wellbeing.

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Celebrating Social Prescribing Day: How Care Navigators are supporting our community

South Asian man sat talking to a care navigator in a medial consultation room

Care Navigation/Social Prescribing is a model that enables health and social care professionals to refer people to a range of non-medical services within their community to improve and support social, mental and physical health and wellbeing.

Recognising that people’s health and wellbeing is affected by a range of social, economic, and environmental factors.

Care Navigation takes a holistic approach that enables people to take control of their own health. With the practical and emotional support of a Care Navigator this allows people to identify ways to improve how they are feeling.

Social Prescribing Day / Care Care Navigators Day

How does it work?

Our Care Navigators spend time helping people to focus on ‘what matters’ to them. They assess the needs of each individual and together create a personalised care and support plan. This may involve connecting them to community groups, classes, workshops, or even advisory bodies for legal advice or debt counselling.

Care Navigating success

There is increasing evidence in the success of Care Navigating/Social Prescribing and the impact it has on both individuals and communities.

“In one evaluation, six care navigators from voluntary care organisations worked in integrated health and social care teams across and county. They carried out up to six face to face interviews with an older person, with a unit cost of £42 (compared to £213 per visit for adult social worker). Health related quality of life measures improved by 17%, people needed to use fewer health services and the project was overall cost effective.” ~ Care Navigation: A Competency Framework

“Thank you so much, you’ve helped me to realise there are resources out there for me” – Patient was experiencing homelessness

 

Is there a difference between Care Navigators and Social Prescribers?

There is no universal definition of care navigation a variety of titles are used, including ‘care navigator (CN)’, ‘social prescriber (SP)’ and ‘link worker’. All these roles provide effective navigation and is a key element of delivering coordinated, person-centred care and support.

Care Navigators are often existing members of staff within Community Services and GP practices. At Sussex MSK Health, our Care Navigators work closely with clinicians, which helps to free up valuable clinical time for addressing physical health needs, while Care Navigators can focusing on non-medical and wellbeing concerns. By providing this additional support patients receive holistic care that extends beyond clinical treatment.

A woman with short dark hair is sat in a medical office for a care navigating conversation talking to a woman with long curly hair

Why have Care Navigators as part of our MSK service?

  • Help and support with barriers to appointments.
  • Liaise with clinicians/admin teams/clinical teams.
  • A chance for patients to unpack, reflect and think about their next steps.
  • Help people in multiple pathways within MSK and help make sense of their treatment plans.
  • Help stop people falling through the cracks and bouncing in and out of the service.
  • There are incredible resources out in the community – directing people more quickly to these can benefit the person.

Many things affect our health and wellbeing. We can all sometimes feel isolated, lonely, or stressed out by work or money. It can also be very difficult dealing with the stress of managing a long-term condition.

We now have a team of 8 people who are helping patients deal with similar concerns every day, creating personalised support plans for our patients giving them access the support and resources they need to help them feel better.

 

Read more about Personalised Care/ Social Prescribing on the NHS website: NHS England » Social prescribing

Or if you’d like to learn more about our MSK service you can find out more here: Community MSK Services in Sussex – Here

Also of interest

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Partnering with Age UK: Making dementia care more accessible https://hereweare.org.uk/blog/partnering-age-uk-making-dementia-care-more-accessible/ https://hereweare.org.uk/blog/partnering-age-uk-making-dementia-care-more-accessible/#respond Tue, 18 Feb 2025 16:16:22 +0000 https://hereweare.org.uk/?p=16246 As a social enterprise dedicated to transforming healthcare through data analytics, we are thrilled to share the inspiring story of Aaron Salter, winner of the Digital Champion Award at the Hospice UK Conference 2024.

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Partnering with Age UK: Making dementia care more accessible

Matthew Riley - a man wearing glasses, a grey suit jacket and blue jacket is stood smiling. Next to him stand a man with dark hair and a blue suit holding the Hospice UK Digital Champion Award

We know that getting a dementia diagnosis can be tough. Waiting lists are long, private options are expensive, and too many people are left without the answers and support they need. That’s why we’re proud to work with  Age UK West Sussex, Brighton & Hove, a trusted organisation dedicated to supporting older people, to make expert dementia assessments more accessible in Sussex.

Age Uk West Sussex Brighton Hove logo

Why increased access to dementia assessments matters

At Here, we run the Brighton & Hove Memory Assessment Service (MAS), part of the NHS’s vital network of dementia diagnosis and support. We know first-hand how essential these services are and how stretched they can be. Demand is high, and while we continue to innovate within our MAS service, the reality is that the NHS operates with limited finances. This means capacity is constrained, and waiting lists for NHS memory assessments can be long. 

Right now, around 40% of people over 65 with dementia remain undiagnosed in the UK. That means thousands of people in Sussex are navigating life without the right support, missing out on treatment, guidance, and the chance to plan for the future.  An early diagnosis can make all the difference, not just for the person with dementia but for their family and support network, too. It opens the door to practical help, medical care, and a better quality of life.  

This is where alternative options, like our collaboration with Age UK, can make a real difference. By complementing NHS services, we give people more choice, ensuring that more people can get the answers and support they need, without unnecessary delays.

A partnership rooted in care 

Our collaboration combines Here’s clinical expertise in dementia assessment with Age UK’s trusted support for older people.  Age UK WSBH is an independent charity dedicated to helping people over 50 stay independent, informed, and connected. From practical advice and information to social clubs and wellbeing support, their work helps older people make the most of life.  For over a decade, Here has delivered dementia services built on compassion, trust, and person-centred care. This partnership allows us to expand that work, ensuring people feel heard, respected, and supported throughout their journey.

More accessible dementia assessments

As a first step, we have launched The Dementia Clinic, a not-for-profit, paid-for service that offers the highest standards of compassionate care while keeping costs as low as possible. We focus on people, not profit, as two not-for-profit, purpose-driven organisations We are committed to making dementia assessments more accessible by: 

 

  • Keeping costs as low as possible while maintaining the highest standards of care. 
  • Making assessments easier to access without unnecessary delays. 
  • Providing compassionate, person-centred support tailored to each person. 
woman in dementia assesment smiling

Our vision 

Our vision is simple: a dementia care system that puts people first. We want to give people control over their care, provide real alternatives to long waiting lists, and reinvest in services that reach even more people. This partnership is a significant step towards making this happen.

Too many people wait too long for a dementia assessment, often feeling lost in the process. By working together, we can change that. Here’s clinical expertise, combined with Age UK’s trusted community support, offers people a fair, high-quality alternative that puts them in control of their care. We’re committed to working with the NHS, our communities, and trusted partners like Age UK to ensure that real needs and lived experiences shape their care services.

Helen Curr
CEO at
Here

We know we can’t fix everything overnight. But by working with partners like Age UK, listening to the people who need these services, and challenging the barriers to access, we can make a real difference. 

If you’d like to learn more about our partnership or working with Here, drop us a line at collab@hereweare.org.uk. If you’re looking for expert dementia support, find out more about The Dementia Clinic.

Also of interest

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Announcing the launch of our new MSK service https://hereweare.org.uk/blog/launch-of-new-msk-service/ https://hereweare.org.uk/blog/launch-of-new-msk-service/#respond Mon, 02 Dec 2024 13:45:36 +0000 https://hereweare.org.uk/?p=15924 We’re delighted to announce the launch of Sussex MSK Health Brighton & Hove and West Sussex, our new Musculoskeletal (MSK) service, starting 2nd December 2024.

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Announcing the launch of our new MSK service

Sussex MSK Health Brighton and Hove and West Sussex - NHS logo

We are delighted to announce the launch of Sussex MSK Health Brighton & Hove and West Sussex, our brand-new Musculoskeletal (MSK) service, which officially begins today – 2nd December 2024.

This launch marks a new chapter in delivering joined-up, person-centred care. Together with our partners Sussex Community NHS Foundation Trust (SCFT), we’re building on over 10 years of expertise in designing and delivering innovative long-term conditions services, including CQC outstanding MSK care. 

Image of a woman with her foot on a practitioners knee receiving MSK treatment

A new era of integrated care

The new community service covers Brighton & Hove and West Sussex, replacing Sussex MSK Partnership Central (SMSKPC), University Hospitals Sussex (UHSussex) and Coastal Sussex Integrated MSK Service (CSIMS).

 

Key highlights of our approach 

  • Integrated care pathways: We connect primary, community, and secondary care, creating seamless experiences for orthopaedics, pain management, and rheumatology. 
  • Patient-first design: Our care begins with meaningful “what matters to you” conversations, empowering people to make informed decisions about their health. 
  • Equitable access: From digital self-management tools to flexible in-person and virtual appointments, our service adapts to meet diverse needs. 
  • Improving outcomes: Focusing on reducing health inequalities, we ensure timely, high-quality care for all. 

 

What sets us apart 

  • 10+ Years of quality: Building on a decade of pioneering MSK care, we have consistently delivered high-quality, patient-centred outcomes. 
  • Collaborative innovation: Our partnership with SCFT exemplifies integrated working across the NHS and beyond. 
  • Ambitious vision: This service is part of a five-year transformation programme, aligning with Sussex’s health strategy, Improving Lives Together.

 

Why it matters 

Musculoskeletal conditions are one of the most common long-term conditions in the UK. Affecting one in three people and significantly impacting their quality of life and independence.

As specialists in long-term condition care, we understand the importance of creating services that are easy to navigate, responsive, and effective at supporting people to live well. 

We’re proud to be shaping the future of MSK care, ensuring that everyone in Brighton & Hove and West Sussex has access to exceptional, personalised support. 

To learn more about our approach and the impact we’re making, visit Community MSK Services in Sussex – Here

Also of interest

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Reflecting on a decade of impact: A farewell to Sussex MSK Partnership Central https://hereweare.org.uk/blog/farewell-sussex-msk-partnership-central/ https://hereweare.org.uk/blog/farewell-sussex-msk-partnership-central/#respond Fri, 29 Nov 2024 09:18:42 +0000 https://hereweare.org.uk/?p=15800 As we approach the conclusion of the Sussex MSK Partnership Central (SMSKPC) service, we’re taking a moment to celebrate the extraordinary journey we’ve shared. Over the past decade, this partnership has been more than a service - it’s been a community, a purpose, and a shared commitment to making a real difference in people’s lives.

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Reflecting on a decade of impact: A farewell to Sussex MSK Partnership Central

Sussex MSK Partnership Central

As we approach the conclusion of the Sussex MSK Partnership Central (SMSKPC) service, we’re taking a moment to celebrate the extraordinary journey we’ve shared.

Over the past decade, this partnership has been more than a service – it’s been a community, a purpose, and a shared commitment to making a real difference in people’s lives.

One woman with long blonde hair is laughing with another woman with dark hair tied up and with the sides of her head shaved wearing glasses

To mark this special occasion, we’ve created a series of videos that highlight the many achievements of SMSKPC and the incredible people who’ve made it all possible. Each focuses on a key aspect of our journey, showcasing the impact and the values that have defined our partnership.

Celebrating 10 years together 

Our first video takes us back to May 2024, when we celebrated ten years of SMSKPC at our annual conference. This event marked a special moment for us – a chance to look back on all that’s been achieved, and to recognise the people who’ve made it possible. 

Over the past decade, it’s been our team’s commitment and shared purpose that have shaped our success, and May’s celebration was a reminder of just how much we’ve accomplished together.

Making an Impact Person to Person 

This video shines a light on the tangible difference our service has made to people and our communities – it’s the personal connections that have been at the heart of everything we do.

Showcasing the positive feedback and gratitude of those who’ve benefited from our service, these stories of care and support truly bring our partnership’s impact to life.

Living Our Values 

It’s the culture that has defined our servicea culture built on strong relationships, shared values, and a deep commitment to patient care. The camaraderie, teamwork, and dedication of our team highlight the connections that have shaped our partnership and made it more than just a service, but a community. 

From the kindness shown in small gestures and moments of support to the collaborative efforts that have made a big differenceand the friendships formed along the waythis video is a chance to honour everyone who has contributed to delivering SMSKPC.

Each individual’s hard work, passion, and care have made this service possible.

A celebration of togetherness 

As SMSKPC comes to a close, this series is our way of looking back with pride and gratitude. We’ve come so far over the last 10 years, and it’s all thanks to the incredible individuals hard work, passion, and care have made our service possible. Together, we’ve built something truly special.

We hope our work inspires others to see the power of community, the importance of shared purpose, and the enduring impact of truly personalised care.

Thank you to everyone involved in being part of this incredible story. 

Stay tuned as we celebrate this final chapter of the Sussex MSK Partnership Central journey and say hello to MSK Health.

Two people sat at desks in a sports hall at laptops looking over their shoulders and smiling
SMSKPC team out walking on an away day
A man with dark hair smiling stood behind two women sitting down, one with dark hair and glasses, the other with long blonde hair

SMSKP ten year timeline

Journey through our memorable moments and key innovations from the past ten years ​to find out more about the development and transformation of SMSKP.

 
2014

Partnership forms

Here created a delivery partnership with Sussex Community Foundation Trust as prime contract holder for MSK

Collaboration

Drawing on strengths of expertise from across the system. Building networks across primary, secondary care the voluntary sector

Culture

Bringing teams together to create their own shared values – together we strive for human and unhurried care.

2015

We were the first organisation to recruit a Patient Director, putting the lived experience voice front and centre of the service. This has now evolved into our Health Builders Programme.

Personalisation

As one of the first services to create Personalised Care Leads we can evidence that seeing truly personalised care leads to better outcomes, better use of resources and saves the health system money

2016

Started addressing letters to patients ​rather than clinicians to ensure ​information is understandable, jargon ​free and supporting the “no decision ​about me, without me” approach

2018

Reached 7% reduction in referrals to ​secondary care, whilst ensuring quick ​access times within the community and ​supporting people to self manage

Quality

Safe, high standard care for patients is enshrined in all we do. We deliver at scale, a complex service, over 10 locations alongside over 200 colleagues

2019

Rated CQC outstanding

Won HSJ Partnership award

Regulated by Care Quality Commission
2020 - 2021

Proactively redirected MSK resource to ​support the urgent and non-elective ​COVID-19 response

2022

Publish The CASE For Change, Creating and Sustaining Excellence in MSK Care

2023

Data

Our decisions are data led. Using our award winning suite of data analytics for optimal resource management and meaningful future planning

Community

We work alongside communities, using our data systems to find underserved groups, we proactively seek to understand how we can meet their needs

Co-creation

Our network of paid and volunteer ​Health Builders – people with lived ​experience – work with us at every level ​of our governance structure and in ​service design and delivery

Vision

We see a future where community powered, personalised MSK care is standard, where seeing the whole person means we provide human and unhurried care for everyone and by doing so, facilitate better outcomes for patients, staff and our community

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