Health services delivery

How to setup health services for long-term conditions

Designing services for long-term conditions

Long-term conditions (LTCs) in the UK are a pressing health and social care issue, encompassing chronic illnesses that require years of ongoing management.

The incremental increase in the number of people with multiple long-term conditions has a significantly detrimental effect on individuals, society, the economy, and health services.

With only 20% of health outcomes stemming from formal healthcare (with social factors and health behaviours accounting for 70% and the physical environment for 10%) we need to look beyond traditional ways of working and ‘rethink’ how we design how people, communities and health and other professionals work together healthcare solutions.

Impact on long-term conditions services

95%

achieved all their ‘what matters most’ goals after stroke service transformation

223%

improvement in DDR in ten years (Dementia Diagnosis Rate)

30%

reduction in MSK referrals to secondary care

A person with multiple long-term conditions is a person first and foremost.

Jo Crease Head of Strategy and Innovation

Jo Crease
Head of Strategy & Innovation at Here

How we design long-term conditions services

“Person-centredness, supported self-management, proactive care, and support for family and carers are fundamental and essential components across the entire care spectrum for people living with LTCs.

This is an important concept that if fully embedded within health and care professional practice and culture would result in significant benefits for people, their families, communities and professionals themselves.”

NHS England – Our Declaration: Person – centred care for long term conditions

Retaining clinical expertise, facilitating patient leadership and reaching the whole community with personalised health services is a challenge.

We can help.  

Our health service design model is built on practical experience in delivering services for long-term conditions like MSK, Dementia, and Stroke.

We work with people seeking care, combining our clinical expertise in conditions, treatments and human behaviour, with what matters to people, their support network and our communities. These unique collaborations and shared decisions unlock sustainable approaches that work for everyone.

By rethinking how support is designed and delivered, our approach puts people and their communities at the centre of better health outcomes.

Drawing on our experience in delivering personalised care, we developed these key pillars of service design for long-term conditions.

Because our services are developed around these core principles, we know they work in practice. No guesswork, just personalised healthcare at scale for better patient outcomes, reduced waiting times, and optimised services.

Joined-up

Working hand in hand with patients, partners and communities to create healthcare that works.

Person-centred

From collaborative design rooted in the perspective of people with lived experience to ‘What Matters to You’ conversations, personalisation comes as standard.

Equitable

We use data to identify under-served communities and use our findings to reach out to co-create solutions.

Optimised

Using the latest technology, we develop smart systems that enable health professionals to deliver exceptional care for the whole community.

Sustainable

Continuous improvement means services are responsive to evolving needs and take advantage of new technology as it emerges.

Cost-effective

With all this built-in, there is no need for expensive retrofits or disruptive transformations down the line; they are efficient, effective, and value-for-money services.