Health services delivery

How to setup health services for long-term conditions

Designing services for long-term conditions

The Department of Health and Social Care’s Major Conditions Strategy emphasises the need for joined-up, equitable and personalised care to meet the challenges of an ageing population and multiple morbidities. We fully agree, and what’s more, we know it works. 

True collaboration, seeing the whole person, reaching the entire community, and working to create health and well-being are the fundamental ingredients of our services; we’ve seen first-hand the positive impact of this approach.

Through our years of delivering CQC outstanding health services, we know personalised care leads to better patient outcomes, reduced waiting lists, more efficient service delivery and happier staff. 

That’s why our services are built on personalisation principles, with ‘What Matters to You’ conversations at the heart of our model. 

Impact on long-term conditions services


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


improvement in DDR in ten years (Dementia Diagnosis Rate)


reduction in MSK referrals to secondary care

Shaping services and support around the lives of people, giving them greater choice and control where they need and want it and real clarity about their choices and next steps in their care

Major conditions strategy: case for change and our strategic framework.

How we design long-term conditions services

The challenge is to retain [specialisms] while pivoting to a model that is built around whole-person care.”

~ Major conditions strategy: case for change and our strategic framework

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.

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. 


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


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


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


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


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


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.

A chronic condition affects our whole lives, from morning to night, throughout the seasons.

Dr Helen Curr
Chief executive at Here

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How else we can help

Health services delivery: We design and deliver CQC ‘Outstanding’ services and pathways.

Tools and training for health professionals: We provide award-winning analysis, automation tools, and time-saving training.

Innovation in healthcare delivery: We develop bold solutions to transform long-term conditions services and pathways.