Improving care for patients with long-term conditions

A Royal Free London (RFL) respiratory consultant is working across north central London to improve the experience of care for patients with long-term conditions (LTCs).

Dr James Brown (pictured) is working with NCL Health Alliance (UCLPartners) to test new models of care to improve managements of LTCs, including fewer appointments, better decision making and easier access to services.

Patients with LTCs and co-morbidities currently often have a disconnected experience of care. Around 70% of healthcare spend is on managing patients with LTCs, and in NCL alone, 430,000 people are living with at least one long term condition.

The aim of the programme is to bring changes across the system for the management of these conditions. This will include finding ways for consultants and coordinators to access information safely and appropriately from across different trusts and finding ways to reliably update patient records across different hospitals.

The programme will be tested at two primary care networks from November 2024, with two further networks joining in early 2025.

James said:

“This is an ambitious project that aims to find a new way of working to help people with multiple health problems”.

“Too often providers of healthcare work in disconnected ways and aren’t able to think about the patient’s needs as a whole. I am delighted to be involved with a project that is bringing together teams from across North-Central London to implement new ways of working.”

Equitable diagnosis and access to healthcare, as well as population health, are key parts of the RFL’s clinical strategy.

James said:

“This project fits very well with the Royal Free London’s clinical strategy aims to improve population health and address health inequalities. Working beyond hospital walls to influence and improve patients’ experience of care overall is central to that.”

Part of the programme includes the formation of a lived experience advisory group. This will be formed of a group of people with first-hand experience to share their thoughts and help inform the design and delivery of the service.

Rachel Lissauer, transformation director, NCL Health Alliance (UCLPartners), said:

“Patients with multiple long-term conditions face a significant mismatch between the care they need and the care they are offered. Many patients have care at more than one hospital. It can be difficult for people with multi-morbidity to be seen ‘in the round’.

"Our programme is testing an approach to allow Consultants to work in an integrated way, across sites and specialities to improve patients’ care and outcomes. It is great to work with Royal Free London and others across NCL to test and learn from this programme."