Long Term Conditions Collaborative: Improving Care Pathways

A resource to improve care pathways for those with long term conditions.

Sharing Solutions for a Shared Challenge

The increasing number of people with long term conditions is a major challenge for health, social care and housing services in Scotland. Improving the Health & Wellbeing of People with Long Term Conditions in Scotland: A National Action Plan sets out our collective response to that challenge.

The Long Term Conditions Collaborative ( LTCC), building on the excellent progress made by Managed Clinical Networks ( MCNs), aims to support you to develop clearly signposted pathways for high quality person centred care that is effective, safe, timely and reliable, makes best use of the skills of the multi-professional team, and is supported by good communication and sharing of information across teams and care settings.

High Impact Changes and Improvement Actions

The Long Term Conditions Collaborative developed a set of clear and tangible improvements that we expect to make a big impact on the way people with long term conditions manage their own care and experience care provided by others. These High Impact Changes apply across the long term conditions pathway from diagnosis through self management, living for today, change in condition and transitions of care to palliative and end of life care.

Each High Impact Change has a bundle of Improvement Actions, all of which need to be implemented to successfully deliver the change. These improvement actions are based on changes that have been tried and tested by health and social care practitioners in the UK and beyond and reflect what people have said should be done to improve their experience of living with a long term condition. They give some solutions to what can seem like a complex and overwhelming challenge.

Improving Care Pathways

From our published LTCHigh Impact Changes and our Improvement Actions we have identified approaches that enhance care pathways for people with long term conditions (Figure 1). These approaches reflect learning from the many condition specific standards and pathways developed by NHS Quality Improvement Scotland and by MCNs across Scotland.

Our focus is generic support for improvement rather than condition specific. We share learning from NHS Board teams across Scotland and provide tools, techniques and a range of practical resources so that partnerships achieve better outcomes for people with long term conditions and an enhanced experience of care. We equip staff with tools to use at different times and in different situations along the pathway.

All our improvement tools focus on ensuring value for the individual. They include Plan Do Study Act ( PDSA) cycles/Model for Improvement; lean-thinking; Value Stream Mapping (process mapping, 6S and 7 Wastes that identify steps and activities that don't add value); DCAQ (Demand, Capacity, Activity, Queue) addressing capacity and flow to streamline pathways and reduce delays, and Poke Yoke to prevent errors thereby increasing reliability, productivity, safety and value across the whole system. Sometimes these techniques are delivered through Rapid Improvement Events.

There is growing interest in the use of the Logic model to illustrate the links between service inputs, outputs, activities and intended outcomes. This approach sets improvement and change in the context of the bigger picture and provides a road map to communicate the vision and to focus and improve its implementation. It offers a useful framework to integrate planning, delivery and evaluation, helps you identify what service approaches and resources are needed and what to measure for short term, intermediate and longer term outcomes. An example of a Logic Model is shown in Appendix 1.

Driver Diagrams are a project tool to breakdown the primary outcome (or main broad aims) into your system components and processes. In other words, to simplify it into increasing levels from primary objectives, then into detailed actions. These all contribute to achieving the overall aim. It allows the team to expand their thinking and to see the logical links at each level whilst always keeping in mind the overarching outcomes. In this case in relation to condition management and how we achieve best practice care for people with long term conditions. An example of a Driver Diagram is shown in Appendix 2.

Designing LEAN Pathways

Innovation and use of lean thinking will be critical for success in making sustainable improvements to pathways for long term conditions. Lean thinking has spread well beyond its birthplace in the realms of post-war Japanese manufacturing industry to secure a firm evidence base in the public sector.

Designing LEAN Pathways


To truly understand what the person wants ( not what we think they want)


To really understand what our current service delivery is and what the problems are.


To link together all the steps, activities and processes in the most efficient way we can (maximising value), eliminating waste and blockages to deliver a better service.


To consider the demand that drives the service, plan for, and better manage it.


Improvement is a journey without end. There is always room for improvement.

Empowerment and Momentum

Lean seeks to empower and motivate frontline staff to make the changes that they feel will improve the system and process, all the time focussing on the needs of the person receiving services. Frontline staff own the process and it is their innovations that will bring the gains required to deliver and sustain a quality service.

Support for Improvement

This document aims to provide you with practical steps to help you improve the health and wellbeing and the quality of care for people with long term conditions.

It is part of a series of LTCC resources:

  • High Impact Changes
  • Improving Complex Care
  • Improving Self Management Support
  • SPARRA Made Easy
  • Proactive, Planned and Coordinated: Care Management in Scotland
  • Anticipatory Care Planning: Frequently Asked Questions
  • Making the Connections - Food For Thought, Anticipatory Care, Self Management and Community-led approaches to Health Improvement

These resources and other tools are available to download from the LTCC Community of Practice website: www.knowledge.scot.nhs.uk/ltc

This website provides access to published resources on the NHSScotland e-library and is complemented by local resources provided by members of the community. The aim of the site is to develop knowledge and share long term conditions related good practice.

The website enables members to:

  • Access education and learning resources
  • Locate and contribute information and evidence
  • Collaborate with colleagues
  • Access information to support evidence-based practice ( e.g. guidelines and policy documents).

Other websites that have useful information about improvement tools:





The five principles of LEAN should underpin our improvement work

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