Long Term Conditions Collaborative: Improving Care Pathways

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


Generic Choice Model for LTC, Department of Health (England), 13 December 2007

Highlights how the care planning process feeds into the commissioning of more personalised services for people with LTC.

A Force for Improvement: The Workforce Response to Better Health, Better Care (2009): The Scottish Government, Edinburgh

The framework contained in this document highlights the role the workforce can play in delivering better care and the work to improve the investment in staff training, development and wellbeing.

NHS Institute

This provides access to the Institute's document on Multidisciplinary Team Working which can be downloaded once registration is complete.

NHS South Birmingham

This link provides access to a webpage describing the core integrated multidisciplinary team and virtual team supporting people with long term conditions.

NHS Innovations

This document provides information of the Pulmonary Rehab Training Programme in NHS Innovations South East

Stroke MCN Scotland

This link provides information on the Framework for Adult Rehabilitation together with a list of high impact changes and recommendations. rehabilitationsummaryofhic1.pdf

University of Birmingham/ NHS Institute for Innovation

This document is a review of UK and international frameworks for improving care for people with long term conditions.

Australian Public Health Information Development Unit

The information in this atlas adds to a convincing body of evidence built up over a number of years in Australia on the striking disparities in health that exist between groups in the population. People of low socioeconomic status (those who are relatively socially or economically deprived) experience worse health than those of higher socioeconomic status for almost every major cause of mortality and morbidity.

Remote daily real-time monitoring in patients with COPD - A feasibility study using a novel device

The study involved remote monitoring and spirometry by patients and resulted in reduced hospital admission based on parallel data from the previous year.

Sheffield PCT

Article on the Sheffield Telehealth Project for people with lung conditions. The team involved won an award in the Innovative Information and Communications category in the Health and Social Care Awards.

Hampshire Community Health Care

Web article about the introduction of Community Hospital Releasing Time to Care projects undertaken in Gosport, Petersfield and Hythe and how direct time to care has increased as a result.

Strengthening The Role of MCNs, HDL (2007) 21, Scottish Executive Health Department

Royal Pharmaceutical Society

Copy of the Executive Study for integrating community pharmacy into long term conditions care.

The Scottish Government

Link to the guide for implementing supplementary prescribing for pharmacy practitioners in Scotland.

Loughborough 2007

An expert group established a series of priorities for improving care for those with long term conditions such as asthma, Chronic Obstructive Pulmonary Disease ( COPD), diabetes and Parkinsons disease.

Northumbria Healthcare NHS Foundation Trust

This links to a presentation by Dr Simon Eaton, Consultant Diabetologist on 'Partners in Care: How to make care planning a reality in your service.

Information and Communication of Real Time Data

Information about The Clinical Portal:



Further reading can be found by visiting the LTCC Community of Practice website:

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