Long Term Conditions Collaborative: Improving Care Pathways

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


Improvement Actions:

  • Use MCNs as improvement champions
  • Share learning from patient and carer participation developed by MCNs
  • MCNs should engage with the relevant local Voluntary Sector groups to oversee quality of disease specific and generic patient information


Managed Clinical Networks ( MCNs) have been around for over 10 years and although each one is different, they all comply with the same core principles. The purpose of a Managed Clinical Network is to link people across boundaries to improve services for the people using them. Very few people are employed in Managed Clinical Networks, rather they achieve results by enabling participants to come together to work through what needs to change.

MCNs have a key role in the work to develop and support the LTC model of care. They have wide functional and system wide membership and include the interest groups relevant to a particular condition. They have a particular role and responsibility for:

  • Provision of disease based clinical leadership - promoting clinical excellence
  • Identification and promotion of best practice to improve disease based care
  • Provision of a focus for various stakeholders to contribute to improvements in both service and care
  • Making change happen - acting as change agents

A large proportion of LTC patients have co-morbidity and, if we are going to be truly person centred, then we need to shift the service towards generic pathways. We need to move away from our current fragmented service needs to be more effectively integrated.

Can we develop one stop ' LTC' clinics to address more than one condition, e.g. Diabetes and CHD - so that people have one visit rather than many, and tell their story once? Clearly this benefits both the person and the service.

The person with a long term condition experiences support from a range of professionals and agencies. All too often there are gaps, overlaps, and poor communication across these individuals and agencies. The MCN takes an integrated approach both within the NHS and across the range of partnership agencies with whom it engages. We all need to recognise that our service is part of a bigger whole. We need to build common goals and clarify our roles and those of our partner organisations to ensure that the journey and processes experienced are truly "seamless".

In a whole systems approach there is a need to give due emphasis and recognition to people's social care and support needs as well as their health needs. Good examples of integrated multi-agency approaches include:

  • Integrated care management
  • Condition management and paths to employability
  • Anticipatory care work on health literacy and financial exclusion issues
  • Multi-agency care networks for older people and learning disability

In any customer improvement programmes, companies focus on obtaining customer input and feedback. The same principle applies to our service improvement. If we genuinely believe in placing the patient at the centre of the service, then we have to actively support patients and carers to provide feedback and ideas. MCNs have been working with people to identify what problems they commonly face. They have great ideas on how to improve care for long term conditions - get their contribution.

There are recurring issues and common themes faced by all MCNs. We need to get better at identifying and sharing success and promoting best practice both within and across MCNs.

Have you fully engaged the energy, expertise and reach of your local MCNs?

The majority of MCNs focus on long term conditions such as diabetes, coronary heart disease, respiratory disease, stroke and palliative care at local NHS Board level.

There are a number of regional networks for cancer, learning disability, epilepsy and child protection.

A number of national networks address paediatric conditions, pathology, diagnostic imaging and acquired brain injury.

There are now 134 MCNs listed on the SHOW website . All are happy to be approached for further details. Please note that the SHOW list is currently being updated. For the most recent version, please contact

Here are some ways that MCNs support quality improvement. Full details can be accessed at:

Sharing Resources and Experiences

MCN Function


Change Agent group Quality Improvement Champions

MCNs have a quality assurance framework. They work with local improvement programmes, rehabilitation coordinators, PFPI structures and clinical governance groups and provide regular quality audit reports

Balance the evidence base with user experience

In developing their COPD guidelines, Lothian's Respiratory MCN involved people with COPD and their carers to advise on the issues they felt needed to be addressed

Engage a wide range of stakeholders

The National Paediatric MCNs support the whole family under difficult circumstances. They do this in innovative ways through facilitated family days, information roadshows and family evenings with invited expert speakers

Improve equity of care

Tayside respiratory MCN champions telepulmonary rehabilitation to increase access for rural communities

Develop generic pathways across related conditions Lanarkshire's MCNs are working collectively with council leisure services to widen access by introducing generic cardio and strength & balance classes, replacing some existing condition-specific classes

Design pathways to enable faster diagnosis/management plan

Diagnostic pathway for heart failure currently being piloted in Victoria Infirmary for GPs in SE Glasgow CHP. See Appendix 4 for full details of the pathway

Develop as multi-agency care networks

The South East and Tayside Learning Disability MCN operates across four NHS Boards and nine local authorities. It produced accessible communication guidance to support setting up a new regional forensic unit

Involve and support carers

Lanarkshire's Palliative Care MCN is training unpaid carers to explore the support needs of other carers, anticipating that the interviews will be qualitatively different when carried out by someone with a shared caregiver identity

Focus on the service user

The Young People's Involvement Group of the West of Scotland Child Protection MCN produced leaflets (pitched at two levels of understanding) on what young people need to know about a forensic medical - not what the professionals think they need to know

Amplify the voice of people who use services

Voluntary organisations have supported many CHD, Stroke, Diabetes and Respiratory MCNs to deliver VOICES training, which supports lay representatives to effectively contribute to MCNs and influence service improvement

Deliver structured education for staff and patients together

The Respiratory network in Ayrshire and Arran is engaged in the Co-creating Health programme where staff and people with COPD learn together

Share and spread good practice

The National Acquired Brain Injury MCN led the development of standards of care for Traumatic Brain Injury and developed underpinning educational competencies to share and spread across Scotland

Collaborate with other organisations to improve services

NHSGG&C's Heart Disease MCN are working with Chest, Heart and Stroke Scotland and British Lung Foundation to set up a heart failure/ COPD support service

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