Long Term Conditions Collaborative: Improving Care Pathways

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


Improvement Actions:

  • Develop an information directory
  • Provide a single point of contact to help access services
  • Provide as much care as possible in the community


Understanding the services and support available and navigating the complex health and social care system can seem daunting both for professionals and for the person/carer living with the condition. Access can be enhanced by applying improvement techniques to understand service needs, match capacity to demand, streamline care processes by identifying and signposting people to the most appropriate person to meet their needs, and by adopting a single point of contact approach for access to services.

Demand, Capacity, Activity, Queue ( DCAQ)

To maximise patient flow, services must be able to manage and flex their capacity and activity to meet changes in demand. To achieve this we need to look at the whole patient journey and, through process mapping and flow analysis, assess the service capacity, overall demand, backlog and activity issues wherever there are queues, waiting lists or capacity bottlenecks. Demand, capacity, activity and backlog need to be measured in the same units for the same period of time. The goal is to redesign the pathway to manage capacity and demand effectively and sustainably.

Referral to extended MDT

Explicit pathways can ensure that people are streamed to the right person, in the right place, at the right time. This may be the doctor, practice nurse, community nurse, CPN, pharmacist or allied health professional as well as the homecarer, social worker or voluntary sector support. Extending the scope of practitioners, introducing a skill mix to the team and involving the support of third sector and volunteers will enhance access and increase the productivity of the extended multi-professional primary and community care team.

AHP/Nurse Led Clinics

AHP/nurse led clinics have a valuable role in the management of people with long term conditions. AHPs and senior nurses undertake assessment, diagnosis, treatment and review for people with a range of long term conditions including diabetes, chronic pain, asthma, COPD, heart failure and stroke. These arrangements allow safe and effective care to be delivered more quickly and closer to home.

Directory of services and support

Staff and people with long term conditions need up-to-date information for effective decision making and signposting to available services. Pathways need to be supported by local protocols and service directories that include hospital and community based services as well as community and voluntary sector supports.

Single point of contact

There are benefits to be gained where health/social care professionals and/or people living with a long term condition can access services through a single point of contact which directs them to the most appropriate services to meet their needs. This minimises delays and duplication in assessments and enables earlier access to interventions. Examples include outpatient referral management centres, systems for direct access to simple equipment and referrals to community rehabilitation teams.


  • The Emergency Access Delivery Programme supports NHS Boards in shifting the balance of unscheduled care so that people will receive emergency care at the most appropriate level of the care system, as quickly and conveniently as possible. For further information visit the Shifting the Balance of Care website: emergency-access-delivery-programme/
  • Many Boards operate an Emergency Response Centre ( ERC) as a single point of telephone contact for GPs to refer patients with urgent medical need. The call advisor takes the patient details and advises the GP of appropriate alternatives to hospital assessment or arranges hospital assessment where appropriate including transport if required.
  • LTC Community Nursing Teams and Service Development Managers in NHS Lanarkshire and in Clackmannanshire have used DCAQ and LEAN methodology to review their processes. They have improved access by planning and allocating their caseload visits more efficiently and releasing time to care. A weekly Nurse Consultant led clinic extends specialist access for people with chronic pain and supports the training and development of community staff to hold local clinic. A Chronic Pain Self Management Toolkit supports people with chronic pain to manage their condition and reduces the need for follow up appointments.
  • Glenrothes and North East Fife have a Single Point of Access service linked to a range of community rehabilitation services through a single phone number or e-referral. This minimises steps in current systems of referral and allocation, reduces inappropriate referrals and minimises delay in assessment and intervention for patients.
  • Many teams have introduced ereferral forms for protocol led access to homecare and equipment provided by local authority partners. This reduces avoidable delays and improves the handover of information across teams and agencies.
  • NHS Forth Valley have developed a Service Information Directory ( SID) as a web based information resource providing easy access to information for patients and staff on what services are available and how to access them.
  • 'Borders Health in Hand' supports people with local information and advice on health and self management.
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