Long Term Conditions Collaborative: Improving Care Pathways

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


Improvement Actions:

  • Build effective working relationships with colleagues in other agencies
  • Ensure case/care managers have the appropriate skill-set and experience
  • Review and develop roles and enhance skill mix
  • Give bespoke care to those with complex needs
  • Clarify who has 'responsibility of care'


Integrated delivery systems such as the Veterans Health Administration and Kaiser Permanente achieve good outcomes for people with long term conditions. In these systems care is organised around multi-specialty medical groups incorporating primary physicians, nurses, allied health professionals and specialists.

In Crossing the Quality Chasm the Institute of Medicine endorsed the contribution made to quality through collaborative working and coordinated and integrated team-based care and support. Key principles are:

  • Effective multidisciplinary team working and optimal skill mix
  • Integrated working across care settings and agencies
  • Anticipatory approach to assessment, care and support planning and review
  • Signposted pathways that deliver coordinated care and support
  • Clarity about responsibility through named case/care manager/key contact
  • Good communication with patient, carer, care team and all agencies
  • A workforce with the appropriate skills and capability

Effective pathways for long term conditions should deliver quality and value, maximise opportunities for independence and deliver person centred care and support closer to home. To achieve this we need multi-agency collaborations to respond to the increasing interdependency of partner organisations aspiring to deliver more personalised services, meet increasingly complex needs and rising public expectations.

Developing Workforce Capability

Sustainable improvement will require significant transformational change within and across partnerships. Developing the workforce is vital for modern, safe and sustainable services. This includes exploring new and extended roles for staff, greater collaboration and more development opportunities across disciplines and care settings.

Appropriate skill mix generates a capable, efficient, flexible team that works productively to achieve better outcomes. Achieving the right staffing and skill mix balance can free skilled practitioners from inappropriate duties and enhance capacity for direct care. It is difficult for educational programmes to keep pace with all the changes taking place in health and social care services. The current emphasis is on developing a capable workforce that can adapt to future challenges.

  • Competence describes knowledge, skills and attitudes at a point in time
  • Capability describes how an individual can apply and adapt learning from experience and continue to develop their potential


A Force for Improvement: The Workforce Response to Better Health Better Care (2009) identifies five over-arching workforce challenges for the 21st century: tackling health inequalities; shifting the balance of care; ensuring a quality workforce; delivering best value across the workforce; and, moving towards an integrated workforce. In the context of demographic pressure and legislative and regulatory frameworks for staff, leadership development is seen as essential in tackling these workforce challenges, in particular aligning service needs with the shape of the current and future workforce.

Co-producing Integration

  • Whatever the organisational structure or resource framework in place, the first step to lever rapid improvement in team based care is through integrated approaches at practitioner level and with people who use services.
  • Integrated community services may include one stop shops, day hospitals, local specialist outpatient clinics, models of care management, intermediate care and local urgent care services. They may also provide augmented care in people's homes and into care homes.

A range of integrated services are described at http://www.shiftingthebalance.scot.nhs.uk/improvement-framework/high-impact-changes/multi-disciplinary-extended-community-teams-including-carers-and-users/

Essential Shared Capabilities

The ten essential capabilities, first developed for Mental Health, describe the capabilities that staff of all grades and professional backgrounds should have or should develop. These have resonance for the multi-professional team caring with and for people who have long term conditions. The ten capabilities are:

  • Work in partnership
  • Respect diversity
  • Practice ethically
  • Challenge inequality
  • Identify needs of people and their carers
  • Provide safe person centred care
  • Make a difference
  • Promote rehabilitation approaches
  • Promote self-care and empowerment
  • Pursue personal development and learning
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