Long Term Conditions

What are our priorities and what do we want to achieve?

Our Long Term Conditions programme has prioritised performance in cardiovascular disease, diabetes and respiratory disease, in alignment with national policy, and performance targets.

What are we doing? Examples of our work

Integrated cholesterol management services

In respect of cardiovascular disease, we have continued to refine our approach to delivering integrated cholesterol management services, for patients with established cardiovascular disease. As part of recovery from the pandemic the lipid specialist nurses saw patients waiting for an outpatient clinic appointment. This accelerated the pace at which we were able to reduce the backlog for lipid clinics, returning treatment times to be in line with national standards.

Innovate heart failure services

We have continued to innovate heart failure services, building on the foundations of the virtual ward, and rapid access clinics established in preceding years. Patients attending hospital are now receiving maximum tolerated doses of medication in line with the latest evidence basis within a community setting. We have initiated a pilot giving patients access to medication in their own homes that normally would only be provided in a hospital setting. We will evaluate this initiative in the summer 2025.

Diabetes prevention, support and new technologies

In respect of diabetes, we have mobilised the Type 2 remission programme (also known as the low calorie diet) for a further year and continued to deliver on the prevention programme (further information in relation to these programmes can be found in the prevention section).

We have continued to roll out the Type 2 Diabetes in Adolescent and Young people service, targeting patients under 40 (who are shown to be less well controlled). We also commissioned and mobilised our Type 2 Diabetes Structured Education programme, to provide face to face options for education.

We continue to support a cross-organisational group that review performance in respect of the uptake of new technologies, such as Hybrid-Closed Loop systems, and target performance in obtaining care processes and treatment targets.

In respect of respiratory conditions, we undertook a review in line with the Joint Forward Plan 2023- 28, given the ambitions to deliver CORE20Plus5 priorities, the major conditions framework and the operational risks identified at each point along the pathway – prevention, access, early detection and diagnostics, treatment including specialist care.

Clinical respiratory pathway review

The review set about engaging a cross section of experts and stakeholders to review the current clinical respiratory pathway, in line with best practice evidence, and was completed across a number of sessions, and produced recommendations and the approval of next steps. This includes further scoping of changes in clinical pathways, a proactive model of care to support a winter response, approach to countywide diagnostics, a review of pulmonary rehabilitation, and establishment of Multidisciplinary Teams (MDTs).