Long term conditions
Overview
We help health and care systems across south London to prevent, detect and better manage long term conditions (LTCs) such as diabetes, cardiovascular disease (CVD) and respiratory illness.
Bringing together commissioners, providers, researchers and industry to support the adoption and spread of proven innovations. Our work focuses on improving outcomes, reducing inequalities and releasing time to care.
Areas of expertise
- Transforming pathways and supporting the spread of evidence-based innovation
- Supporting innovators and developing industry partnerships
- Enabling strategic commissioning, including consensus building, planning, and pathway redesign
- Designing and delivering change programmes and quality improvement
- Developing the workforce through training, capability building and learning programmes
Our current programmes support the following four core areas of work:
Cardiovascular Renal Metabolic Fellowship
The challenge
Primary care teams faced increasing levels of cardiometabolic risk, limited capacity, and unequal access to training. This contributed to variation in prevention and management across south London.
Solution
We co-designed a CPD-accredited Fellowship programme, combining clinical masterclasses, quality improvement training, and coaching. Fellows delivered real-world improvement projects across 12 boroughs, building capability in areas including hypertension, lipids, diabetes, chronic kidney disease, atrial fibrillation and weight management.
250
Trained over 250 clinicians across 63 primary care networks
5,000
Supported care for more than 5,000 patients
1,000
Enabled over 1,000 patients to receive newly initiated or optimised treatment
2%
Resulted in only 2% of patients requiring referral to secondary care
Been replicated across multiple NHS regions, supported by an active alumni network
Improving access to respiratory diagnostics in areas of deprivation
The challenge
Access to diagnostic testing for asthma and chronic obstructive pulmonary disease (COPD) was limited and inequitable, contributing to late diagnosis, misdiagnosis, and avoidable hospital admissions.
Solution
We established respiratory diagnostic hubs in areas of deprivation across south west and south east London. Working with primary care networks, the hubs introduced Fractional Exhaled Nitric Oxide (FeNO) testing alongside other lung function tests, bringing high-quality diagnostics closer to home.
1 in 3
In Bromley, 1 in 3 patients tested were from the most deprived 20% of the population
Respiratory testing rates in Merton doubled, with an additional testing site established
Increased access to quality-assured diagnostics in community settings
13%
In Sutton, enhanced recall processes increased testing among the most deprived groups (from 6% to 13% of referrals)
Get in touch
If you are looking to improve outcomes in long term conditions through innovation, we can support you to scope opportunities, align with national priorities, and implement change.
Projects
Latest
