NHS England pilots new scheme to help GPs tackle long-term conditions

NHS England is to launch a new pilot scheme that aims to help general practitioners assess the care and support needs of people with long-term conditions.

A new assessment tool, known as patient activation, is designed to help GPs put people with long-term conditions at the centre of the care and support they receive. It measures the knowledge, skills and confidence these patients have to manage their own health, and highlights where they need extra support.

The pilot, which will cover 150,000 people, is being launched in partnership with The King’s Fund, The Health Foundation, five clinical commissioning groups and The Renal Registry.

The launch follows the publication of a recent report from The King’s Fund, Supporting people to manage their own health: an introduction to patient activation, which introduces the concept of patient activation and its potential for application in England.

Research has also shown that people with long-term conditions with higher activation levels have better health outcomes, and that people with lower activation levels incur higher health care costs.

The challenge for health care professionals will be to work with the 10 per cent of people who have low levels of activation. Studies have shown that when the right services and support are put in place their activation and health improves, and they are able to make changes which improve their well-being.

Dr Martin McShane, NHS England’s Director for Long-Term Conditions, said: “I wish I had known about patient activation thirty years ago; I’m very excited about its potential to improve peoples’ lives. It’s about understanding that when talking to patients that there are two experts in the room – one with individual experience, the other with medical expertise. This pilot will bring together the best of both, putting patients at the heart of their consultation.”

Sheffield general practitioner Dr Ollie Hart said “I am a big supporter of the value of considering patient activation in clinical care. Patient activation is about a paradigm shift in how we as patients and clinicians interact and work together to get the best possible outcomes. Working like this means I can better understand where patients with long-term conditions are coming from and match my interventions to their needs.”

Adrian Sieff, Assistant Director of Strategy at the Health Foundation, said “The higher a person’s activation – their knowledge, skills and confidence – the better they are at managing their long-term conditions, resulting in better health outcomes. Patient activation can work as both a core diagnostic tool and an intermediate outcome measure.”

Dr Helen Gilburt, Fellow, Health Policy, The King’s Fund, said: “The evidence summarised in our new report shows that measuring patient activation can play an important role in improving health outcomes, encouraging healthy behaviours and tackling health inequalities in England.”


  1. Mrs Bridget Leech (Dr A B Shevlin FRCGP retired) says:

    I am a volunteer carer ambassador CarersUK in E Midlands.Having been a carer of my husband for 8 years-he was confined to a wheelchair and GP for 30 yrs+, i think it important to include that-‘essential other’ who supports the person with the Long Term condition, either family member or friend ie ‘unpaid carer’ See Triangle of which was primarily put forward for mental health but could apply to all. If they are supported and educated to understand the basics of the condition, their medication and how to keep both of them as well as possible at home and not just look at nhs support, I think activation would work much better.There is still a top down approach a lot of the time.The voluntary sector also can play a big part. There is a lot of good will and expertise out there if you ‘look outside the box’ !!!
    Bridget Leech

  2. Liz says:

    It strikes me that this could be a good tool and a good opportunity for GPs and community pharmacists to work together to support people with LTCs in the community. It would also fit very well with the “Healthy Living Pharmacy” ethos where pharmacy teams are trained in change managment , behaviour change and in some cases, in health coaching.
    It would be good to be able to run a community pharmacy pilot.

  3. Mike Kirk says:

    I have been active in the field of brain injury rehab for 10 years and involved in care and advocacy for people with LTC, since 1993. What the hell is all this management speak and shuffling the deckchairs on the Titanic. You people and your quango style acronyms need a lesson from the people at plain English. All practitioners know, including those who spout this patient oriented outcome goals stuff and wellness vacuity, you know this: there is too little money; taxpayers want things they do not want to pay for, esp for others care; demand is rising exponentially. Issuing endless exhortations and policy papers to GPs and others will not make the ends of this polarity meet. I have a Post Graduate Diploma in public sector commissioning. There is a conspiracy of rhetoric and not telling the public what you know they will reject. This is not adult decision making. There is a telling poem you should read: We Are The Hollow Men. People with ABI are not going to be served well by GPs, the great majority of whom know vitually nil about its sequelae or LT nneds. For all the talk and endless paper over the last 30 years indeed, no greater proportion of resources are going to community care options. You know that LA social services have reduced hours of domicilary care by 25% in 4 years, what an achievement. LA as you know full well, cannot afford to manage the people discharged from hospital. Discharge remains akin to beachy head.

  4. Trevor Fernandes says:

    Regarding the Patient Activation pilot, can anyone tell me which areas will be covered in the pilot? Which are the five CCGs involved in the pilot?


    • NHS England says:

      Hi Trevor,

      Thanks for your comment.

      The five CCGs are Somerset, Islington, NHS Horsham and mid Sussex, Tower Hamlets and Sheffield.

      Kind Regards
      NHS England

  5. Paul Munim says:

    For patient activation to work there needs to be support and encouragement for patients from local community organisations through services such as befriending, volunteer support and advice. There is a real danger that without local organisational support any gains will not be sustainable. We have created a website which enables patients to find their local community organisations and access support from them. We would urge health professionals to find a way to help patients access local organisations to support their patient activation. Our website is a free service that professionals can use.