Resources for long term conditions

Resources to support delivery of the long term conditions programme:

  • Our Declaration sets out the importance of person centred care for people with long term conditions, what needs to change and why we need to change. It was developed for and with input from health and care professionals, policy makers and people with long term conditions.
  • House of Care: The House of Care is a framework model that provides a holistic approach to long term conditions.
  • LTC Dashboard: Clinical Commissioning Group (CCG) Outcomes tool and explorer is an interactive tool for commissioners and clinicians based on the 44 sustainability and transformation areas with the ability to drill into CCG and local authority areas to support intelligence-led decision-making and benchmarking for long term conditions across five areas; risk factors, prevalence, quality of care, quality of life and economic activity.
  • Atlas of Variation which includes insights into how CCGs compare nationally and with areas that have a similar demographic.
  • Commissioning for Value packs providing practical support for clinical commissioning groups (CCGs) and local health economies, in gathering data, evidence and tools to help them improve the way care is delivered for their patients and populations,.
  • The Long Term Conditions Year of Care Commissioning Programme Implementation Handbook is the main output of the Year of Care Commissioning Programme. It describes the experiences of five care economies working as part of the programme as they work towards developing capitated budgets for some patients and services.
  • NICE draft clinical guideline on multi-morbidity: Assessment, prioritisation and management of care for people with commonly occurring multi-morbidities. Evidence based recommendations for people with multi-morbidity, a tailored approach to care and frailty.
  • A collaboration including SIMUL8, Datalytics, a small group of CCGs, and NHS England has developed a tool to help organisations understand the financial and/or activity implications for new models of care for people with long-term conditions across different cohorts of patients and settings.
  • Supported by NHS England and the Coalition for Collaborative Care, a group led by Plymouth University have developed a guide to commissioners on how to use metrics, measures and insights to commission person centred care.
  • The recovery, rehabilitation and reablement (RRR) simulation model, developed by Simul8 Healthcare, aims to improve the quality of care and outcomes for patients by delivering a seamless RRR service for acute admitted patients, based on their entire needs and not just their diagnosis.
  • Co-production case study: A co-production approach to care and support planning.


Handbooks provide practical support for clinicians and commissioners about how to implement good person centred long term condition care.  They include:

Resources to support the musculoskeletal programme:

Resources to support the neurology programme:

Resources to support the paediatric asthma programme: