Locally we have high levels of deprivation, and this can mean that some people struggle to access healthcare to diagnose and manage their long-term conditions. Long-term conditions such as diabetes and cardio-vascular disease (CVD), are amongst the top five causes of early death for local people.

Our aim is to ensure we reduce the prevalence of people with long term conditions in our population, and that we support those people living with long term conditions to live longer and happier lives through effective processes of prevention, detection, and treatment.

Our plan is to:

  • prevent treatable conditions, through effective prevention programmes
  • ensure patients continue to receive services post COVID-19 to help them to recover
  • engage patients to improve their understanding of their condition and how to manage it
  • support patients to manage their condition effectively, through self-care and use of digital technologies
  • integrate pathways to manage care in primary and community settings and avoid conditions getting worse or having an urgent need for health intervention (exacerbation)
  • support the delivery of local health inequalities initiatives based upon the Core20PLUS5 framework.

Outcomes to be achieved

  • Earlier diagnosis.
  • Reduce preventable illness.
  • Improved life expectancy.
  • Reduced mortality.
  • Patient empowerment, increase patient led condition management.

  • Reduced pressure on urgent and emergency care.
  • More effective utilisation of capacity/resources.
  • Better use of technologies.

  • Improved health outcomes, reduced health inequalities.
  • Collaboration/joint working with wider system partners e.g. Local Authorities, third sector.
  • Greater integration of pathways/services.
  • Leadership through Clinical Learning Networks.

Work Programme

Programme To be delivered


Delivery of prevention, detection and treatment programmes relating to structured education programme, National Diabetes Prevention Programme, Low Calorie Diet, Extended Continuous Glucose Monitoring, Multi-Disciplinary Footcare Teams. New guidance is also being considered.

2023/24 to 2027/28

Post COVID-19 Services

Ensuring patients continue to receive access to post COVID-19 services in a timely manner.

2023/24 to 2024/25

Cardiovascular Disease (CVD)

Delivery of initiatives to improve early detection and management of CVD including hypertension case finding, Blood Pressure at Home Service, delivery of Cardiac Improvement Programme.

2023/24 to 2027/28


Development and delivery of pulmonary rehabilitation five-year plan including development of spirometry services, expansion of remote monitoring programme and lung health check programmes.

2023/24 to 2027/28

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