PRJ 1257 Primary Care Long Term Conditions Locally Commissioned Service

NCL ICB commissions a significant number of Locally Commissioned Services from General Practice. These services are provided in general practice but are not part of the General Medical Services contract. They are delivered as part of a list-based service either by practices or through a GP Federation.

NCL ICB wishes to commission a long-term conditions service from primary care, via a locally commissioned service. The service will provide a consistent and holistic approach to the identification of people living with or at risk of developing a long-term condition, and the delivery of care and support for people with long term conditions within general practice and primary care networks.

The NCL LTC LCS model of care is based around the Year of Care approach, widely implemented across the UK, which uses the House of Care as a framework.

Personalised care and support planning, holistic and proactive care are at the heart of the model of care. The model of care draws on existing evidence-based approaches that will enable practice staff to collaborate with patients to define and work towards their individual care goals and to plan and coordinate care, particularly for those higher risk patients with multimorbidity, living with complex health and care needs.

The model of care includes identification and diagnosis as well as optimal treatment, supporting practices to close their prevalence gap through case finding. It includes risk stratification of all those in scope, and a defined frequency of contacts, to support effective primary care workforce planning over the year of care.