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Integrated care for long-term conditions

Learn how our two-year programme improved care for people with cardiovascular disease by using new models of care to integrate primary and secondary care.

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Around seven million people in the UK are living with cardiovascular disease (CVD), a long-term condition (LTC) often associated with comorbidities such as diabetes, high blood pressure and obesity.1

The number of people living with multiple LTCs is predicted to keep growing. Estimates suggest that in England, 9.1 million people will be living with one or more serious LTCs by 2025.2 This would add billions of pounds in extra costs to already pressured health and social care systems.

The current healthcare system is struggling to cope with the increased demand of managing people with multiple LTCs, who are regularly in and out of hospital, in part due to the fragmentation of health services.

The call for change

People living with CVD often have complex requirements around medication optimisation, management of comorbidities, symptoms and social care support.

An integrated approach to improve the interface between primary, community and acute services can enable people to have a better quality of life. It offers them improved access to treatment and care, can help avoid unnecessary hospital admissions and will make better use of NHS resources and its workforce.4

Outcomes are consistently poor for patients who receive sub-optimal care. Specialist services and redesign of care pathways can improve prognosis and quality of life.

The NHS is currently committed to developing new models of care.5 These will allow the health and social care system to manage multiple comorbidities in an increasingly ageing population.

People with LTCs and co-morbidities can have a better quality of life if:

  • they have improved access to treatment and care
  • it is delivered via an integrated approach
  • there is an improved interface between primary, community and acute services.

Our programme

We funded a two-year Integrated Care pilot programme at nine NHS organisations across the UK. The aim was to improve service provision for people living with CVD by integrating primary and secondary care by developing several models of care.

Another key part of the programme focused on improving the skills and capacity of primary and community care to offer self-management for people living with CVD.

The nine projects in our Integrated Care pilot adopted the programme to their local context using a variety of approaches. These evidence-based studies support current thinking that integrating services can maximise resources and improve population health.6

Some common themes that emerged from the interventions were:

  • early supported discharge and active hospital in-reach
  • home visits with specialist services
  • nurse-led, open-access community and hospital clinics
  • multi-speciality clinics and networking
  • practice risk register auditing and training
  • healthcare professional education and professional development
  • patient-led focus groups, shared decision-making and self-management tools.

The pilot was independently evaluated from setup to delivery by ICF GHK. The evaluation report [PDF] highlighted the outcomes and impact produced by each project within the programme. This generated a narrative on the overall programme-level outcomes and made recommendations.

More than 18 million people are living with LTCs in the UK.
Source: BHF estimate [3]

Evidence for change

Each of our pilot sites reported on a variety of positive outcomes from their local service redesign/education and audit programmes:

  • improved identification, diagnosis and management of CVD patients
  • improved patient quality of life and patient satisfaction
  • significant increase in patients’ ability and confidence to self-manage and knowledge of their condition
  • up-skilling of HCPs adopting a more holistic approach such as consideration of psychological and social care needs
  • implementation of new care and referral pathways that reflect an integrated service
  • improved links across the local health economy between service providers
  • reduction in unplanned hospital admissions and reported cost savings
  • adoption of care pathways and services for managing other LTCs such as diabetes.

Case study: East Cheshire

Local challenges

  • Population of around 375,000, with a growing number of elderly people with multiple LTCs.
  • CVD accounted for approximately 25% of early deaths.7
  • Pressures on consultant cardiologist access.
  • 15% of East Cheshire hospital admissions were due to CVD

Local solutions

  • Hospital in-reach improved earlier diagnosis and management of CVD patients identified outside of cardiology wards.
  • Early supported discharge plans developed by nurses for in-patients, with follow-up community care plans.
  • Nurse-led services such as rapid-access clinics provided earlier care for patients with heart failure (HF), atrial fibrillation and chest pain.
  • HF community clinics, working with the local intravenous therapy service, moved care away from the hospital and into the home.
  • A self-management tool helped patients access appropriate care in line with severity of symptoms. Patients also played an active role in shaping local services via focus groups.


  • Waiting times down from one week to two days for cardiac review of patients in hospital.
  • Fewer patients seen in secondary care.
  • Patients allowed to remain at home, especially at end of life, despite being on intravenous diuretic therapy.
  • 96% of patients surveyed reported improved health outcomes.8
  • Patients reported being more comfortable, empowered and feeling safer.
  • Over one year, £1.1m saved due to fewer hospital admissions and shorter stays.
  • The East Cheshire services have been sustained beyond the BHF programme.

What we found

Integration does not always result in tangible cost savings in a health system due to the shift of resources from secondary to primary care. However, if services are joined up, there are likely to be substantial cost savings by prevention of hospital admissions, due to better access to care.

Most of the projects within the programme have had their services fully commissioned and sustained beyond the BHF funding.

Two of the projects reported combined savings of over £1.5 million over 1.5 years, mainly due to hospital admission avoidance. The cost benefit ratio of the service equated to a savings of almost £9 for every £1 spent on healthcare. Note: these savings were based on number of hospital admissions avoided multiplied by cost of bed days (national tariff) per length of admission (based on the National Heart Failure Audit). Treatment costs were also incorporated into the expenditure.

Resources and further information

Integrated Care Best Practice
Access a CPD-accredited, evidence-based summary of the BHF Integrated Care Programme, including three case studies and their outcomes.

NICE case study
Our innovative pilot has been adopted by NICE guidance as a QIPP case study.

Service innovation portfolio
Read more on our evidence-based service innovation programmes.

Try our business case toolkit
Interested in setting up your own integrated care service? The BHF Business Case Toolkit could help you make your case.

Contact us

To speak to us about how you could pioneer more integrated services in our area, contact us today.


1  BHF (2017) estimate based on GP patient data and latest UK health surveys with CVD fieldwork
2  Royal College of General Practitioners (2016). Responding to the needs of patients with multimorbidity: A vision for general practice
3  BHF estimate from ONS Opinions and Lifestyle Survey 2013
4  Department of Health (2013). Cardiovascular Disease Outcomes Strategy
5  NHS England. Five Year Forward View, 2014
6  ICF GHK. BHF Integrated Care Final Evaluation Report, 2015
7  Living Well for Longer in Cheshire East. The Annual Report of the Director of Public Health, 2012-2013
8  50 patients were randomly selected using the Advanced Quality Alliance (AQuA) self-management assessment questionnaire and a modified version of the Patient Activation Measure (PAM). 

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