Celebrating success in LTC LCS

In 2024, Mr. T, a patient living with hypertension, attended his routine Long Term Condition Check and Test appointment. What he thought would be a routine visit turned into a turning point in his health journey.

During his appointment, the results revealed some concerning changes: his weight and BMI had increased, his cholesterol levels were elevated, and his QRISK score had risen, putting him at increased risk of heart disease and stroke. His blood pressure was well controlled.

In a supportive and holistic conversation with the Nurse Associate, Mr. T reflected on the changes in his lifestyle over the past year. Since his son had returned home after university, their shared eating habits had shifted towards more takeaways and processed meals -  something Mr. T had not considered until the nurse asked him what mattered most to him and how he might begin to take control of his own health.

The patient reported that it was this personalised, patient-centred approach that made all the difference. That conversation had given Mr. T the space to think about what he wanted. He wanted to try to turn things around for himself.

Motivated by the support and shared decision-making, Mr. T committed to changing his diet and lifestyle. He began cooking healthier meals, reducing processed foods, and increasing his physical activity—all with the goal of reclaiming his health.

In March 2025: Mr. T returned for his next annual Check and Test appointment. He had lost 10 kg, his cholesterol levels had significantly improved, and his QRISK score was now at a low risk level.

Mr. T credits the Nurse Associate and LTC monitoring for giving him the tools, time, and encouragement to make meaningful changes

Mr. T’s story is a powerful example of how the LTC LCS Model of Care is helping patients take control of their health through reflection, education, and personalised support.

A  nurse has shared her excitement about a noticeable and welcome change in the way patients are engaging with their long-term condition (LTC) care this year.

In her practice, as part of the LTC LCS Model of Care, patients are encouraged to attend their annual check and test appointment during their month of birth—and it's a change that is catching on.

"I'm so happy with what I’m seeing," the nurse reported. "This year, more patients are calling us themselves to book their Check and Test appointments on time—during their birthday month. They are remembering when to come in, understanding what to expect at each step, and taking ownership of their health.“  The nurse added that there is also less pushback from patient when admin staff are calling to book these appointment and she attributes this to a better understanding on the process.

She explained that “patients are becoming more familiar with the model: they know what the annual process looks like, and are seeing  the value of staying on top of their condition through regular checks “

"What’s most exciting is that people aren’t just reacting to health issues anymore - they’re being proactive. It feels like the model is starting to bed in, and the patients are stepping into the driver’s seat when it comes to managing their LTCs."

This story is one of many early signs that the LTC Model of Care is helping to reshape not only service delivery - but the patient experience, too. As patients continue to embrace their roles in managing their health, clinicians like this nurse are feeling the impact, and celebrating the success.

A lady in her late 60s, living with hypertension, was recently diagnosed with diabetes. She had been trying to lose weight for a few years, but with little success. At a routine hypertension review, we discovered her diabetes and began to discuss options. We talked about the low-calorie diet and, more importantly, explored her personal goals.

She told me, “I’m not fussed about reversing my diabetes.”

Instead, her goals were simple but powerful:

• To be able to run around with her grandchildren. (Her granddaughter had recently said how sad she felt that “Nanny can’t run around with me.”)

• To live longer.

That first goal is incredibly practical and deeply personal to her. She doesn’t really care about what clinicians usually focus on — HbA1c targets or blood pressure readings. What she does care about is enjoying time with her grandchildren, staying well enough to be present in their lives, and watching them grow.

We agreed that the low-calorie diet was a good choice for her, both for weight loss and the possibility of diabetes remission.

Six months later, she returned for follow-up having successfully lost weight. This weight loss brought unexpected benefits: relief from knee pain she had assumed was just ageing, a new outlook on food and movement, and the freedom of being able to move without weight holding her back. Her determination to run with her grandchildren also motivated her to cut down on smoking — from 15 cigarettes a day (a habit since age 15) to just one pack of 20 a week.

Here, the numbers were not important to the patient. It’s was not about her BMI, HbA1c, or blood pressure — or even the fact that she still smokes.

What mattered is that having a personal, meaningful goal helped her to lose weight and smoke less — on her own terms, not medicalised ones. These changes naturally align with our goals as clinicians, but more importantly, they give her the chance to enjoy being a grandmother to the fullest.

And when we think about it, these habits ripple down. Her grandchildren now see a grandmother who runs around the park with them — a role model showing that being active is part of living well.

In August 2023, Mr. M, a patient living with diabetes, hypertension, and lumbar disc prolapse, attended an urgent on-the-day appointment feeling giddy and faint amidst a chest infection. What initially seemed an acute issue revealed deeper challenges impacting his health and the barriers to long term condition care.

During the consultation, his blood pressure was elevated at 189/90, and the GP learned that Mr. M had stopped taking his medications. He felt despondent about his chronic back pain and the lack of engagement from secondary care clinics, which had left him frustrated and isolated. His pain often caused him to neglect meals, further affecting his medication adherence.

Mr. M was awaiting a repeat spinal epidural injection, but repeated attempts to secure an appointment through his orthopaedic team had been unsuccessful. He wanted to escalate via PALS but was unsure how. The GP took time to support Mr. M by helping him access his NHS app and hospital letters, and promptly sent an urgent email to expedite his care.

A holistic conversation emphasised the importance of maintaining his fitness for potential surgery or injections. Motivated by this, Mr. M agreed to restart his medications. He also underwent urgent blood tests that day. Although fearful of injectable treatments, he accepted dapagliflozin and gliclazide but initially declined injectables despite his HbA1c being 94.

A Primary Care Network First Contact Practitioner appointment was arranged, where physiotherapy support and exercises were provided promptly. The physiotherapist encouraged Mr. M to consider neuropathic pain medication.

By April 2024, Mr. M’s pain had reduced significantly with regular pregabalin use, supported by a dossett box to improve medication compliance. His blood pressure improved to 130/74, and his HbA1c dropped from 94 to 74 while on gliclazide, metformin, and dapagliflozin.

At his latest follow-up, Mr. M agreed to start injectable insulin and reported feeling more positive about his health and pain management, as he had been seen by orthopaedics and listed for a repeat spinal epidural. Inspired by his renewed outlook, he revisited his passion for painting—and as a gesture of gratitude, gifted the GP a painting for the clinic room.

Mr. M’s journey highlights the power of personalised, holistic care that addresses physical health alongside emotional wellbeing, empowering patients to regain control and hope.