Long-Term Chronic Conditions Support Service
Empowering Patients • Supporting GP Practices • Reducing Pressure on Primary Care
The Challenge: Managing Long Term Conditions effectively with limited resources in primary care
Managing long-term conditions (LTCs) in primary care has become increasingly complex and resource intensive. The top 10% of frequent attenders account for nearly half of all GP appointments, visiting the GP practice on average 5 times more regularly than other patients. These frequent attenders commonly have long-term conditions, social and mental health problems, and low self-efficacy (Kontopantelis, 2021).
The recent Network Contract DES 25/26 and the NHS 10 Year Plan both highlight the importance of taking a preventative and proactive approach to those living with chronic conditions such as:
- Type 2 Diabetes
- Cardiovascular Disease (CVD)
- Hypertension
- Chronic pain and multimorbidity
With new QOF indicators all relating to CVD. CVD causes a quarter of all deaths and is the leading cause of premature death in deprived areas, but is largely preventable with lifestyle change (NHS, 2019).
Our Response: A Proven Model for Better Long Term Condition Support
At Pure Unity Health, we’ve worked with over 300 PCNs since 2016, initially through MSK and chronic pain services. Building on the success of our Pure Pain Support Service, we’ve developed a scalable, evidence-based Long-Term Conditions Coaching Service, fully reimbursable via ARRS.
Delivered by Health and Wellbeing Coaches, with the option of adding Social Prescribing Link Workers, our service eases the burden on clinicians and enables practices to deliver high-quality, patient-centred care. Our focus is on supported self-management and empowerment, giving patients the skills, knowledge and confidence to understand and manage their long-term condition more effectively. By working on what matters to the individual, patients work towards meaningful goals and improve their overall quality of life, resulting in increased self-efficacy, improved lifestyle choices, and ultimately reduced demand on the healthcare system.
Our model fully aligns with the vision for integrated neighbourhood working, preventative, and proactive care focussing on each PCN’s individual priorities. Using data driven proactive searches we aim to target those most in need, tackling inequalities in health and ensuring practices meet their CVD QOF targets.
What We Offer
A fully managed, embedded service with tailor made resources and specialist trained coaches for patients living with:
- Type 2 Diabetes
- Hypertension
- Cardiovascular Disease
- COPD & respiratory conditions
- Persistent Pain
- Multimorbidity and lifestyle-related conditions
Our model includes:
- One-to-one and group coaching
- Lifestyle behaviour change support
- Goal-setting and self-management planning
- Optional Social Prescribing: housing, loneliness, finance, and community connections
- Measurable outcomes and full integration into MDTs
- Primary Care Pain Support Service
Background For patients in Doncaster living with persistent pain, access to secondary care pain services has been limited, with long waits and periods where referrals
- Primary Care Pain Support Service
Presented at Therapy Expo 27-28 November 2024. Award winning poster. Background Chronic pain is a pressing public health issue, with 30-50% of people living with
- Primary Care Pain Support Service
Presented at Therapy Expo 27-28 November 2024. Award wining poster. Background High levels of long-term opioid use were identified in North Doncaster, with over 35%
- Primary Care Pain Support Service
The Challenge Chronic pain patients often require complex, long-term support that primary care is not currently equipped to provide effectively. With 30% – 50% of
- Primary Care Pain Support Service
Pain Specialist Health and Wellbeing Coaching to Support Deprescribing in Primary Care Pure Physiotherapy have been working in partnership with Doncaster North PCN providing First
Why This Matters for PCNs
Our service helps PCNs:
- Achieve new CVD QOF targets in DES 25/26 (e.g. BP and cholesterol management)
- Reduce frequent attenders and practice pressure *82.5% of patients do not visit the GP practice during the programme*
- Deliver your Personalised Care requirements under the ARRS scheme
- Align with NHS Long Term Plan, Darzi Report, and prevention-first care
- Improve patient engagement, outcomes, and long-term self-care
Health coaching and social prescribing significantly reduces GP attendance, increases patient activation and supports lifestyle-led prevention (Kontopantelis et al., 2021; Boehmer et al., 2023)
For PCNs, neighbourhoods, and multi-neighbourhood providers, managing long-term conditions effectively is no longer just a clinical necessity — it is the key to delivering sustainable, equitable care. Pure Unity Health’s LTC Support Service offers a proven, scalable model that reduces pressure on practices, empowers patients, and brings the ambitions of the Network Contract DES and the NHS 10 Year Plan to life, from individual practices to whole neighbourhood systems.
Read Our Latest Insights on Long Term Conditions
- First Contact Physiotherapy, Long Term Conditions, NHS Services
In my previous post, I discussed the Network Contract DES 25/26 and its emphasis on Cardiovascular Disease (CVD) and prevention. Now, with the long awaited
- First Contact Physiotherapy, Long Term Conditions, News
The care and management of Long Term and Metabolic conditions is becoming increasingly complex and resource draining for both Primary and Secondary care. The top
- First Contact Physiotherapy, Long Term Conditions, News, NHS Services, Primary Care Pain Support
In the June 23, 2025 episode of The General Practice Podcast from Ockham Healthcare with Ben Gowland, Vicky Maskill (Director of NHS strategy and
- First Contact Physiotherapy, Long Term Conditions, NHS Services
The 2025/26 Network Contract DES has put a sharp focus on cardiovascular disease (CVD) prevention, with new QOF indicators that directly impact practice income. The
- Long Term Conditions, NHS Services, Primary Care Pain Support
Across the UK, general practice is under immense pressure. GPs are managing growing demand, increasing complexity, and limited time — a situation that is becoming
The Evidence: Coaching That Delivers
- Frequent attenders with LTCs use 40–50% of GP capacity (Kontopantelis, 2021)
- Health coaching increases activation, reduces medication reliance and boosts self-efficacy (Boehmer et al 2023) *Average 39% increase in self-efficacy across all Pure LTC services in Jan 2024 – Jan 2025*
- Social prescribing shows up to 42% reduction in GP use in high-need populations (Tameside & Glossop case study)
- A recent systematic review demonstrated that Health Coaching is effective at reducing blood pressure, improving dietary behaviours, and improving self-efficacy (Fei Meng et al, 2023) *The most effective way to meet BP and cholesterol QOF indicators, whilst improving patient experience*
Our Results: Pure Pain Support Service
Delivered across multiple PCNs, our Pure Pain service has demonstrated:
- 82.5% of patients require no further GP appointments
- Improved mental wellbeing and function *39% average increase in self-efficacy*
- High engagement from underserved groups with tailored community support groups
- Outstanding patient and stakeholder feedback
GP Feedback
“Please continue this service!!!!!!”
“We must keep this service going in East Bedford PCN.”
“It’s an outstanding impact that so many patients didn’t contact GP again.”
“Patients are heard and seen promptly instead of months of wait.”
Patient Feedback
“I’ve found the advice and resources you’ve provided really helpful, and I’ve felt genuinely listened to and supported throughout. It’s been such a positive experience and I’m really grateful for all of your help.”
“Really great service that has really supported me and put me first. The sessions have been life changing in a positive way and really helped me to accept, manage, and change my mindset towards my long-term health condition.”
Why Outsource to Pure Unity Health?
Many PCNs struggle to recruit, manage, and embed ARRS roles effectively. We remove the barriers:
- No HR headaches
- No supervision gaps
- No fragmented delivery
- No strain on practice managers
We Provide:
- Full HR, contracts, and compliance
- Clinical and professional supervision
- Integrated MDT working
- Flexible team models: Coaching only or Coaching + Social Prescribing
- Scalable and evidence-led outcomes reporting
“A fully supported, professional team embedded into your PCN — without the HR or management burden.”
Real-World Impact
- Reduced GP and urgent care usage
- Increased patient activation
- Improved outcomes in pain, diabetes, CVD, and multimorbidity
- Data-driven ROI and alignment with ICS metrics
- Addresses Health Inequalities, aligns with integrated community working and NHS 10 year plan
Want to discuss how we could help support your practices, and empower your patients?
Contact us today to learn more