Delivering better services for people with long-term conditions: Building the house of care

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This paper describes a co-ordinated service delivery model – the ‘house of care’ – that aims to deliver proactive, holistic and patient-centred care for people with long-term conditions. It incorporates learning from a number of sites in England that are working to achieve these goals, and makes recommendations on how key stakeholders can work together to improve care for people with long-term conditions.

The model differs from others in two important ways: it encompasses all people with long-term conditions (not just those with a single disease or in high-risk groups) and it assumes an active role for patients, with collaborative personalised care planning at its heart.

Key findings

The house of care metaphor illustrates the whole-system approach needed to improve care, and emphasises the interdependency of each part. Care planning is at the centre; the left wall represents the engaged and informed patient; the right wall represents health professionals committed to partnership working; the roof represents organisational systems and processes; and the foundations represent the local commissioning plan. Key elements are as follows.

  • People with long-term conditions play an active part in determining their own care and support needs through personalised care planning.
  • Collaborative relationships between patients and professionals, shared decision-making and self-management support are at the heart of service delivery.
  • Tackling health inequalities is a central aim, given that people in lower socioeconomic groups are more likely to experience long-term conditions. 
  • Each individual is engaged in a single, holistic care planning process with a single care plan regardless of how many different long-term conditions they have. 
  • Individual needs and choices are aggregated to provide a local commissioning plan.
  • Self-management support may be provided by community and self-help groups alongside statutory services.

Policy implications

  • NHS England and the Department of Health should work together to encourage a coherent approach at national and local level to care planning for people with long-term conditions.
  • NHS England should develop and test funding mechanisms and encourage the development of  technology to support planning and information-sharing.

More on long-term conditions


Miss Puvan Markandoo

Consultant (retired),
Comment date
09 January 2014
Keen to volunteer in integrated care services.

John Cooper

Castle Vale Partnership board / Haealth & Wellbeing
Comment date
27 December 2013
Doctors need to be more proactive rather than reactive.

Peter Devlin

Clinical Director & GP,
Brighton Integrated Care Service Ltd
Comment date
09 October 2013
This model is very helpful, and has more than a lingustic link with the concept of a patient's "medical home".
Although this is clearly written from a predominantly medical health perspective, it would be easy to insert "client/user" into the left wall, and "care worker" into the right wall.
I wonder if the house requires foundations, and if so, could this not be the contracting model? Many of the functions you assign to the commissioners, could be incorporated into the right sort of prime or alliance contracting model. This would help move health commissioning into a much more outcome focussed and less micro-managed place. It also opens the way for a joint local authority and CCG commissioning approach.


Specialist Occupational therapist at the Edware Parkinson's Unit,
CLCH communtiy NHS Trust
Comment date
08 October 2013
Although patients may receive coordinated MDT care on the health front this may not be adequate as joined up care( with Social care) that will address their social/psychological needs is missing.

Mike Clark

Comment date
03 October 2013
Although some references to social care, the document is overwhelmingly set out from a health perspective.

No mention of 'housing'.

Interested to hear how many people outside of health have been involved in development and training around the model and how LAs, Housing, Social Care, independent Sector, HWBBs, Healthwatch and others will be engaged in development.

Roni Ross

Comment date
03 October 2013
To get joined up medical care one needs to also look at multi pharmacy and the ethics of using drugs not tested in this way.

Consultants need to work together to provide more streamlined care and GP surgeries move away from being prescription clinics as real medicine is much more than crisis management with drugs, although we are sincerely blessed to have that facility. GP's are talented enough to offer wholistic care but more alternative/ complementary avenues of care must be brought under their umbrella which are not drug based.

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