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We are a partnership of NHS, councils, and voluntary sector organisations, working together to improve health and care in Barnet, Camden, Enfield, Haringey, and Islington.  

Home E Our working areas E Supporting people with long-term conditions

Supporting people with long-term conditions

Long-term conditions are physical health conditions that cannot be cured but can be controlled with lifestyle changes, medicines or other treatments. They often have a big impact on a person’s life.

The risk of developing a long-term condition can be influenced by several lifestyle factors such as poor diet, lack of exercise, smoking and drinking alcohol. Poor housing conditions as well as limited access to healthcare, education, and employment opportunities, can also play a role in increasing the chances of long-term health problems too.

Most people will see their GP or other healthcare professionals at their GP surgery to get support and advice for their long-term condition/s.

From October 2023, GP surgeries across north central London will be treating and supporting people living with certain long-term conditions in a different way which focuses on personalised care and treatment to help them manage their long-term conditions effectively and prevent health issues getting worse wherever possible.

We hope that by planning care together with patients, they will build the confidence to manage their health successfully, reduce their risk of being admitted to hospital, and generally have a better quality of life – all of which contribute significantly to NCL ICS’s ambition to improve population health across NCL.

As well as treating people with long-term conditions, this new approach focuses on proactively identifying people at risk of developing long-term conditions and earlier detection and diagnosis of long-term conditions.

These conditions covered under the service are as follows:

  • Diabetes
  • Cardiovascular disease for example:
    • strokes, transient ischaemic attack (mini stroke)
    • heart failure (inability of the heart to pump blood round the body properly)
    • ischaemic heart disease (narrowing of coronary arteries due to fatty build up), and
    • peripheral artery disease (slow, progressive circulation disorder)
  • Hypertension (high blood pressure)
  • Hyperlipidaemia (high cholesterol)
    • Non-alcoholic fatty liver disease
  • Atrial fibrillation (condition causing an irregular and often abnormally fast heart rate)
    • Chronic kidney disease
    • Asthma
    • Chronic Obstructive Pulmonary Disease (COPD)
How will it work?

People who have already been diagnosed with one of the conditions listed above will be invited by their GP surgery to have a Yearly Health Check. This will consist of three appointments (a Check and Test Appointment, a Discussion Appointment and Follow-Up Appointment).

Over the course of the year, depending on what their situation is, individuals could have the opportunity to work with different health professionals including GPs, nurses, health and wellbeing coaches, and social prescribers.

Appointment discussions will focus on:

  • Identifying what is important to their health and wellbeing,
  • Setting personal goals and what would need to happen to achieve these and
  • Deciding on actions which will help them to successfully manage their conditions.

Individuals will also have the opportunity to discuss other areas of their lives that may be impacting on their physical and mental health and wellbeing, such as housing or employment.

People may be offered advice and support to help them eat well, exercise, stop smoking, to get better sleep, as well as seasonal health advice such as how to stay well in winter.

This new way of working will mean that people are directly involved in, and making decisions about, their own health and wellbeing.

This new approach launched in October 2023. Eligible patients will be contacted over the year by their GP surgery.

This short video below shows how the Yearly Health Check will work by following NCL resident Sergio’s journey.



This new approach is set to launch in October 2023. Eligible patients will be contacted over the year by their GP surgery.


How patients have helped shape the service

To make sure that the approach we are taking to treating and supporting patients with long-term conditions will meet our residents’ needs, we involved residents and worked with local voluntary and community groups to design key parts of the service offering.

Residents’ experiences and perspectives have improved the service, making it more accessible and better tailored to the different needs of people living with long-terms conditions.

Residents also contributed to developing the patient-facing materials for the service, such as the appointment invitation letters and the service leaflet.