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 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.


Hi, I am very interested in this article to be able to do a better job for the patients with cronic disease. It of utmost importance that they can be able to take decions for themselves based on knowlegde of their disease and also valuing their own experience.
by Berit Marie Flønæs

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