Primary Care Services

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 highlighted the importance of taking a preventative and proactive approach to those living with chronic conditions such as:

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 achieve 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

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)

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*

Case Study: 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.”

“The programme has been very helpful, more than any therapy and physio that I have had before. I have been able to talk about how I feel and it has been good for me so thank you.”

Why Outsource to Pure Unity Health?

Many PCNs struggle to recruit, manage, and embed ARRS roles effectively. We remove the barriers:

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