Long Term Conditions Framework - Consultation Response

Published: 26/06/2025

Introduction

Recent surveys report over one third of people in Scotland now live with at least one long term health condition.  People are now living longer and the prevalence of long term conditions increase with age.  Managing this effectively is therefore a priority to the Scottish Government.

Current policy approach is condition specific, so those conditions that have no strategy and framework in place will receive less resource even if they are a major contributor to disease burden (for example, Chronic Kidney Disease). Due to lack of resource and funding it is unrealistic and unviable to increase the list of condition-specific policies, therefore the Scottish Government propose a change to current policy approach at a National level to benefit more people and support NHS Reform.

This consultation seeks views and experiences on current long term conditions policies and proposes the development of a new long term conditions framework.    

As most conditions will require similar interventions and monitoring the new approach to policy will include integration with wider policies and cross-cutting actions with high-level principles that apply to various conditions to benefit more people and those with multiple long term conditions.  This must also be balanced with improvements of condition-specific actions which remain a priority. 

Themes of existing commitments for condition-specific policies by Scottish Government include the following:

1.  Access to care

2. Data

3. Self-management and patient information

4. Clinical information / education

5. Prevention and early intervention

Analysis of the work delivered in these areas has shown that a proportion of this was non-condition specific and could benefit a wider array of conditions.  This supports the proposal for a new policy approach covering existing themes and with a focus on patient-centred, equitable, high quality care with time- limited action plans to improve people’s experience of the NHS when dealing with long term conditions.

Community pharmacies play a vital role in managing long term conditions, so we have chosen to respond to the consultation to ensure that members interests are represented. 

The full consultation can be accessed here, with our draft response included below for review.

• 1. Do you agree that Scottish Government should move from a condition specific policy approach to one that has a balance of cross-cutting improvement work for long term conditions alongside condition-specific work?

  Yes.

  This is a desirable approach as most long term conditions will require similar monitoring and interventions.  It will not only allow more people who are dealing with long term conditions that currently have no policy and therefore resources to have access to services and interventions but will improve the experience for those suffering from multiple conditions, avoiding unnecessary referral journeys.

  Improving identification and management of these conditions is imperative to support individuals to live life in better health while also reducing the pressure on other NHS services when these conditions are poorly managed.

  One concern would be that measurement of progress/success may be more challenging where there are fewer condition-specific strategies and plans.

• 2. Are there any improvements in prevention, care or support you have seen in a long term condition you have, or provide care and support for, that would benefit people with other long term conditions?

  Community pharmacies in Scotland have a long history of delivering preventative interventions such as smoking cessation support and we believe with sustainable funding and resources could deliver more screening interventions to detect and prevent ill health.

  A recent study in Community Pharmacies in NHS Tayside identified individuals at risk of developing or having diabetes and through appropriate assessment were either provided advice or given a point of care HbA1C blood test which supports diagnosis of diabetes.

  This cohort of people, who would otherwise be unaware of their risk of developing diabetes, were then supported to access advice and care appropriate to their blood test results. Most (87%) were signed up to a digital lifestyle education app, 6.2% met the criteria to be referred to an intensive 9-month diabetes prevention programme, and a further 6.3% were referred to their GP under suspicion of undiagnosed disease.

  Other potential clinical areas for Community Pharmacy teams to support detection and prevention of long term health conditions include an effective national weight loss service and cardiovascular disease screening. Our network of 1,244 pharmacies are easily accessible and are a key touchpoint for both people who already receive NHS care and those who are disengaged from services – we firmly believe that this accessibility and reach could be harnessed to great impact with respect to detection and prevention of illness

• 3. Do you have any thoughts about how areas for condition-specific work should be selected? This means work which is very specific to a health condition or group of health conditions, rather than across conditions.

  Selection should be based on evidence, allowing comparison between conditions and selection of those that are responsible for the highest burden of disease for the individual and cost to the NHS. This must, however, be balanced with an assessment of evidence-based intervention success for that condition.

• 4. What would help people with a long term condition find relevant information and services more easily?

  NHS Inform is a valued resource that may not be apparent to all individuals.  Community pharmacies are well placed to disseminate information and advertise resources known to be effective.  The whole NHS system would benefit from training and regular updates on what is available from each major provider.

  Digital enhancements, using apps for information and managing health is the future so a Scottish NHS app would be beneficial.

• 5. What would help people to access care and support for long term conditions more easily?

  The knowledge of where to access care and support – providing the whole NHS system with training and updates on what is available from each major provider to enable appropriate referral and educate patients.

  Development of more robust referral pathways - this is particularly important for Community pharmacies who are often the first port of call for people with minor illness or long term conditions.

• 6. How could the sharing of health information/data between medical professionals be improved?

  To enable seamless transfer of care and unnecessary referral journeys between services, an efficient method of sharing of information between professionals needs to be established (e.g. shared care plans), with appropriate role-based read and write access extended to all involved in the care of the individual.

  Role-based access to records is imperative for Community Pharmacists to manage patients’ health needs safely and effectively.

• 7. What services outside of medical care do you think are helpful in managing long term condition(s)? You may wish to comment on how these services prevent condition(s) from getting worse.

  There are many charities providing significant support, however these are often regional and variable.  A National view on trusted and effective non-medical resources would be useful to raise awareness for the whole system, along with further education and training for healthcare teams.

• 8. What barriers, if any, do you think people face accessing these (nonmedical) services?

  Awareness and an understanding of quality of these non-medical services is required.  There may be access barriers, for instance, if it currently requires referral from a healthcare professional.

• 9. What should we know about the challenges of managing one or more long term conditions?

  From a Community Pharmacy perspective, the challenge we face is managing a patient’s health condition without having all the necessary, relevant information to make informed decisions.  All that our teams have available is the information from prescriptions or what the patient communicates as well as a view of basic information on the Emergency Care Summary. Some progress has been made in a few local Health Board areas towards Clinical Portal access, but ultimately role-based read write access to patients’ records is essential to allow for patient-centred care and to support NHS Reform.

• 10. What would strengthen good communication and relationships between professionals who provide care and support and people with long-term condition(s)?

  An efficient method of sharing of information between professionals needs to be established (e.g. shared care plans), with appropriate role-based read write access extended to all involved in the care of the individual. This will be essential if we are to truly shift the balance of care into the community and make better use of the growing prescribing capability and capacity in the community pharmacy network.

• 11. What digital tools or resources provide support to people with long-term conditions?

  NHS Inform is a useful resource along with information provided by Charities.

• 12. What new digital tools or resources do you think are needed to support people with long-term conditions?

  An efficient method of sharing of information between professionals needs to be established (e.g. shared care plans), with appropriate role-based read write access extended to all involved in the care of the individual. Ambitions for Community Pharmacy in Scotland are hindered without this access.

  Pharmacists are experts in medicines and pharmaceutical care and are well placed to manage long term conditions due to the contact and relationships they have with patients and their representatives. It is our view that pharmacotherapy sits with our profession and can be delivered within the community setting.  Over a third of community pharmacy sites now have prescribing capability and we are on a trajectory to achieve full coverage by the early 2030s.  This will further support the shift of care into the community with patients able to access care services closer to home. The Medicines Care and Review service available in Community Pharmacies is in place to provide care and support to patients with long term conditions, however this service should be reformed to incentivise specific interventions which proactively support patients to get the very best out of their medicines, whilst minimising medicines-related harm.

• 13. How do you think long-term conditions can be detected earlier more easily?

  Community pharmacy could support screening efforts for long term conditions.

  A recent study in Community Pharmacies in NHS Tayside identified individuals at risk of developing or having diabetes and through appropriate assessment were either provided advice or given a point of care HbA1C blood test which supports diagnosis of diabetes.

  This cohort of people, who would otherwise be unaware of their risk of developing diabetes, were then supported to access advice and care appropriate to their blood test results. Most (87%) were signed up to a digital lifestyle education app, 6.2% met the criteria to be referred to an intensive 9-month diabetes prevention programme, and a further 6.3% were referred to their GP under suspicion of undiagnosed disease.

  Other potential clinical areas for Community Pharmacy teams to support detection and prevention of long term health conditions include an effective national weight loss service and cardiovascular disease screening. Our network of 1,244 pharmacies are easily accessible and are a key touchpoint for both people who already receive NHS care and those who are disengaged from services – we firmly believe that this accessibility and reach could be harnessed to great impact with respect to detection and prevention of illness.

  We are particularly interested in understanding how our network might support the rollout of Artificial Intelligence-supported screening tools as these are developed in the coming years.

• 14. What barriers do people face making healthy decisions in preventing or slowing the progress of long-term condition(s)?

  Education and awareness – Evidence suggests people are unaware of the health conditions they may have or what steps to take to prevent development or progression of conditions. 

  Community pharmacies play a key role in ensuring there is a health promoting environment in the pharmacy and provide access to appropriate health education information, materials and support. Our teams are the experts in medicines, and with the appropriate resource and commissioning would be able to further support the people of Scotland to get the very best out of their medication whilst minimising the risk of harm.  This could be realised through development of the Medicines, Care and Review service for individuals with long term health conditions, used as a structured means of ether detecting care issues or reaffirming safe and effective use of medicines.

• 15. Is there anything currently working well within your community to prevent or slow progression of long term conditions?

  Community pharmacies in Scotland have a long history of delivering preventative interventions and we believe with sustainable funding and resources could deliver more screening interventions to detect and prevent ill health.

  A recent study in Community Pharmacies in NHS Tayside identified individuals at risk of developing or having diabetes and through appropriate assessment were either provided advice or given a point of care HbA1C blood test which supports diagnosis of diabetes.

  This cohort of people, who would otherwise be unaware of their risk of developing diabetes, were then supported to access advice and care appropriate to their blood test results. Most (87%) were signed up to a digital lifestyle education app, 6.2% met the criteria to be referred to an intensive 9-month diabetes prevention programme, and a further 6.3% were referred to their GP under suspicion of undiagnosed disease.

  Other potential clinical areas for Community Pharmacy teams to support detection and prevention of long term health conditions include an effective National weight loss service and cardiovascular disease screening.

• 16. How can the Scottish Government involve communities in preventing or slowing the progress of long term conditions?

  Scottish Government can use the Community Pharmacy network for disseminating information known to be effective.

• 17. Are there additional important considerations for people with long term conditions? For example, people who; live in deprived areas and rural and/or island areas, have protected characteristics e.g. race, disability, who are in inclusion health groups e.g. homelessness, or who experience stigma due to perceptions of their long term condition e.g. people with dementia?

  You will find there are more Community pharmacies in areas of higher deprivation where individuals subsequently have poorer health outcomes compared to more affluent areas.  This allows us to deal with health inequalities head on, providing equitable access to services and delivering health care as close to home as possible, removing the barrier of travel costs.

  We recommend the commissioning of extended hours for community pharmacies where required to improve access for patients.  Currently pharmacies choosing to operate beyond model hours receive no additional funding but incur staffing and other running costs for doing so.

• 18. Given that racism and discrimination are key drivers of inequalities, what specific actions are necessary to address racism and discrimination in healthcare?

  Further education and training to support cultural awareness.

• 19. Is there anything else you would like to raise that was not covered elsewhere in the consultation paper?

  We strongly recommend that major policy areas are standardised using a ‘Once for Scotland’ approach.  This will make clear to the NHS workforce, patients and their families where and how to access the most appropriate services and resources for their needs at that time.  This will improve peoples experience of the NHS with the ultimate aim to improve the health of people in Scotland.

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