Workforce and patient safety: primary and community care co-ordination for people with long-term conditions

Summary response We accept the recommendation to review and evaluate the care co-ordinator role. This role is well established in general practice, with over 4,900 care co-ordinators employed through the Additional Roles Reimbursement Scheme under the Network Contract DES. The Workforce Development Framework for Care Co-ordinators outlines scope, boundaries, and minimum training requirements. However, reviewing the care co-ordinator role alone will not lead to a 24/7 single point of contact for patients. Care co-ordination spans health and care sectors, pathways, teams, specific patient cohorts, and is often led by the most appropriate professional. For example, children with epilepsy should have their care co-ordinated by epilepsy specialist nurses. Commitments outlined in the 10 Year Health Plan for England will support improvements in care co-ordination, and 24/7 support for patients. The plan outlines how Neighbourhood Teams will deliver personalised, co-ordinated care via multidisciplinary teams. This includes but it not limited to: People with complex needs will have an agreed care plan. Everyone will have a virtual assistant to provide 24/7 advice and guidance via the NHS App. My NHS GP tool will provide a single, trusted source of instant advice for patients who need non-urgent care, available 24/7. A Single Patient Record (SPR) will make sure patients get seamless care no matter where they are in the NHS. Exploration of technology to increase clinical capacity could give the NHS an opportunity to tap into global talent, deliver 24/7 access and increase productivity. Workforce transformation is key to the ambitions of the 10 Year Health Plan, which recognises care must be locally led by pioneering neighbourhood health teams focusing on patients with multiple long-term conditions. Workforce models will be designed to be integrated, and proactive to ensure that teams have the skills and roles to effectively co-ordinate care for people with multiple long-term conditions. Actions planned to deliver safety recommendation: Continue to further promote existing materials that support implementation of care co-ordinators in primary care, by Autumn 2025. Other dependencies identified: Work of Primary, Community, Vaccinations & Screening (PCVS) including Neighbourhood Health. Review the workforce development framework, and any associated training, for care co-ordinators to ensure alignment with the 10 Year Health Plan, work underway by March 2026. Other dependencies identified: 10 Year Health Plan. Work of Primary, Community, Vaccinations & Screening (PCVS) including Neighbourhood Health. Engage with Neighbourhood Teams to identify and respond to local workforce development needs, including training and upskilling to embed effective multidisciplinary teams (MDTs) delivering coordinated care at neighbourhood level, by 2025/26. Other dependencies identified: Work across NHS England directorate including community services and Urgent and Emergency Care. By 2027, 95% of people with complex needs will have an agreed care plan, by 2027. Other dependencies identified: 10 Year Health Plan. Work across the Department of health and social care supported by NHS England teams for oversight and delivery. By 2028, patients will be able to see who is involved in their care, communicate with professionals directly, draft and view their care plans, by 2028. Other dependencies identified: 10 Year Health Plan. Work across the Department of health and social care supported by NHS England teams (including leadership from digital teams) for oversight and delivery. Publication of 10 Year Workforce Plan, by 2025/26. Launch the National Neighbourhood Health Implementation Programme, by Summer 2025. Other dependencies identified: Yes Wider X-HMG initiatives. Response received on 21 July 2025.

Summary response The Department of Health and Social Care (DHSC) recognises the importance of providing coordinated, patient-centred and personalised care for people with one or more long-term conditions. To inform its 10 Year Health Plan (published 3rd July 2025), DHSC has worked with NHS England and a wide range of partners, frontline staff and members of the public through Change NHS. We received over 270,000 contributions to the engagement overall and over 1.9 million visits to the Change NHS website. This Plan ensures parity across all diseases, and that seamless, proactive and timely care for people with one or more long-term conditions is effectively coordinated across multiple agencies. The vision for a Neighbourhood Health Service, as laid out in the Plan, will bring care into local communities, convene professionals into patient-centred teams and end fragmentation. At its core is a new preventative principle, that care should happen as locally as it can, digitally by default, in a patient’s home if possible, in a neighbourhood health centre when needed, and only in a hospital if necessary. In the next three years, this approach will be rolled out to those most failed by the current system. For instance, people with long-term conditions will benefit from teams that include hospital specialists, GPs and other care professionals, meaning better health outcomes, fewer complications and fewer unplanned hospital visits. They will also have access to advice, guidance, self-care support and appointment management via the NHS App. We will set a new standard that, by 2027, 95% of people with complex needs, including those with one or more long-term conditions, will have an agreed care plan. We know many areas are already delivering aspects of neighbourhood health, and have launched a National Neighbourhood Health Implementation Programme to support systems across the country to test new ways of working, share learning, and scale what works. We also recognise many patients with one or more long term conditions will be waiting for care. The 10 Year Health Plan sets out a transformed vision for planned care by 2035, and work is already underway following the Plan’s publication. Planned care will be more efficient, timely and effective and will put control in the hands of patients. In our Elective Reform Plan we have committed to working with patients and carers to co-design the standards of experience patients should expect whilst waiting for planned care. This will include designing standards which consider the specific communication, coordination and support requirements of people with one or more long term conditions so their needs are appropriately met. We welcome this report and thank the HSSIB for highlighting this issue. Actions planned to deliver safety recommendation: Launch the National Neighbourhood Health Implementation Programme, by Summer 2025. Set and work towards a new standard for agreed care plans, delivery of standard by 2027. Provide supporting guidance documents, including a Model Neighbourhood and a Neighbourhood Health Partnership Framework, expected early 2026. Further products to be shared in coming months. Response received on 23 July 2025.