We responded to a challenge set by The Modern Outpatient Programme, Scottish Government, to identify opportunities to innovate care for people living with multiple long-term conditions.

In Scotland, it is estimated that 47 per cent of the adult population have at least one long-term condition and the number of people who live with multiple and complex conditions is growing. Currently, specialist care is delivered in hospitals, with each condition treated separately. This way of organising care requires people living with multiple conditions to attend many different appointments, which impacts on their life and can be very tiring, and also represents an inefficient use of NHS resources. This project asked the questions:

How could our health system be organised around the person living with multiple long-term conditions rather than around individual conditions?

How would this change their experience of care?

The project was undertaken between August 2017 and February 2018, with the purpose of informing the ongoing and future work of The Modern Outpatient Programme.

Film credit: Louise Mather



The objective of the project was to develop a person-centred vision for the future of outpatient care for people living with multiple long-term conditions. The aims were:

1) To understand the current challenge, specifically:

a) The challenges of living with multiple long-term conditions and the kinds of support people value;

b) The challenges health professionals experience in supporting people living with multiple long-term conditions within the current health and care system;

c) The challenges of innovating in outpatient care.

2) To generate ideas for new ways of working to support people living with multiple long-term conditions:

a) To understand how people living with multiple long-term conditions would like to be supported in the future;

b) To support NHS staff to co-design new person-centred models of care to meet the needs and aspirations of people living with multiple long-term conditions.

3) To distill the insights and ideas generated into a roadmap for the development of person-centred models of care, supported by new digital tools.

I've come away with a realisation that we operate within very complex systems and yet we have the opportunity to do things differently should we wish to do them differently. However, that requires us to work together, and to create time together, to have that space to think differently about how we might structure our services as we go forward.

Alasdair Pattinson

Site Director and Hospital General Manager, Dr Gray's Hospital


During our pop-up public engagement we learned that people highly value the health professionals and assistants who listen and understand their needs as an individual. People told us about incredible doctors, nurses and teams taking great care of themselves or their loved ones. We also learned about the frustrations of parking near to the hospital, and the need for more practical information before an appointment.

From our interviews with people living with multiple long-term conditions, we understood the importance of a person's experience when receiving a diagnosis. This can impact on how people feel about their condition, how they engage with health professionals and the time it takes for them to accept, learn and manage their condition. The early stages can be an anxious time, and there is an opportunity to improve the information shared about what they can expect from both the condition and the health service.

We also learned that people rarely have conversations with health and care professionals that consider the impact of their multiple conditions and discuss their health and wellbeing in an integrated way.  These types of conversations are vital in understanding how to self manage, and in supporting people to live well with their conditions.

One of the most insightful moments from the process was seeing the transformative power of the real stories captured in the interview maps. Interview participants generously shared their ‘health stories’ through the maps: NHS staff told us that having this level of insight into the person’s past experiences and aspirations for living well with their condition is hugely valuable in understanding how to design their care.

Through the co-design workshop we were able to place these real people at the centre of the service, and through this NHS staff identified many opportunities to innovate care.

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