Long-Term Condition Management:
Practical Strategies for Primary Care
However, rising demand and increasing complexity make managing LTCs more challenging than ever. By 2035, projections suggest that nearly two-thirds of adults over 65 in England will live with two or more chronic conditions many (17%) will have 4 or more. 1. The changing shape of General practice saw the number of general practices fall by 20% between 2013 and 2023. 2.
Practices and Primary Care Networks (PCNs) need smarter, scalable approaches to address these challenges. They need to shift the focus from reactive care to planned, preventative strategies that optimise resources and improve outcomes. Emerging digital solutions can support both patients and practices. The Government’s 10-year plan for health and care with ‘three big shifts’ identifies the case for reform. 3.
Redmoor Health’s LTC Management Webinar Series is designed to help practices and PCNs refine their approach. Through a series of expert-led sessions, we’ll explore the practical steps required to deliver better LTC management, from population health segmentation and self-care initiatives to workforce planning, optimising recall systems to end to end LTC management service.
With practical insights, demonstrations of innovative tools, and actionable guidance, these webinars provide a clear roadmap to help primary care teams tackle LTC challenges in 2025 and beyond.
Upcoming Webinars
Session 1: Population Health Management Masterclass: Taking a Proactive Approach to segmentation and LTC management
Panel Speakers:
Dr Steve Laitner and Dr Tim Cooper from Suvera
Focus:
How population health segmentation helps practices and PCNs plan care for different patient cohorts, from those who can self-manage to those requiring complex care.
Topics Covered:
- Segmenting patients by condition, complexity, and frailty to target care effectively.
- Designing care pathways that reduce workload and improve outcomes.
- Examples of how population health strategies work in practice.
Session 2: Supporting Self-Care: Empowering Patients to Manage Their Health
16th January 2025, 13:00-14:00 – Lisa Drake & Matt Sweeney plus guests
Panel Speakers:
Ian Wharton, Founder CEO Aide Health
Grace Gimson: Founder & CEO of Holly Health, a personalised digital coaching platform used in over 200 GP practices, supporting patients to build motivation, confidence, habits and health outcomes, at a large scale.
Dr Alexia Pellowe: Clinical Director at East Ayrshire Health and Social Care Partnership, NHS Arran & Ayshire Digital Services Clinical Director, and NHS Education for Scotland patient safety & improvement Associate Adviser.
Focus:
This session explores strategies and tools to promote self-care, supporting patients to take ownership of their health, reducing pressure on practices, and improving experience and outcomes.
Topics Covered:
- Practical ways to help patients with tools like symptom checkers, viewing records, medication management.
- Promoting preventative care, including vaccinations, screenings, understanding results and health education.
- Case Studies: How digital solutions can support patients when not in practice, considering personalised health coaching, self-management strategies and nudge behaviour theories that lead to positive habits, supporting better health outcomes.
Session 3: Planning and Stratification: Using Data to support your LTC planning
23rd January 2025, 13:00-14:00 – Lisa Drake, Matt Sweeney
Panel Speakers:
Simon Swift, CEO at HN is a data science and AI expert with a passion for leveraging information to drive informed decision-making. He has extensive experience in applying data-driven solutions across healthcare. He is also a Non-Executive Director with Adviseinc Ltd, a specialist healthcare procurement data specialist business. His varied career exemplifies his commitment to advancing data-driven strategies in healthcare and technology.
Conor Price, Founder and CEO at Primary Care Analytics is dedicated to progressing both clinical and non-clinical aspects of the field. He focuses on promoting population health, digital innovation, and showcasing the value of Primary Care. Conor’s experience ranges from strategic advisory roles within NHS Trusts to frontline services in General Practice to Primary Care BI in a CCG, giving him a deeper understanding of healthcare at varying levels. He uses his strategic skills and collaborative leadership style to shape the future of data in General Practice, bringing together partners and leaders to discuss necessary changes, improvements and overcoming barriers.
Focus:
Stratification helps practices prioritise care effectively and align resources with patient needs. This session provides strategies for sustainable, high-impact planning, identifying which patients could be prioritised early for support.
Topics Covered:
- Using stratified care to identify priority patients and intervene early.
- Reduce demand on urgent and emergency care, without adversely impacting on primary care.
- Aligning workforce planning with QOF and PCN DES requirements.
Session 4: Optimising Recall Systems: Efficiency in Action
10th February 2025, 13:00 – 14:00 – Kylie Halliwell & Sarah Chappell
Panel Speakers:
Dr. Simon Doyle is a Senior Digital Health GP at Abtrace and is dedicated to healthcare improvement through innovative digital solutions. With experience in public and private sector healthcare management, he combines clinical expertise with a strategic approach to enhance patient care and streamline healthcare delivery. Alongside his work as an NHS GP in London, Simon works to ensure practices achieve full benefit realisation from the Abtrace Proactive Monitoring Tool in terms of efficiencies, enhanced patient safety, and increased practice revenue.
Sachin Gupta has been working in Primary Care for over 6 years as part of a Practice Management team. He started Hippo Labs in 2021, driven by a desire to overhaul the inefficient GP systems he was faced with. Starting with Proactive Care, Sachin and the team are passionate about building tools for practice teams that reduce frictions and improve outcomes.
Harris Reed, Head of Implementation, dedicated to driving digital transformation in Primary Care, combining passion with expertise at Hippo Labs. As Head of Implementation, Harris focuses on delivering innovative digital solutions that empower frontline NHS staff and enhance patient care, striving to support a brighter future for primary care.
Focus:
Recall systems underpin effective LTC management. This session focuses on making recall processes more efficient, timely, and patient-focused.
Topics Covered:
- Building recall systems that integrate with QOF cycles and patient care plans.
- Practical advice on coding, data quality, and disease register updates.
- Tools and workflows to manage recalls efficiently, communicating including batch messaging across multiple platforms, digital invites and reminders.
Session 5: A different approach to delivery
25th February 2025, 13:00 – 14:00 – Lisa Drake, Matt Sweeney
Panel Speakers:
Dr. Will Gao, Co-founder and Chief Commercial Officer of Suvera, a digital healthcare provider that partners with GP practices to deliver proactive management of long-term conditions. UCL-trained medical doctor, graduated with First Class Honours in Physiology. One of the youngest NHS Clinical Entrepreneur Fellows, and a fellow of the National Innovation Accelerator (NIA) programme and the Mid and South Essex Innovation Fellowship programme.
Georgina Craig, Director at Experienced Led Care
Focus:
Using the wider Additional Roles team to support your patients.
Topics Covered:
- Using ARRS roles to extend capacity and deliver group consultations or coaching.
- Pharmacy led managed service
- Tools and workflows to manage recalls efficiently, including batch messaging and digital reminders.
- Developing personalised care in a group setting
Why join this series?
This webinar series is designed to support practices and PCNs in delivering effective LTC care, offering:
- Practical strategies tailored to the challenges of modern primary care.
- Expert insights from leading clinicians and suppliers.
- Demonstrations of tools to help streamline processes and improve outcomes.
- Real-world case studies showcasing what works—and how to implement it.
Register now to gain the tools, knowledge, and confidence to manage LTCs more effectively in 2025 and beyond.
Register now to gain the tools, knowledge, and confidence to manage LTCs more effectively in 2025 and beyond.
Interested in our Long-Term Condition Management Webinars?
