We have a new website go to gov.scot

Long Term Conditions Collaborative: Making the Connections - Food For Thought



Our shared aspiration is to design, develop and deliver services so that people are neither financially nor socially excluded from society as a direct consequence of their health. This requires that people with long term conditions, their carers and families:

  • have systematic access to services which will assess and meet not just their medical but their wider emotional and social needs
  • are enabled and supported to be an active participant in their care; playing as active a role in decisions about their treatment, care and support as they wish
  • are supported to continue to play an active part in society and not excluded culturally, socially or financially
  • are recognised and supported as key participants in this journey
  • can navigate access to services and facilities which already exist in the local community, including library and leisure services.

To make this happen, health, social care, community and voluntary partners need to work together to be more responsive to the full needs of people.

What is already happening?

The Macmillan Model

In the past five years Macmillan Cancer Support has invested over £30 million to develop collaborative working between health, social care and third sector partners to provide new models of service for people living with cancer. The scale and impact of the Scottish Cancer Benefits Network is such that it is a proven model for partnership working between local government, NHS and the third sector. This support to address the social challenge that faces individuals and their families has already delivered significant improvements in the lives of people living with or beyond cancer. Macmillan aim to raise the profile of these services through Long Term Conditions Alliance Scotland ( LTCAS) membership and beyond, building on the key principles of what has already worked for people with cancer.

The key principles

  • Early, targeted and ongoing intervention with a focus on high volume groups.
  • A team of advisors who are trained to understand the impact of a cancer/long term condition on a person's eligibility for benefits.
  • Utilise the existing expertise, knowledge and networks within the Local Authority - augment where appropriate through formal training.
  • Develop robust practices/protocols for the identification, referral and delivery of advice for everyone who is affected by a long term condition.
  • Embed these practices within clinical processes to ensure they become a routine part of EVERY person's clinical journey.
  • Develop a team approach between clinicians and advisors.
  • KEEP IT SIMPLE - use what exists and bring these principles together to the benefit of those people who need it most.

Pilot sites in NHS Forth Valley and NHS Tayside have now been funded by the Scottish Government to develop the long term conditions approach to this model.

Chest Heart and Stroke Scotland ( CHSS) funds welfare benefits advisors in Lanarkshire and Glasgow in partnership with Citizens' Advice Scotland. These services raised more than £795,000 in client financial gain over the last year. The model is being extended to Fife through work with Fife Citizens Advice and Rights Bureau. Other voluntary organisations have similar arrangements to support financial health.

The Money Matters Service has operated in partnership with NHS Greater Glasgow & Clyde to deliver financial inclusion support to people in the Keep Well programme. This includes benefit entitlement and maximisation, help with debts, advice on pensions and other savings.

Food For Thought:

  • Do you know how to signpost people to their local benefits advice and support services?