The Challenge 

Long-term conditions place significant pressure on both patients and healthcare services, often leading to poorer outcomes and fragmented care.

Around one in four people in the UK live with a long-term condition, and many manage multiple health issues at the same time.

Health inequalities further increase these challenges, with people in deprived communities experiencing shorter life expectancy and more complex healthcare needs. The impact on the NHS is substantial, with long-term conditions accounting for around 70% of healthcare spending, 50% of GP appointments, and the majority of hospital activity.

The Solution 

A six-month pilot project in North & East Cornwall brings together Suvera’s remote digital long-term condition clinic with community-based Health Coaching to improve engagement and outcomes for patients who have not responded to traditional GP recall pathways. The programme targets people living with hypertension and diabetes who are at higher risk of poor outcomes, with at least 1,500 patients eligible to be invited.

The aim of the pilot is to improve access and engagement for previously non-engaging patients, strengthen self-management and patient confidence, and support improvements in wellbeing and clinical outcomes. It also focuses on strengthening links between patients and community-based services, helping people access wider support for lifestyle, social connection and prevention. A key ambition is to strengthen cross-organisational working around individuals and population groups, bringing together primary care, digital clinical teams and the voluntary and community sector to provide more coordinated, person-centred neighbourhood support.

The model combines proactive digital reviews, condition monitoring and remote outreach with trusted, community-led wellbeing and lifestyle support through Health Coaches. By integrating digital remote clinical management with locally delivered community support, the programme aims to offer more accessible, personalised care for patients living in rural and coastal communities.

This approach allows neighbourhood teams to bring together clinical, social and lifestyle support around the patient, strengthening prevention pathways and reducing barriers linked to geography, transport, working patterns, digital exclusion and confidence. ​

Our work in partnership

This project is a collaboration between Cornwall and Isles of Scilly Integrated Care Board and Cornwall Partnership NHS Foundation Trust,​ Suvera, Three Harbours and Bosvena Primary Care Network, ​VSF Cornwall and the WellFed programme, and Bodmin Way, working alongside ​Health Innovation South West, ​the University of Bath and the University of Exeter. ​

Health Innovation South West has been commissioned to deliver the real-world evaluation, to generate insights on feasibility, equity and early impact, supporting our mission to improve outcomes for people living with Multiple Long-Term Conditions.

The evaluation will help us understand how well the model is working in practice – who it is reaching, how people are engaging, and whether the hybrid offer is improving confidence, wellbeing and early health outcomes.

We will assess changes in patient activation, experience and wellbeing, alongside early clinical indicators. The evaluation will also explore how effectively the digital and community components integrate, whether access is equitable, and what influences engagement with hard-to-reach communities.

The programme will support us to understand how integrated models can improve access, engagement, and self-management,  while strengthening links to community services and support. These insights will inform decisions on future adoption and spread across the South West, particularly for rural and coastal populations.

University of Bath are evaluating the WellFed Programme across CIoS, and University of Exeter are conducting a health economic analysis of the Suvera model. ​