LTC referral information

The Healthier You: Long Term Conditions Prevention Programme is an NHS initiative that delivers tailored behavioural interventions to people with hypertension, aiming to reduce the incidence of long-term conditions (LTCs) such as cardiovascular disease, by supporting healthy lifestyle changes through structured group and digital support.

Key areas include:

• Understanding hypertension and why making behavioural changes is important to support long-term wellbeing and, where appropriate, weight management.
• Understanding hypertension and the importance of lifestyle changes for long-term health and, where appropriate, weight management.
• Nutrition guidance for balanced eating, heart-healthy choices, and sustainable meal planning.
• Physical activity support, tailored to personal preferences and abilities.
• Sleep and stress management to overcome barriers to health and blood pressure control.
• Goal setting with behaviour-based goals and a holistic view of progress.

Eligibility confirmation remains the responsibility of the prescriber; Xyla does not verify eligibility

• Age 18 – 80 years old
  • Individuals aged over 80 can join the service if the referrer completes a clinical assessment and confirms in writing that the benefits of the programme outweigh any potential risks of taking part in a weight-loss programme
• Diagnosed with hypertension
  • This could be high blood pressure now, or blood pressure is in normal range because it is controlled with medication
• Patient from one of the practices included in Wave 1*

Exclusion Criteria

• Existing or previous diagnosis of type 2 diabetes
• Diagnosed with non-diabetic hyperglycaemia
• Existing or previous diagnosis of gestational diabetes
• Active eating disorder
• Severe/moderate frailty as recorded on a frailty register
• Undergone bariatric surgery in the last two years
• Pregnant

For the avoidance of doubt:

• If an individual has non-diabetic hyperglycaemia or a previous history of gestational diabetes with normoglycaemia, they should be treated as part of the Diabetes Prevention Programme (DPP) cohort
• The LTCP cohort is specifically for those with hypertension who do not meet the DPP cohort criteria

Bedfordshire, Luton and Milton Keynes

• Red House Surgery
• The Blenheim Medical Centre
• Wheatfield Surgery
• Gardenia Practice

Norfolk & Waveney

• Harleston Medical Practice
• Prospect Medical Practice
• Ludham & Stalham Green Surgeries
• East Norfolk Medical Practice
• Magdalen Medical Practice

Leicester Leicestershire and Rutland

• Ibstock & Barlestone Surgeries
• Castle Medical Group
• Spinney Hill Medical Centre
• South Leicestershire Medical Partnership
• The Billesdon Surgery
• Merridale Medical Centre

Service Users are to be offered an informed choice between 3 delivery channels.

1. Remote group sessions; LTC tailored live, interactive sessions via MS teams led by a trained health coach
2. Digital Programme – LTC tailored, personalised guidance through an easy-to-use app, delivered by our digital Partner Oviva
3. In person face to face group sessions – LTC tailored, interactive sessions with up to 20 participants per group, held at a local venue and led by a trained health coach.

The purpose of the LTC Pilot Programme is to provide comprehensive, practical, and person-centred support to patients with hypertension.

With the aims to:

• Reduce the incidence of new long-term conditions (LTCs) and cardiovascular disease (CD) by supporting healthy lifestyle changes
• To assess the effectiveness of the service in reducing LTCs and CD.

Objectives

• Supporting people to achieve or maintain a healthy body weight, with appropriate dietary guidance
• Encouraging increased physical activity and reduced sedentary behaviour
• To maximise completion rates of Service Users, including across groups that share a protected characteristic

How long will someone need to wait to access the programme?

• Contact initiated within 5 operational days via email and SMS.
• If no response, follow-up via phone and letter within one calendar month.
• After three unsuccessful contact attempts, the individual will be discharged.

Prescriber Service User Programme updates

Reporting will mirror that of the NHS DPP programme. Information will be shared at the following points;

• Referral Received
• Programme Start
• Not Started- Discharged
• Not Completed- Discharged
• Completed

This information will be sent to the contacts we currently have on file for the NHS DPP. If you need any contacts adding, please do let us know. Please be aware that this contact list will be used for both NDPP and LTCP.

Discharge occurs when:

• No contact after three attempts over one calendar month
• Three consecutive uninformed missed sessions (F2F or Remote)
• No activity for three months (Digital).
• No response to re-engagement efforts.

Clinical responsibility remains with the prescriber.

• Clinical oversight of medication and ongoing clinical management remains with the participant’s GP practice.
• Xyla does not advise on individual medication or set blood pressure targets; participants with questions about medication will be signposted to their GP
• The programme does not provide blood pressure monitors, nor will blood pressure be monitored in the sessions
• As weight can affect blood pressure and overall health, we collect a weight measurement at each session.

• If a participant becomes pregnant during the programme, the provider must tailor the intervention according to NICE Guideline NG247 for pregnancy, adjusting weight loss goals and providing appropriate dietary and physical activity advice.
• If a participant is discharged from the LTCP programme (for example, due to non-response, declining the service, or missing sessions), they may be re-referred if they continue to meet the eligibility criteria.

The referral pathway will have been communicated by your ICB.

There are 3 referral windows

1. January – March 2026 (Wave 1 practices)
2. January – March 2027 (Wave 1 and 2 practices)
3. January – March 2028 (Wave 1,2 and 3 practices) Please contact scwcsu.ltc@nhs.net for any additional support if needed.