LTC Referral Information

The Healthier You: Long Term Conditions Prevention Programme is an NHS pilot to deliver tailored behavioural interventions to people with hypertension, aiming to reduce the incidence of long-term conditions (LTC) such as cardiovascular disease, stroke, chronic kidney disease and dementia. 

The programme aims to reduce the incidence of these long-term conditions by supporting healthy lifestyle changes. The programme will run for 9 months, and patients can join face to face group sessions, remote group sessions, or access the programme digitally via an app.  

Key areas include:  

• Understanding hypertension and why making behavioural changes is important to support long-term wellbeing   

• 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 

Referrers are responsible for ensuring that patients are eligible to take part in the programme before inviting them to join the programme. To be eligible, patients must be: 

• Diagnosed with hypertension – this could be high blood pressure now, or blood pressure in the normal range because it is controlled with medication 

• Aged 18 – 80 years old  

• Registered at one of the practices taking part in the programme 

Patients who are aged 81 and over may be able to join the programme as an exception, if the GP practice deems them suitable to take part and that the benefits of the programme would outweigh the risks. If this is the case, please contact us on scwcsu.ltc@nhs.net to discuss. 

Patients are not eligible to take part in the programme if they have: 

• Existing or previous diagnosis of type 2 diabetes​ 

• Existing or previous diagnosis of 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

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 LTC programme is specifically for patients with hypertension who do not meet the DPP cohort criteria. 

Patients who are pregnant cannot start the programme. However, if a patient becomes pregnant during the programme, they can continue attending the programme. They will be advised to follow their medical team’s advice first, and the LTC programme advice to be layered on top. In the event there is a contradiction, they will be told they must follow their medical team’s advice. 

Wave 1 of the pilot programme has a referral window of January – March 2026. There are 15 GP practices that have been randomly selected to join wave 1 of the pilot. Those are: 

 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 

Referrals to the LTC programme will mostly be made via searches provided by your ICB, to search for and send an SMS to all eligible patients at the practice. Those patients will be prompted in that SMS to sign up to the programme. 

If you would like to refer a patient outside of this process, please ensure that they are eligible for the programme and registered at a participating GP practice. Please then contact the patient to advise them that they are eligible to take part and that they can sign up here: https://xylaservices.com/ltc or by calling 0333 577 3011. 

Please contact scwcsu.ltc@nhs.net for any additional support if needed. 

Patients will be offered an informed choice between 3 delivery methods. Those are: 

• In person group sessions: These group sessions are run by a trained health coach, in a variety of convenient local venues, with up to 20 patients per group. They allow patients to connect with others on the same journey, in a supportive, expert-led environment. 

• Remote group sessions: These group sessions are live, interactive group sessions, run by a trained health coach using video conferencing. This allows patients to connect with others in the same supportive, expert-led environment, but from the comfort of their own home. 

• Digital programme: This allows patients to access the programme individually, either app only or with telephone call support too. Patients can access personalised guidance through an easy-to-use app, ideal for busy schedules. 

When patients sign up to the programme, they will immediately be taken to information about the different programme delivery methods. This page will allow patients to pick which programme type is best for them, and in the case of face to face and remote groups, see what group sessions are currently available. They will also be able to book into all three delivery methods here. 

If a patient doesn’t self-select a programme method and group, our team will be in contact with them to discuss the programme and ensure they are able to get started. Patients are also able to contact our team to discuss their booking or ask any other questions, on 0333 577 3011 or by emailing preventingltc@xylaservices.com. 

Patients will be discharged from the programme upon completion of the 9-month programme, or in the below cases:  

• If they no longer want to take part in the programme 

• No contact made after 3 attempts, by different contact methods if possible, and no response to a final unable to contact letter 

• Three consecutive uninformed missed sessions (F2F or remote) 

• No activity for three months (digital) 

The LTC programme will mirror the NDPP programme and so you will receive letters, containing SNOMED codes where appropriate, at each stage in the programme. Therefore, you will get notification of: 

• Starting the programme 

• Discharge due to no successful contact 

• Discharge if contact made but did not start the programme 

• Discharge during the programme 

• Completion of the programme 

Clinical oversight of medication and ongoing clinical management remains with the patient’s GP practice. 

We will collect weight measurements throughout the programme. The programme does not provide blood pressure monitors, nor will blood pressure be monitored in the sessions. 

We cannot advise on individual medication or set blood pressure targets; patients with questions about their blood pressure or medication will be signposted to their GP.  

If a patient is discharged from the LTC 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. 

If you have any questions that are not answered here, please don’t hesitate to contact our team on scwcsu.ltc@nhs.net.