Impact review 2020-21: supporting people with long-term conditions

By using KiActiv, it has helped me come to terms with the limitations I now have, whilst also giving me a structured way to increase my physical abilities on a daily basis. This has helped my mental wellbeing, and made me feel more in control of my health.


Digital self-management


patients enrolled on the 12-week KiActiv® Health programme to support their everyday physical activity and self-care

Through our Future Challenges programme, we partnered with KiActiv® Health, a clinically proven digital therapy designed to improve the self-management of long-term health conditions, on a number of projects across the West.

The Bath Centre for Fatigue Services (BCFS) introduced use of KiActiv® Health to empower patient-led behaviour change for patients with chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME) symptoms

Sirona Health and Care are using KiActiv® Health to help people living with chronic obstructive pulmonary disease (COPD) to improve the self-management of their condition by supporting them to understand and improve their everyday physical activity.

And in response to the challenges presented by Covid-19, we supported a project with Wiltshire Health and Care to use KiActiv® Health to support respiratory patients as an alternative to face-to-face pulmonary rehabilitation during the pandemic.

Read more about our work with KiActiv

Proactive care frameworks for long term conditions

We are supporting GP surgeries in the West to pilot Proactive Care Frameworks, tools to risk stratify patients with long-term health conditions to optimise care and promote self-management.

Developed by UCLPartners, one of the London AHSNs, the frameworks cover atrial fibrillation, high blood pressure, high cholesterol, type 2 diabetes, asthma and COPD.

We are working with surgeries to pilot the frameworks for asthma and type 2 diabetes. The resources available for participating practices include access to motivational coaching, facilitation of team meetings to discuss project goals and workforce changes, and signposting to clinical training and resources.

By sharing learning between these pilot sites and across the national AHSN Network, we are able to understand the requirements and success criteria for implementing the frameworks more widely.

Read more about the Proactive Care Frameworks

Rapid Uptake Products


hospital trusts in the West of England have adopted HeartFlow to diagnose patients with suspected coronary artery disease


hospitals in the West of England are now using gammaCore to treat patients with severe cluster headaches

As part of the AHSN Network’s support to the Accelerated Access Collaborative, we are driving adoption of a number of transformative technologies and medicines through the Rapid Uptake Products (RUP) programme.

This includes increasing the use of a number of solutions for people with long-term conditions.

Lipid Management: High Intensity Statins, Ezetimibe and PCSK9 Inhibitors

We are supporting the increased use of lipid management medicines to help prevent cardiovascular disease (CVD) due to high cholesterol. Through this NICE-approved clinical pathway, the aim is to improve a person’s lipid profile, by reducing cholesterol concentration in the blood by treating patients with the right medicine along the evidence-based pathway. The pathway includes three medicines: high intensity statins (HIST), ezetimibe and PCSK9 inhibitors.

High intensity statins and ezetimbe are prescribed in primary care and so we’re running a pilot in Bristol, North Somerset and South Gloucestershire with 10 practices to search for patients who need optimising and may need PCSK9is. We are also working with Royal United Hospitals Bath, Gloucestershire Hospitals and University Hospitals Bristol and Weston to increase uptake of all three.


HeartFlow is a non-invasive diagnostic tool creates a 3D model of the coronary arteries to help rapidly diagnose patients with suspected coronary artery disease.

By non-invasively identifying which patients do and do not need intervention, clinicians can reduce unnecessary downstream non-invasive testing and invasive procedures, reducing costs and improving patient outcomes.

We have supported the rollout of HeartFlow and all five hospital trusts in the West of England are now using the tool.


gammaCore is a handheld non-invasive device that alleviates the symptoms of severe cluster headaches through electrical stimulation of the vagus nerve. Through the Rapid Uptake Products programme, three acute trusts in the West are now using gammaCore with our support: Gloucestershire Hospitals, North Bristol Trust and Royal United Hospitals Bath.

Read more about our support for Rapid Uptake Products

Support for hospitals

As part of work to support the National Patient Safety Improvement Programmes, our adoption and spread workstream focussed on three areas: the COPD discharge care bundle, the asthma discharge bundle, and the safe tracheostomy care programme.

With implementation of the COPD and asthma discharge bundles heavily impacted by Covid-19, we provided tailored support to each of our hospital trusts based on their capacity and baseline.

The tracheostomy care programme was accelerated due to Covid-19 and after a review by each trust on the level of their use of the care bundle, we offered tailored support, including learning/sharing webinars for staff across the West of England.

Read more about our patient safety support for hospitals