Long-term conditions

IAPT services have evolved to deliver benefits to people with long-term conditions (LTC), providing genuinely integrated care for people at the point of delivery. The NHS Long Term Plan (LTP) requires all areas to commission IAPT-LTC services for their local population. The requirements include:

  • Roll-out in all boroughs by 2018/19
  • Co-produced and implemented with service users and families
  • Co-located in physical healthcare pathways including co-location of therapists in primary care
  • IAPT clinicians working effectively with the wider system
  • Agreed access criteria for IAPT-LTC
  • Concordance with IAPT standards
  • 25% Access target for adults with relevant disorders (in line with Core IAPT access target)

National resources

The following resources are available for IAPT services to guide IAPT-LTC implementation.


Additional resources

Case study: King’s College Hospital – Three dimensions of care for diabetes

Case study: Buckinghamshire – IAPT LTC

Case study: Sheffield Chronic pain and lower back pain pathway

The responses to the Key Lines of Enquiry (KLOEs) audit of IAPT-LTC provision in London show that all London IAPT services offer IAPT-LTC pathways, although individual services are at varying levels of development and maturity of the core requirements. A London IAPT-LTC leads network with representation from all 32 London IAPT services has been set up as a sharing space to bring all services to similar levels of maturity.

We explored IAPT-LTC provision in London IAPT services and a few examples from our conversations are highlighted below.

City & Hackney

Through its ‘Talk Changes for Health Pathway’ (https://talkchangesforhealth.org.uk/), the IAPT service provides support to help people find new ways to manage their diabetes, to feel in control and live life to the full.

A mailout was sent to all patients with diabetes and Irritable Bowel Syndrome (IBS) at two GP surgeries. The aim was to shift the language or mindset from mental health problems to seeking psychological coaching or support for their LTC. The pilot was done pre-COVID with approximately 10% response to the mailout. The initiative will be rolled out across all GP surgeries in the borough post-COVID.

Tower Hamlets IAPT service have been liaising with Community Health and Health Psychology services at Bart’s to review referral pathways across IAPT to specialist physical health services (for diabetes and Chronic Obstructive Pulmonary Disease (COPD)). This work has been delayed by the pandemic and subsequent lockdown.

More recently they have liaised with health psychology colleagues in pulmonary rehabilitation and are part of their care pathway for COVID survivors.

Hammersmith & Fulham partnered with the Hammersmith & Fulham Learning Disability Service to establish a joint care pathway between the Community Learning Disability Team (CLDT) psychology service & IAPT, to facilitate improved access to psychological therapy for people with learning disabilities who are also struggling with symptoms of low mood and anxiety. There is an executive summary of the research (here) that was completed in collaboration with the Hammersmith & Fulham IAPT service. This led to the development of adapted versions of PHQ-9 and GAD-7  and assessment of their performance as measures. There are also two papers that detail the wider work i.e. service pathways and a press release that gives an overview of the work:

Hammersmith and Fulham Learning Disability Service paper

Hammersmith press release

Haringey was a Wave 1 site for IAPT-LTC development, so has an established pathway. The service linked in with diabetes, respiratory and health psychology teams at the start of IAPT-LTC development and will continue doing this when Covid restrictions have eased.

High turnover of staff within the IAPT-LTC team remains a big challenge for the service, as it is harder to recruit to these roles. IAPT-LTC training is not very popular, as it requires coursework and producing a portfolio. The IAPT-LTC caseload can be quite difficult to treat – patients are often complex.

Hillingdon IAPT service has been involved in developing post-Covid 19 pathways for those with long Covid and will link this work to existing LTC pathways, which include integrated physical and mental health care. The team is developing replicable pathways with West London Mental Trust where outcomes can be evaluated and measured across several services.

Greenwich IAPT Greenwich IAPT set up an integrated LTC service in May 2021, which developed out of an LTC workstream. The service runs psycho-educational workshops that are embedded within the cardiac rehabilitation service, the pulmonary/COPD rehabilitation programme and the long-COVID respiratory rehabilitation programme.  The service also has strong links with the Frailty & Falls MDT, which we attend on a regular basis, and runs monthly consultation sessions with the community rehabilitation team. In Greenwich, community health services are provided within Oxleas NHS trust, which has been an advantage as patient records are on the same system. The Greenwich LTC IAPT lead is also linked into the health psychology team and attends regular team meetings, where pathways, service developments and individual patients can be discussed.

Havering IAPT service provides GPs with LTC referral cards to refer patients with LTC, who require psychological support to the IAPT service. There is also an established care pathway link with the diabetes clinic whereby a PWP link worker sits in the diabetes clinic for 1 full day per week to triage appropriate patients to the IAPT service.

Kingston IAPT service are co-located with the diabetes day unit that deals with complex diabetes patients at Kingston hospital. Two IAPT clinicians work on-site for 1 full day per week to provide psychological support to the patients who require it. The clinics were run online during the COVID-19 pandemic but will return when services return to face-to-face provision. Recovery rates from these group of patients were reportedly higher than would have been expected.

Both teams have worked well together to co-produce leaflets and other pieces of information together and there has been cross-training across the two teams. Diabetes UK are very keen to get involved on the project as well due to its success.

The crucial learning for the IAPT service from the project is that motivated and willing physical health partners are crucial to the success of any IAPT-LTC collaboration.

Croydon IAPT has an LTC team who have seen a wide range of conditions since the service was set up. Due to the way local services are structured it has been hard to co-locate with diabetes and cardiac services. However, we noticed we had a number of referrals for IBS and pelvic pain from the urogynecology and gastroenterology departments who work closely together. After reaching out to a psychologist in the department, we were able to set up colocation which will involve screening patients who attend the clinic and offering consultation to clinicians.


MIND and the IAPT service have successfully connected with the pulmonary rehabilitation service patient groups, running workshops offering mental health sessions and introduction to what the service offers. They also offer a workshop in-house for COPD service users.

A challenge is that they have not had the same level of success with the diabetes and cancer cohort, particularly noted as Harrow’s ethnic minority population have a high prevalence of diabetes. There are plans to create diabetes transformation community hubs where multi-disciplinary meetings (MDTs) will take place and the service is hoping to connect with diabetes patients this way.

Bexley IAPT have a chronic fatigue service. Patients with chronic fatigue are initially referred to the IAPT chronic fatigue service rather than the secondary care provider (SLAM), which provides graded exercise therapy. If the patients need more support after that, they are referred to secondary care. The service has a monthly multi-disciplinary meeting with Oxleas and SLAM to discuss chronic fatigue patients.

Hillingdon IAPT were part of the wave-1 early implementer sites for collaborative IAPT and LTC work in 2017. The legacy of this project has continued, and the service set up care connect teams and is working with social prescribers to support them in linking people into their service and providing information on how those with LTCs should be managing their wellbeing.

COVID-19 has brought a unique challenge for the service on how to engage with this patient cohort. During the first lockdown, the service identified those older adults over 70s with a long-term condition, who were seen on our service in the previous 18 months, as they were vulnerable to isolation as well as COVID-19.  The service contacted this identified cohort, as well as existing LTC patients, to ask how they were coping without family/friend and whether they needed our support from IAPT or other organisations.

Newham have developed partnerships with diabetes and cardiac rehabilitation to deliver one-off workshops / webinars once a month for stress management and anxiety.

Bromley IAPT deliver one session within the 8-week courses run by COPD and cardiac rehabilitation clinicians on managing the disease. They also deliver a 10-week course based on ACT and one session is jointly delivered with a physiotherapist.

Hillingdon IAPT service also created a Senior PWP role (Job Description) to focus on working on outreach, group work and LTCs, and will continue to rebuild links with GPs, health centres and other healthcare teams to identify LTC patients for their service.

Lewisham’s IAPT service makes IAPT resources more relevant to LTC patients’ needs and provide training/support to therapists to adjust/ adapt the content accordingly. For example, LTC materials include reference to loss and adjustment for those who are newly diagnosed with an LTC and include anxiety resources and breathing exercises for those with COPD.

Havering IAPT provided a brief CBT training to physical health LTC colleagues such as district nurses, so they can more easily detect mental health needs such as low mood (using a shorter version of the PHQ-9 questionnaire designed by the service), when engaging with their patients. Patients identified as requiring professional help are then referred on to the IAPT service.

One of the PWPs in Bromley IAPT is trained to deliver ‘walking away from diabetes’ courses, focussed on diabetes prevention and lifestyle changes. The 4-hour sessions are co-facilitated with a public health colleague, to address the obstacles to lifestyle changes.