A GP surgery in the Scottish Highlands will test whether treating patients based on their symptoms—like breathlessness—rather than their individual disease labels can improve care for people with multiple chronic conditions. The UK’s ageing population means more people live with several long-term conditions at once, yet the health service still organises care around single diseases. This mismatch leads to fragmented treatment, unnecessary hospital visits, and widening health inequalities, especially between urban and remote rural areas. The project, a collaboration with NHS Lanarkshire and NHS Highland, uses systems engineering to map current care pathways, model alternatives, and run pilot programmes focused on breathlessness as a common symptom across heart and lung diseases. If successful, the approach could shift the NHS from reactive “sickcare” to proactive, home-based healthcare. Patients with multiple conditions would receive coordinated support for their whole experience of illness, not separate appointments for each diagnosis. The team will produce visual maps of current and future care systems, a policy brief for decision-makers, and early evidence showing improved quality of life and treatment satisfaction within 18 months.
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Research question: How can systems engineering perspectives, methods and tools transform health delivery services from disease-based to whole person symptom-focused healthcare? Background: The demand on UK health and care services is growing with increasing aging populations. The cost of chronic and multiple long-term conditions (MLTC) are increasing, leading to the need for wide ranging changes to health interventions, keeping people out of hospital, treating people near to or at home. A proactive healthcare system focused on disease prevention and health promotion is needed requiring a seismic shift from sickcare to healthcare. With a salutogenic vision, this project tackles health inequalities across urban and rural environments, partnered with NHS Lanarkshire and NHS Highland. Aims and objectives: The development phase of the Innovation Hub aims to explore a radical change from disease-based approaches to symptoms-focused management, including prevention, diagnosis, treatment and long-term care through the integration of health symptom science and systems engineering. Pilot examples will be used to demonstrate the new focus on symptoms e.g. breathlessness as a common presenting symptom. The associated objectives are: 1. understand the needs, requirements and implications (benefits and risks) of a symptom-focused approach to health delivery for remote and rural, deprived/older and/or urban deprived/younger populations, with a focus on breathlessness within the context of cardio-respiratory diseases and associated multimorbidity as the chosen MLTC; 2. define the precise MLTC focus and establish innovation and research programmes for the Innovation Hub; 3. form and develop the consortium, operational processes and governance structure across academia, patient-carer community, public, industrial, and policy stakeholders for the Innovation Hub, potentially in a hub and spoke model Methods: A mixed-methods approach will be used, with methods from design, systems engineering, and operations research. Qualitatively, ecosystem mapping and system architecting workshops will be used to identify ‘as-is states’, challenges, and required intervention. Focus groups and interviews with service users will be used for needs elicitation and evaluation during the pilots. Quantitatively, system dynamics modelling and simulation, data mining of secondary sources e.g. electronic health records will be core methods throughout. Timelines for delivery: Three work packages (exploring as-is, creating to-be, evaluating and hub developing) will take 18 months. Data collection starts in Aug '23. Final results and full Hub proposal are delivered in Dec '24. Anticipated impact and dissemination: Findings will contribute to the body of evidence on the application of health symptom science and systems engineering in the diagnosis and management of service users. Results will be disseminated through visual ecosystem maps and models of current and future states across the two health boards and early evidence through pilot cases of how to support the whole-person with multiple chronic conditions. In patients presenting with breathlessness, we will demonstrate a significant improvement in quality of life and patient treatment satisfaction scores in the first 18 months. People with lived experience, healthcare professionals and others will be engaged in presentations at national and international workshops, peer-reviewed publications and a policy brief for decision-makers
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