Long term conditions in general practice Part 1: An introduction to management

In the first of two articles on the management of long term conditions in the general practice setting, we will be looking at the systems, skills and workforce that need to be in place to manage them effectively

A long term condition (LTC) is a health problem that cannot be cured and which the individual will have throughout their life. Usually the symptoms and progression of the condition can be controlled through medical management and lifestyle interventions. Prevalence increases with age, as does the incidence of people having more than one LTC. Approximately 15 million people in the UK have a long term condition and 24% of those have more than one long term condition.¹ LTCs account for 50% of GP consultations and 70% of total health and social care spend.² Patients with long term conditions are at increased risk of hospitalisation and mortality.³ Cardiovascular disease and lung disease are in the top five causes of premature deaths in the UK.⁴

As well as ageing, the prevalence of LTCs is linked to lifestyle factors. Health promotion strategies, such as NHS Health Checks, are targeted at those at risk with the aim that prevention or early recognition of disease will reduce the number of people developing LTCs in the future.

Care of the person with an LTC in primary care includes the whole disease trajectory – from diagnosis until end of life. Management will include health education, support to achieve self-management, symptom and deterioration recognition, medical management and palliative care. In order to achieve this there needs to be a structured approach; how this is achieved will depend on the needs of the practice population, the skills of the general practice nurses (GPNs) and the organisational structure of the practice. It is suggested that when services for long term conditions are commissioned or designed they move away from a clinician led, disease focused service to one that puts the patient and supported self-management at the centre. One such model is the House of Care.⁵

IDENTIFYING PATIENTS

It is vital that the practice maintains up-to-date and accurate disease registers of patients with LTCs so that they can be identified easily, otherwise patients may not receive the care they need. Thus the first step in the management of LTCs is validating the disease registers, which involves identifying any patient with a chronic illness who does not currently appear on the relevant disease register. The support of an audit clerk or administrator and the GP is invaluable in this process.

Performing a search of the relevant READ codes (a list of specific codes to enable standardised data collection of clinical diagnoses, procedures and treatments6) for a specific LTC produces a list of all the patients with that diagnosis – assuming that diagnoses have been correctly READ coded. There is usually an expected prevalence for the LTC. For example, the expected prevalence for heart failure is 1.5 to 2.3% of the practice population.⁷ The individual practice’s prevalence can be calculated from the disease register search and compared with the expected prevalence. This gives an indication of the completeness of the disease register and an indication of how many patients are potentially ‘missing’. The result does, however, have to be taken in context with the demographics of the practice. For example, a practice that has a significantly younger than average practice population, such as a practice with a high number of university students, will probably have a lower than expected prevalence of some conditions, and conversely a practice with a very elderly population may have a higher than expected prevalence of some long term conditions.

To find the patients who should be on the disease register it will be necessary to search for other diagnoses or treatments or investigations that are commonly linked to that specific LTC. For example, to find patients who have coronary heart disease (CHD) and who are not on the CHD resister, a search could be done on all patients who do not have a READ code of CHD but who are prescribed a nitrate medication (e.g. isosorbide mononitrate or glycerine trinitrate spray). It is unlikely that the patient will have been prescribed a nitrate preparation for anything other than a cardiac problem. A review of these patients’ records will be necessary to see if they do have CHD; the relevant READ code then needs to be added to the patient record.

Disease registers need to be continually updated with new diagnoses as they are made, not only by the GPs and GPNs, but also by other members of the multidisciplinary team and secondary care. This information comes from a variety of sources (see box 2). Mechanisms need to be in place to ensure that this information is captured and recorded in a retrievable format. It needs to be clear whose responsibility it is to enter this information on the clinical system and standardised READ codes must be used.

PREPARATION FOR LTC MANAGEMENT

Setting up a system for reviewing patients with long term conditions requires careful planning to ensure that resources are used appropriately and cost effectively, and that patients are reviewed in a timely and efficient manner. Patients can be reviewed in dedicated clinics or on an ad hoc basis. Dedicated clinics may be preferable, as they allow the GPN to deal with a number of patients with similar conditions at the same time rather than having reviews interspersed with treatment room duties. It can also be easier to coordinate with other members of the team who support the clinic such as healthcare assistants (HCAs). However, this approach may be less convenient for patients who have to fit their appointments around work and other commitments. As not all patients with long term conditions feel unwell they may not appreciate the benefits of a regular review of their condition and will not attend appointments if they are not convenient.

Working out how much time is needed to manage the specific LTC is important in the planning stage. The total time overall will vary according to the length of the consultation, how many times a year patients need to be reviewed, and how many patients are on the disease register.

The length of the consultation time can be a contentious one, as appointment times for managing long term conditions vary from practice to practice, ranging from 15 to 40 minutes. A report by The King’s Fund suggested that if the investigations and examination were done prior to the review, 20 minutes would be sufficient but there needs to be flexibility to allow for more complex patients and those with more than one long term condition.⁸ Lack of time during the consultation compounds difficulties in making an effective diagnosis or recognising problems – put simply, there is a lot to cover in a single 10- or 15-minute appointment. This increases the likelihood of some aspects of care being overlooked.⁹

The issue of mulitmorbidity requires particular thought. A substantial proportion of people with LTCs experience co- or multi-morbidity – the presence of two or more conditions simultaneously.⁹ The the evidence suggests this is more often the rule than the exception. One study of patients attending general practice in Canada found that 69 % of 18–44 year olds, 93 % of 45–64 year olds and 98 % of those aged 65 and over had two or more long-term conditions.¹⁰

A particularly common form of multi-morbidity is the existence of mental health problems such as anxiety or depression, or neurological problems such as dementia, alongside physical health problems such as diabetes, arthritis or cardiovascular disease.⁹

So consideration needs to be given to patients with more than one long term condition and how these patients are reviewed. Ideally a patient with diabetes and CHD should not have to attend two separate long term condition clinics but should have a combined review. This not only saves clinician time but is more convenient for the patient and provides a more comprehensive disease review as the interplay between the two diseases is taken into account. Alternatively the system needs to be flexible enough to allow for a shorter review of the patients CHD if they have recently had a diabetes review as much of what will be covered regarding lifestyle modification, self-management and clinical assessment will have been covered in the previous review.

There should be a practice protocol in place to ensure consistency of care and that all aspects of good management are covered. This protocol needs to be based on the latest evidence and agreed by all the relevant healthcare professionals in the practice involved in the management of LTCs. It should be periodically reviewed to sure it remains up to date. The computer template used to record the outcome of the consultation should reflect the practice policy.

SKILLS AND EXPERIENCE

GPNs are usually generalists. As generalists, it is understandable that GPNs do not necessarily have extensive or detailed knowledge of every LTC and how these should be managed, but many have acquired or could obtain specialist skills and experience in the management of LTCs. The King’s Fund recommends that GPNs should have accredited training in long term condition management.⁹ Local training providers and universities often provide accredited courses or modules in long term condition management and there are also distance learning courses available.

As well as the required knowledge of the specific condition, the GPN needs to have up-to-date, evidence-based understanding of the appropriate medical management as well as specific clinical skills such as electrocardiogram (ECG) recording and interpretation or spirometry. Some clinical skills require the clinician to demonstrate that they have the required skill set. For example, in order to perform spirometry all clinicians over the next four years will need to ensure they have Association for Respiratory Technology and Physiology accredited training. While GPNs provide the bulk of long term condition management in primary care there are other members of the multidisciplinary team who can play an important role. With appropriate training and formal assessment of their competence healthcare assistants (HCAs) can support the GPN in care delivery. They can record observations (blood pressure, pulse, temperature, height, weight, body mass index or waist measurement) record ECGs or peak flows, take bloods, do foot checks and deliver health education such as smoking cessation. This allows the GPN more time to develop a management plan in conjunction with the patient and promote self-management.

Medication is often the mainstay of managing chronic diseases. Many patients with LTCs, especially those with co-morbidities, are on multiple medications.

A key area of concern is around potential adverse interactions between medications prescribed for different conditions. NICE guidelines state that prescribers should be vigilant for such interactions.¹¹ Increasingly, pharmacists are being used in general practice and they can be a valuable resource for medication reviews. The Royal Pharmaceutical Society suggests that pharmacists can enable the patients to get the best outcomes from their medication, ensuring that the patient is taking the correct dosage and not having any adverse events.¹² As it is estimated that 30-50% medications prescribed for long term conditions are not taken correctly this could be useful in improving patient management.¹¹

CALL AND RECALL

Consideration needs to be given to how the patients are going to be invited to attend for a review of their long term condition. The GPN will – ideally – have administrative or HCA support to do this in order to ensure that all patients are invited for review in a timely manner. Invitations need to be sent out in a coordinated approach which matches the availability of the GPN. Some areas have found inviting the patients for their annual review in the month of their birth a convenient way of doing this.

The information sent to the patient should contain an explanation about the review and why it is important, as this ensures that patients – in particular those patients who do not feel unwell and may not be inclined to attend – can see the benefit of attending. Follow up phone calls may need to be made to those who do not attend.

Patients also need to be made aware of what they need to do before the review. Wherever possible patients should have all the investigations or tests they may need before the appointment. This may include bloods, ECGs or spirometry. This makes for a more effective consultation and is a better use of time as it reduces the need for follow up. For example, if current blood test results are available before the review, medication can be titrated if necessary without the need for a further appointment once they are available.

CONCLUSION

It is not a good use of GP time to deliver chronic disease case management. Nurses are better skilled, more cost-effective and efficient at doing it,⁹ so the management of long term conditions has become a significant part of the GPN’s workload. GPNs need to be sure that they are targeting all patients who would benefit from their expertise and making sure that they provide evidence-based, up-to-date care. This can achieved through robust systems in the practice to ensure that all patients with long term conditions are included on the relevant disease registers and invited for review in a timely manner with appropriately skilled healthcare professionals.

REFERENCES

1. Department of Health. Long Term Conditions Compendium of Information, third edition 2012

2. NHS England. Enhancing the quality of life of people with long term conditions https://www.england.nhs.uk/wp-content/uploads/2014/09/ltc-infographic.pdf

3. Khalid J, Raluy-Callado M, Curtis B, et al. Rates and risk of hospitalisation among patients with type 2 diabetes: retrospective cohort study using the UK General Practice Research Database linked to English Hospital Episode Statistics. Int J Clin Pract 2014; 68(1): 40–48

4. Department for Health. Living Well for Longer: National Support for Local Action to Reduce Premature Avoidable Mortality. 2014

5. The Health Foundation. Introducing the ‘House of Care’ http://www.health.org.uk/newsletter/introducing-%E2%80%98house-care%E2%80%99

6. NHS Digital. Read Codes. https://digital.nhs.uk/article/1104/Read-Codes

7. Davies MK, Hobbs FDR, Davis RC et al. Prevalence of left-ventricular systolic dysfunction and heart failure in the Echocardiographic Heart of England Screening study: a population based study. Lancet 2001; 358: 439-44

8. Coulter A, Roberts S, Dixon A. Delivering better services for people with long-term conditions: Building the house of care. The Kings Fund 2013. https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/delivering-better-services-for-people-with-long-term-conditions.pdf

9. Goodwin N, Curry N, Naylor C Managing people with long-term conditions. The Kings Fund 2010. https://www.kingsfund.org.uk/sites/files/kf/field/field_document/managing-people-long-term-conditions-gp-inquiry-research-paper-mar11.pdf

10. Fortin M, Bravo G, Hudon C, et al. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005;3(3):223–28.

11. NICE Clinical Guideline 76. Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, 2009. https://www.nice.org.uk/guidance/cg76

12. Royal Pharmaceutical Society. Improving care for people with long term conditions, 2016. http://www.rpharms.com/policy-pdfs/rps-caredoc-english.pdf