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Managing Long Term Conditions: Stability and Quality of Life for all

More and more of us are living with long term conditions like diabetes, heart disease or arthritis.

It has long been an NHS priority to keep people as healthy and stable as possible, to reduce health crises or hospital admissions.

In this article, we talk generally about long term conditions – also called chronic diseases – and how we’re working to keep people as healthy as possible.

Defining Long Term Conditions

We mean a condition, disease or illness that doesn’t have a cure. With long term conditions, the priority is to control the illness so that people can live and age well.

This is typically done with medication, support, or other therapies. Here are some of the most common types of long terms conditions:

  • Cardiovascular – diseases affecting the heart like angina or hypertension (high blood pressure)
  • Respiratory – to do with lungs and breathing, such as asthma or COPD (chronic obstructive pulmonary disorder)
  • Diabetes
  • Chronic pain like arthritis
  • Cancer
  • Mental health conditions like depression, anxiety, or bipolar disorder
  • Neurological conditions such as MS (Multiple sclerosis)
  • Long Covid

Why is it an NHS priority?

Long term conditions mean people will continue to need some medical intervention throughout their lives. And, of course, when more people need more regular care, it increases demand on the NHS.

We have a growing and ageing population. There are more of us, and we are living longer. And more of us have long term conditions.

Across the UK, more than 26 million people have a chronic disease, with 10 million living with more than one condition. Over half of everyone over 60 – 58% – have a long term condition.

It is better for patients and the NHS to proactively keep people well rather than treating them when their health worsens.

Management and Reviews

You’ll be invited for a yearly review if you have a chronic disease.

Reviews are a chance for clinical teams to check in on your overall health and see how well your medication or other treatments control your condition.

It’s also a chance to look for ways to improve things. Changes in medication or dose might help, or there may be new therapy or support options to explore.

Regular reviews mean small, subtle changes get picked up more quickly, and the impact of changes can be seen.

GP practices contact patients when their reviews are due.

For patients with more than one condition, you’ll generally be invited to a single, longer review to look at your overall health rather than one disease at a time. This is sometimes called Year of Care, with appointments in the month of your birthday.

Tackling Inequalities

We’ve mentioned that age is a factor, with 58% of over 60s having at least one long term condition, compared with 14% of under 40s.

Other factors that can make you more likely to develop a chronic disease include gender, ethnicity, and deprivation.

On top of that, if people can’t get to their reviews through lack of mobility, worsening health, or other reasons, it can lead to a downward spiral in their wellbeing.

Across our PCN, tackling these sorts of health inequalities is a priority.

Like our Home Visits team, who help housebound people with acute illnesses, we have introduced at-home health reviews. It’s part of making sure everyone has the same access to the care they need.

Sophie is a Nurse Associate working with the 4 GP practices in North Gosforth. She visits housebound patients to do their chronic disease reviews and ensure they get the best treatment, support, and care possible. We will be launching a similar service for the 3 Jesmond Lower Gosforth Practices soon.

Here’s what a typical day looks like for Sophie, how she works with patients and why her role is vital in tackling health inequalities.

A Day in the Life of Sophie, Nursing Associate

Hi, I’m Sophie.

I’m a Nursing Associate working with the four GP practices in North Gosforth Primary Care Network.

I spend a lot of my time visiting patients at home, doing chronic disease reviews and making sure they have the best treatment, care and support possible.

This is what a typical day is like for me.

A Day in the Life of Sophie, Nursing Associate

8 am: Log in and check work load

The first thing to do every morning is get logged into the clinical systems for whichever practice I’ll be working with that day.

I work across all four practices in North Gosforth so it’s important I can access patient records.

I can make sure I’m up to speed with each patient’s history before I go to see them, and the Practice teams can let me know anything else i need to be aware of.

I’ll check my workload, see how many patients I’ll be visiting, and make a plan of how to get around to everyone.

I’m visiting mostly housebound people who would struggle to get to their GP practice under their own steam. Me doing this means people don’t miss out on essential health care and aren’t disadvantaged

8 am: Log in and check work load

9 am: Morning Visits

With my bag stocked with everything I might need, I’ll set off for my morning visits.

Everyone I see has a chronic disease or long-term condition. Our aim is to keep on top of the illness as much as we can, and help people have the best possible quality of life.

Regular reviews mean we can really understand how people are getting on, spot things before they become a problem, and make changes to their treatment or support if they are things that will help.

I’ll record people’s height, weight and blood pressure, check their pulse rate and take a blood sample. If someone is diabetic, I’ll do a foot check, and there are specific questions to ask if someone has asthma or COPD (chronic obstructive pulmonary disease).

9 am: Morning Visits

12 pm: Samples/Restock/Lunch

After my morning visits, I’ll have blood samples to get ready to send off to be processed.

I’ll also check through my bag to see what I’ve used so far and restock anything that I might run short off.

Then it’s time to grab some lunch on the go before heading back out for my afternoon visits.

With everything from the morning sorted out, and everything needed for the afternoon ready, I’ll head back out to see more patients in their homes.

12 pm: Samples/Restock/Lunch

1 pm: Afternoon Visits

Personalised Care and Support Plans (PCSPs) are another big part of my visits with people. They are an in-depth assessment of how someone is coping at home. It’s about looking at all parts of their life and wellbeing, and seeing where we can help.

I’ll ask about any equipment they have, like mobility aids, and discuss whether they can get themselves up, washed and dressed and make meals.

We might talk about their weight, food intake and any problems they have with swallowing food or drink or taking their medication.

Continence, sleep, mood and memory are also important areas to cover, as is their home environment and if there are fall risks.

If there is support available that would make a difference, I’ll arrange for that to be followed up either my colleagues in the PCN or by other community services.


1 pm: Afternoon Visits

5 pm: Finishing off and Tidying Up

The last part of my day is about making sure everything has been completed.

Any samples from the afternoon visits need to be sent off and patient records updated.

If anyone I’ve seen needs to be referred to another service, I’ll arrange that as well.

I work closely with the other teams in the Primary Care Network – the Home Visits team, our Clinical Pharmacists and Social Prescribing Link Workers.

We’ll often discuss issues or ideas with each other to make sure we’re getting our patients the best possible care to keep them safe and well in their homes.

5 pm: Finishing off and Tidying Up

Whole Person Focus

As Sophie said, a big part of her work is boosting people’s overall wellbeing.

This feeds into our Network-wide approach of focusing on the whole person, not just a specific condition or illness.

Our whole network team work closely with each other and regularly share ideas and approaches. When one team see an opportunity for another team to help a patient, they’ll make a referral.

Whether it is acute care from our Home Visits team, medication expertise from our Clinical Pharmacists or support packages and connections to community groups through our Social Prescribers, the team works together to bring a new level of expert services to help proactively manage patients’ health.

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