Long-Term Conditions & Complex Care
Most GP appointments now involve people living with long-term conditions, and many have more than one.
Learn how to run a person-centred review, manage multimorbidity, apply key NICE targets, carry out a structured medication review and test yourself with real-world scenarios.
The Person-Centred LTC Review
Tap each stage to see how to turn a routine review into a care and support planning conversation.
Prepare Gather the information
Arrange tests and measurements before the review, so the appointment is spent on the conversation rather than collecting data. Send results to the patient in advance where possible.
- Bloods and checks done first
- Results shared ahead of time
- Review the medication list
Explore What matters to you?
Start with the person, not the condition. Ask what matters most to them, how their conditions affect daily life, and what they want to get out of the review.
- Priorities and goals
- Impact on daily life
- Ideas, concerns, expectations
Prioritise Weigh benefits and burdens
With several conditions, guidelines can conflict. Balance the benefit of each treatment against the burden of tests, appointments and medicines.
- Treatment burden
- Risks versus benefits
- Frailty and life expectancy
Plan Agree it together
Agree realistic goals and actions using shared decision-making. Record an individualised care plan that the patient keeps a copy of.
- Shared decision-making
- Personalised care plan
- Self-management support
Review Keep it coordinated
Set a clear review date and decide who is responsible for coordinating care, especially when several services are involved.
- Clear follow-up date
- Named coordinator
- Communicate across teams
Managing Multimorbidity
Five principles, informed by NICE guidance on multimorbidity (NG56). Tap each card to reveal it.
Condition Review Essentials
Choose a condition to see the key points to cover at a review.
Hypertension: Review Essentials
- Clinic BP target below 140/90 if under 80, and below 150/90 if 80 or over
- Home or ambulatory targets are 5 mmHg lower (135/85 and 145/85)
- Check adherence and side effects before stepping up treatment
- Assess cardiovascular risk and review lifestyle factors
- Check for postural hypotension in older people
Based on NICE guideline NG136. Use clinical judgement for people with frailty or multimorbidity.
Type 2 Diabetes: Review Essentials
- HbA1c target is usually 48 mmol/mol on lifestyle measures or a single drug not linked to hypoglycaemia
- Usually 53 mmol/mol if on a drug linked to hypoglycaemia, such as a sulfonylurea
- Annual checks include blood pressure, lipids, kidney function, urine ACR, BMI, smoking status and foot assessment
- Make sure the person is attending diabetic eye screening
- Consider relaxing targets where intensive control isn’t appropriate, such as in frailty
Based on NICE guideline NG28. Agree individual targets with the person.
COPD: Review Essentials
- Offer smoking cessation support at every opportunity
- Check inhaler technique and adherence before changing treatment
- Refer to pulmonary rehabilitation if functionally limited by breathlessness (usually MRC grade 3 or above)
- Make sure vaccinations are up to date
- Agree a personalised self-management plan, including what to do in an exacerbation
Based on NICE guideline NG115. Confirm the diagnosis with spirometry if it hasn’t been done.
A summary only. Always check current NICE guidance, NICE CKS and local formularies.
Structured Medication Review Checker
Work through these seven steps, based on the widely used 7-Steps approach to polypharmacy, to check how complete your review is.
- Aims: Have you asked what matters to the patient and what they want from their medicines?
- Essential: Have you identified the essential medicines that must not be stopped?
- Unnecessary: Have you checked for medicines that may no longer be needed?
- Effective: Are the medicines achieving their intended goals?
- Safe: Have you looked for side effects, interactions and risks such as falls or kidney problems?
- Cost-effective: Are the most cost-effective options being used?
- Patient-centred: Is the patient willing and able to take their medicines as agreed?
Test Yourself With Scenarios
Five common long-term condition scenarios. Choose an answer to see instant feedback.
Q1. An 83-year-old with hypertension has a clinic blood pressure of 146/84. They’re well, with no postural symptoms. What’s the most appropriate step?
NICE NG136 recommends a clinic target below 150/90 for people aged 80 and over.
Q2. A patient with type 2 diabetes takes metformin and gliclazide. What HbA1c target does NICE usually suggest?
For people on a drug associated with hypoglycaemia, such as a sulfonylurea, NICE NG28 usually suggests a target of 53 mmol/mol.
Q3. A patient with five long-term conditions feels overwhelmed by appointments and medicines. What’s the best first step?
NICE’s multimorbidity guidance (NG56) recommends starting with the person’s goals and the burden of their treatment.
Q4. A patient with COPD gets breathless walking 100 metres on the flat and has to stop (MRC grade 4). What should you offer?
NICE NG115 recommends pulmonary rehabilitation for people functionally limited by breathlessness, usually MRC grade 3 and above.
Q5. An 88-year-old with moderate frailty takes 12 medicines and has had two falls. What’s the most appropriate approach?
A structured medication review lets you weigh benefit and harm with the patient and stop medicines that are no longer helping.
Keep Learning
This guide is for education only. Always use your clinical judgement and check current NICE guidance, NICE CKS and local pathways.