Is Your Practice Getting Long-Term Condition Care Right?

Long-term condition care is at the heart of general practice – reviewing your systems now can improve outcomes, support equity and help prepare for CQC inspections

CREDIT: This is an edited version of an article that originally appeared in Enhanced Primary Care

In general practice, the ongoing care of patients with long-term conditions (LTCs) forms the foundation of daily clinical work. Conditions such as asthma, diabetes, chronic obstructive pulmonary disease (COPD), hypertension and heart disease require more than episodic treatment. They demand continuous monitoring, proactive management and person-centred care. Many patients live with more than one LTC, making coordinated care essential.

A structured audit of your current systems, clinical processes and patient engagement strategies can ensure that your approach is delivering the best possible care – while also supporting wider goals such as reducing hospital admissions, improving equity and preparing for CQC inspections.

Improving Outcomes Through Proactive Management

When long-term conditions are managed effectively, the results are clear: patients are more likely to avoid complications, fewer emergency hospital admissions occur and individuals report a better quality of life.

A robust LTC management system empowers patients to remain in control of their condition, rather than relying on being reactive to deterioration. This, in turn, builds confidence and reduces pressure on urgent care services. Reviewing your recall system, consultation structure and follow-up process can help ensure that care remains one step ahead of the condition.

Personalising Care to Meet Individual Needs

Personalised care is more than a buzzword. The Care Quality Commission (CQC) expects practices to involve patients in their own care planning and ensure interventions are tailored to the individual’s health needs, preferences and life circumstances.

By auditing your current approach, you can determine whether your care plans are genuinely person-centred. Are patients actively involved in decisions? Are their goals reflected in the management plan? Do they have the tools, understanding and encouragement to self-manage wherever possible?

Ensuring Consistency and Equity Across the Practice Population

Long-term condition management also plays a vital role in addressing health inequalities. A consistent, fair recall and review system ensures that no patient is left behind regardless of their condition, background, or ability to advocate for themselves.

This means developing a system that proactively reaches out to patients, schedules reviews efficiently and reduces duplication where patients have multiple LTCs. Auditing your systems can highlight where improvements are needed – perhaps some patient groups are underrepresented in reviews, or perhaps certain conditions are consistently overdue. Addressing these gaps supports equitable, population-wide care.

Preparing for CQC Inspections with Confidence

A comprehensive audit of your LTC management also serves as excellent preparation for CQC inspections. Each element of the audit can be mapped to specific CQC ‘We’ statements, making it easier to provide evidence that the care your practice delivers meets regulatory expectations.

Are your systems proactive, fair, and efficient? Are your care plans meaningful and co-produced with patients? Are reviews well-structured and streamlined to reduce duplication for patients with multiple conditions? Are your coding practices accurate, and are exception reports justified? These are all key areas inspectors are likely to explore and being ready with clear answers and documentation helps demonstrate quality and continuous improvement.

Empowering Patients and Supporting Practice Teams

At the core of effective LTC management is the partnership between the practice and the patient. Ensuring patients have access to the right tools, resources and support to self-manage their condition can make a profound difference to their health journey. Whether it’s structured education, digital monitoring tools, or targeted lifestyle advice, supporting self-management helps patients take control and reduces reliance on emergency services.

For practice teams, a structured, well-audited approach to LTC care also reduces stress and confusion. It creates a system where responsibilities are clear, patients are better informed, and the team can work more collaboratively and efficiently.