Wye Valley Surgery

Long term conditions

A long-term condition (LTC) is an illness that cannot be cured but it can usually be controlled with medicines or other treatments. Examples of long-term conditions include diabetes, epilepsy, and asthma.

Individual long-term conditions

About 15 million people have a long-term condition and approaching 3 million have 3 or more LTCs (Long-term conditions and multi-morbidity | The King’s Fund). Looking after people with long term conditions is an important part of our practice work.

Below we cover individual medical conditions, and some practice processes which provide support for all long-term conditions:

You can find many of the common long-term conditions under

Supporting LTCs there is information on medication and investigations.

Information on how shared decision making can help a LTC consultation with a health care professional.

Medication and prescriptions

Investigations (blood tests)

Accessing your information on your LTC more easily

Updating your clinical record
We may occasionally ask you to help us update your clinical record with clinical information (e.g., blood pressure readings). Any practice clinical forms we ask you to update can be found under

Updating your personal details
Please update your personal details on the practice system if you are a carer

Information on our practice chronic disease clinics

  • Chronic disease (LTC) Clinics Clinics

A holistic approach to long-term conditions

A broader approach goes beyond just a focus on the medical condition and considers other areas in a person’s life which can impact on health. There is local support for such an approach much of which you can access without needing to see your GP.

Your GP/nurse may touch on some of these aspects in a review and you can always bring any of them up yourself in a consultation. On some occasions your GP/ nurse may suggest a more detailed broader approach addressing an individual’s full range of needs. This approach with some additional features is termed “personalised care and support planning” which is covered in Long term Conditions Support (Adults).

Below we consider how you can be supported more broadly:

For all of us even without a long-term condition an attention to mental, social and physical wellbeing can be helpful.

Wellbeing

These areas should not necessarily be seen as separate, so for example joining a walking club can provide exercise which can help with mental wellbeing and give you the opportunity to meet other people.

The value of considering healthy living goes beyond just a reduction in risk factors for a person’s long-term condition. It can also prevent the development of other long-term conditions and many cancers as explained in Reduce your risk of series and can allow people to live longer with a better quality of life (see under Live Longer Better). Healthy living is considered here with local support you can access without needing a referral from your GP.

Adopting lifestyle changes
It is important to acknowledge that changing any habit is not easy for any of us. Individually understanding how we can achieve any change on a permanent basis is an important step forward. There is more on this under Lifestyle changes.

We know that what is going on in a patient’s whole life can have an important impact on the management of their long-term condition. Here there are links to information on the social side of life including local support.

Social support some quick picks

“People with one long term condition are two to three times more likely to develop depression than the rest of the general population. People with three or more conditions are seven times more likely to have depression.”  NICE 2009: Depression in adults with a chronic physical health problem.

Some people with long term conditions may develop anxiety and depression and we provide information below, including local support beyond your GP.

Mental health

Flu
A free flu vaccine is offered to some people with long-term conditions because you are more likely to experience serious complications from flu if you have certain long-term conditions. There is information on the

Other vaccines
There is also information on other vaccines which you can get in the practice

Identification of an emergency
We are all at risk of developing sepsis, however some people with long term conditions can carry a higher risk. This includes people with diabetes, people taking immunosuppressant drugs (e.g., for rheumatoid arthritis) and people with multiple long-term conditions who are frailer or aged over 75. Understanding sepsis can help with early identification and thus quicker treatment. There is more information under

Emergency action plan
You may discuss your action plan for an emergency with your doctor / nurse. Some potentially helpful information includes

Social care (only if relevant)
Planning for the future can improve the quality of life and avoid decisions needing to be made in a crisis. Even if one never needs extra support knowing what is available can provide reassurance. If a person has a carer, supporting the carer is very important.

Please update your personal details on the practice system if you are a carer

Understanding your choices and stating preferences for end-of-life care (only if relevant)
Dying well, or what constitutes a ‘good’ death will mean different things to us all.  A person sharing their wishes with a health care professional (after a discussion of the choices) gives that person knowledge that they are in control of future events and can also provide comfort to their family, knowing their loved one’s wishes are being carried out.

Quality care checklists and local support

Quality care checklists are a form with a series of health questions and answers but unlike many forms, checklists are not submitted back to the practice when you complete them. They are for your own use to help you develop a better understanding of your condition(s), including where relevant, options with local support.

These checklists can be completed at any time but we do ask that you complete any relevant checklist before a medication review (particularly your annual review) to help you get the most out of your medication review.

We include a list of all our long term condition quality care checklists and a further explanation of checklists below:

Remember that these checklists are not submitted to the practice though we may ask to you add scores/ numbers to the “universal medication review” form from these checklists.

You should start with completing the “long-term condition and medication” checklist.

Long-term conditions and medication checklist

This checklist covers features which are common to many long-term conditions which are not duplicated in the other checklists.

Other checklists

Review any checklist(s) which are relevant to you.

Medical Conditions

Mental Health

  • Depression and Anxiety Checklist (Though not necessarily a long term condition we include here for any patient with a long term condition who also has depression or anxiety).
  • Mental Health Checklist under the support of the local mental health team (includes schizophrenia and psychosis)

Medication 

Introduction
Quality care checklists are a form with a series of questions but unlike some other practice forms these forms are not submitted back to the practice when you complete them. They are for your own use to help you develop a better understanding of your condition(s), including where relevant options with local support.

How to use them
Many will use quality care checklists just for information or may access local services without ever needing to attend their GP practice. Some will use a checklist to support a conversation they will have with a practice clinician. Some will use a checklist after a practice consultation to follow up on an action that was discussed in a consultation.

What individual patients do with a checklist will be variable. Some will do nothing on the checklist but they will have developed a broader understanding and may consider some of the options in the future, some will do everything relevant on the list.

What type of questions do checklists ask
Quality care checklists fundamentally ask 4 key questions of patients to help them with their care.

  1. Are you aware about an aspect of your condition?  May include
    Broad aspects (e.g., what lifestyle risk factors are relevant for your condition) or
    Specific points about your condition? (e.g., What the range of your target blood test value might be for your condition)
  2. Would this option be helpful to you? May include
    Local support (e.g., direct access to mental health psychological support) or
    A practice option (e.g., online access to your investigations)
  3. How can you be better protected and made safer? (e.g., if you potentially are at a higher risk of sepsis  providing information on how you can detect sepsis early)
  4. How can you plan for potential future events? (e.g., a care plan)

Not all quality care checklists will cover all 4 questions, but may just focus on one such as safety.

Practice Forms

We may on occasions ask you to complete a practice form relating to a long-term condition to help us update your clinical record. These forms can be found under update your clinical record. Please only submit a form if you are asked to.

Videos and podcasts

Many people prefer to see a video or listen to a podcast as it offers a different way to understand health information. On the videos and podcasts page there are links to some relevant videos and podcasts covering various topics relating to long term conditions.

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