Long Term Conditions Collaborative: Improving Care Pathways

A resource to improve care pathways for those with long term conditions.


Improvement Action:

  • Embed care and review prompts and protocols in information systems



An accurate, complete and current register is the crucial starting point to improve care with and for people with long term conditions. By ensuring the register is complete, information is correct and people are being treated to target, practices will ensure better outcomes for their patient population.

The use of agreed protocols to code patient information ensures consistency within the practice team. Standardised templates ensure a systematic, consistent approach to recording accurate and complete information. Once the register has been established and validated it is essential that its validity is maintained by ensuring that information on new and existing patients is gathered and recorded accurately.


The ongoing management of people with long term conditions depends on having a system for call/recall that ensures people are invited for review at least annually and that attendance and follow-up of people who do not attend is tracked.

The use of birth date or recall dates allows the practice to spread the reviews over the year. Use of a multi-disease register means the person will attend only one or a minimum number of clinics thus saving appointments for the practice and time for the individual.


A template or checklist for the annual review should include:

  • Physical examination
  • Laboratory tests and investigations
  • Lifestyle issues for discussion
  • Support for Self Management

Lifestyle issues may include topics such as smoking, alcohol, stress, physical activity, sexual problems and healthy eating. This extends to conversations about supporting well being, understanding current treatment and medication, managing symptom control, identifying personal goals and anticipatory care planning.

A system of short appointments, disease specific clinics, and practitioners with specialist interests may suit people with acute illness, single conditions or need for brief episodic contacts. For people with multiple morbidity, lifestyle challenges and comorbid mental health problems it is helpful to schedule planned holistic reviews that address the individual's overall support needs and allow a more integrated approach to anticipatory care and support for self management. This is particularly important where people have low levels of literacy. Practices participating in the Scottish Primary Care Collaborative ( SPCC) have used the following ideas to improve outcomes for people with long term conditions:


  • Agree definitions for the disease description and define the Read codes to be used to ensure consistency of coding
  • Identify missing key indicators from register
  • Cross reference people on register with people receiving repeat prescriptions to ensure that everyone is on the register
  • Ensure that everyone on the register has had their diagnosis confirmed by the appropriate test e.g. spirometry, kidney function or blood glucose
  • Make one person responsible for coding and updating register


  • Use the patient's birth date or recall date and invite patients to attend for a review by sending a personalised letter or telephoning the patient
  • Use repeat prescription note to inform patients that a review is due and that no further scripts will be issued until the review takes place


  • Ensure that blood results are available at the review
  • Identify people with suboptimal results and review treatment
  • Develop practice protocols for staff use to ensure consistency of treatment and advice
  • Improve patient education through the use of leaflets regarding medication and results
  • Construct systematic coordinated recall for people with multiple morbidity

Did Not Attends

  • Use prompts in patient notes or the computer system for the patient to be reviewed at next visit or telephone the person to ascertain why they did not attend and arrange alternative date


  • Armadale Medical Practice validated their diabetes register and introduced a managed programme of care for people with diabetes
  • Thornhill Health Centre, Dumfries and Galloway - Practice Nurse Janette McQuarrie redesigned her diabetic clinics to ensure that laboratory results were available in time for the clinics
  • Sleet Medical Practice on the Isle of Skye applied Improvement Methodology across the extended practice team to develop systematic recall for people with diabetes
  • Dr Lorna Dunlop, Riverview Practice, Johnston, Renfrewshire developed an IT solution to coordinate the recall of people with multiple morbidity and established the role of a complex care nurse ( DRM Dunlop Recall Management)

Further information can be found in this Scottish Primary Care Collaborative Report

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