People with long-term conditions including cancer

As a GP your role is to:

• work with patients, their families and carers, and other healthcare professionals involved in their care, in a collaborative manner that supports patient activation; encourage individuals to develop the knowledge, skills and confidence to take an active role in their own self-management 
• work collaboratively with people living with long-term health conditions to agree individualised goals, identify support needs, develop and implement plans, review their response over time and amend plans as required  
• move away from a disease-based model of care towards a person-centred system that takes a biopsychosocial approach, considering each person’s experience of living with their condition(s) and their individual context holistically 
• involve the whole multidisciplinary team to facilitate holistic person-centred approaches to care 
• proactively encourage lifestyle changes that will reduce the risk of other health problems in those who have already developed long-term conditions, cancer or multimorbidity.

A long-term condition is defined here to mean any medical condition that cannot currently be cured but can be managed with the use of medication and/or other approaches and therapies.¹ This contrasts with acute conditions, which typically have a finite duration, for example an upper respiratory tract infection.

In relation to the care of people with long-term conditions and those living with and beyond cancer, consider the following areas within the general context of primary care:

• the natural history of the condition(s), including whether acute or chronic 
• the incidence and prevalence, including in different demographic groups 
• typical and atypical presentations 
• recognition of normal variations throughout life 
• risk factors, including lifestyle, socio-economic factors and those from the family history 
• diagnostic features and differential diagnosis 
• decognition of ‘alarm’ or ‘red flag’ features 
• appropriate and relevant investigations 
• interpretation of test results 
• management, including initial and continuing care, chronic disease monitoring and emergency care 
• patient and carer information and education, including self-care 
• prognosis.

For people with long-term health conditions, the interactions between and cumulative effects of multiple conditions, treatments and therapies must be considered, as well as the needs of the individual and their carers and relatives based on their circumstances. Through a holistic approach, the benefits and potential harms of investigation and treatment need to be discussed and decisions shared with patients. These interactions bring additional complexity to care, beyond the biomedical aspects of the specific health conditions.

Common and important conditions

Long-term conditions cover a wide range of health conditions, including but not limited to any condition or combinations of condition in the categories listed below:

• non-communicable diseases (such as osteoarthritis, cardiovascular disease) 
• communicable diseases (such as human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS)) 
• certain mental health disorders (for example, schizophrenia, depression) 
• sensory impairments (for example, blindness, permanent hearing loss).

Examples of common long-term physical health conditions include:

• certain cancers 
• cardiovascular (such as hypertension, angina) 
• dermatological (such as eczema, psoriasis) 
• ear, nose and throat problems (such as Ménière’s disease, sleep apnoea) 
• endocrine (such as diabetes, hypothyroidism) 
• gastroenterological (such as coeliac disease, irritable bowel syndrome) 
• gynaecological (such as endometriosis, polycystic ovarian syndrome) 
• haematological (such as pernicious anaemia, anaemia of chronic disease) 
• neurological (such as dementia, epilepsy) 
• ophthalmological (such as glaucoma, macular degeneration) 
• renal (chronic kidney disease, polycystic kidney disease) 
• respiratory (such as asthma, chronic obstructive pulmonary disease (COPD)) 
• rheumatological (such as fibromyalgia, rheumatoid arthritis) 
• urological (benign prostatic hypertrophy, overactive bladder) 
• other (such as post-Covid-19 syndrome, angioedema).

Consider the following areas in the context of long-term conditions and cancer:

Natural history of the condition(s)

• Different trajectories of illness commonly seen in long-term conditions and cancer: these take many forms, but common trajectory patterns include stepwise (for example vascular dementia), exacerbations (such as COPD), gradual decline (for example frailty) and relapse or recurrence (such as breast cancer) 
• Conditions that may become chronic through treatment or through the natural process of the disease

Service issues

• Active identification, surveillance and follow-up and the use of information technology and processes to achieve this 
• Continuity of care within organisations and teams and with individual healthcare professionals 
• Whole-system approaches to care, including integrated care models with GPs working in multidisciplinary teams alongside secondary care, social care and others  
• The role of multidisciplinary teams, taking a holistic approach and connecting people to services and community groups for practical and emotional support  
• The important role of third-sector providers (such as voluntary organisations, community groups and social enterprises) that can tailor support for people with certain long-term conditions 
• Identifying and supporting unpaid carers of people with long-term conditions

Multimorbidity

Multimorbidity refers to the presence of two or more long-term health conditions. This includes physical and mental health conditions, ongoing conditions (such as learning disability), symptom complexes (for example, frailty or chronic pain), sensory impairment (such as sight loss) and alcohol and substance misuse. In patients with multimorbidity, consider:

• opportunistic and proactive identification of polypharmacy and multimorbidity 
• reducing the burden of multimorbidity, including associated investigations, appointments and treatment, on the quality of life of the patient and their carers and family 
• the possibility of coexisting mental illness such as depression and anxiety 
• the possibility of one or more long-term conditions disguising other conditions, such as cancer 
• the patient’s needs, preferences, priorities and goals, including the role of carers and family 
• providing whole-person care, considering a patient’s social, mental and physical wellbeing 
• the benefits and risks of guidelines addressing single health conditions, hence the need for a whole-person-centred approach 
• the benefits of an agreed personalised management plan to coordinate care.

Cancer

One in two people in the UK now develops cancer at some point in their lifetime, and GPs play a vital role in preventing, diagnosing and caring for people with cancer.

Living with and beyond cancer

More patients are living with and beyond a cancer diagnosis (‘cancer survivorship’) and live with the long-term effects of cancer and its treatment. These effects are wide-ranging and include, but are not limited to:

• physical (such as long-term effects of surgery, chemotherapy, radiotherapy and hormone treatment) 
• psychological (for example, adjustment, depression, anxiety, post-traumatic stress) 
• financial (such as change or loss of job, costs of care, costs of unfunded treatments) 
• social (for example, loss of role, educational impacts, breakdown of relationships).
• Other important issues include:
• the recognition of signs and symptoms of recurrence and relapse 
• continued health promotion relating to future health risks, including cancer (screening may be indicated, for instance in people with the BRCA gene mutation who could be at additional risk of developing other cancers).

Case discussion

Rose Bennett is 72 years old and has osteoarthritis, type 2 diabetes and asthma. She takes significant responsibility for caring for her grandson, who has behavioural difficulties. Her daughter supports her as much as possible.

Due to concern about Rose’s breathing being ‘a bit up and down’, her daughter requests a GP appointment. When you contact Rose for a telephone triage call, she understands the importance of controlling her medical conditions but finds it hard to prioritise this when her daughter and grandson also need her support. You arrange to see her face to face to assess her breathing further. During the face-to-face consultation, you notice that her mood seems low, but you only have time to discuss this briefly, focusing mainly on her asthma management.

Six months later, Rose comes back to see you. You notice that she has frequently attended for emergency appointments and has missed her last two routine reviews because she had to look after her grandson. You speak with a colleague after your clinic for advice about how you could help her further and agree she would benefit from a holistic needs assessment.

You send a task to the reception team, asking them to contact Rose to arrange two appointments at times convenient to her, one with a practice healthcare assistant and a second, longer GP appointment. During the first appointment, the healthcare assistant collects relevant information and performs tests you have requested.

Rose attends the second GP appointment with her daughter. During this 30-minute appointment you facilitate the conversation to prioritise her goals for the next year. She admits that she has been feeling low for many months and that improving her mood would be her priority, to help her support her grandson and manage her other health problems better.

You explain that a local talking therapies service could provide her with support to manage her mood problems. She decides to self-refer to this. As her breathing is currently manageable, you agree to focus on her diabetes for the rest of the appointment.

By the end of the consultation, you have both agreed on a shared plan of care. You arrange a follow-up appointment to review Rose’s response over time and amend the plan if necessary. 

Questions

These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.

RCGP toolkits

The RCGP toolkits are regularly updated and are available on the RCGP website.

Personalised Care Institute

The Personalised Care Institute aims to equip health and care professionals with the knowledge, skills and confidence to help patients get involved in decisions about their care. It provides eLearning and resources on shared decision-making, supported self-management, social prescribing and personalised care.

Applied Knowledge Test (AKT)

• Cancer symptom management
• Recognition of alarm symptoms for cancer
• Management of chronic heart failure
• Simulated Consultation Assessment (SCA)
• A man who had leukaemia as a child attends frequently for apparently minor conditions 
• A woman with Ehlers-Danlos syndrome is struggling to manage her work as a primary school teacher

Workplace-based Assessment (WPBA)

• CbD (Case-based Discussion) with a woman who cares for her frail and elderly, blind father with dementia, who is also your patient. She is asking for your help as she can no longer cope with him 
• Learning log on a man living in a nursing home who is treated with dialysis and wants to stop treatment 
• Learning log on a young adult who has cerebral palsy and epilepsy

References

1. NHS Data Dictionary, Long-term physical health condition.