For many GP practices, long term condition (LTC) management can feel like a constant balancing act.
The start of the financial year often brings good intentions and plans for proactive care, but as operational pressures build and appointment demand rises, structured LTC reviews can quickly drift down the priority list. Before long, practices find themselves facing the familiar end-of-year rush to close QOF gaps, complete annual reviews and meet contractual requirements before the end of March.
However, the direction of travel across primary care is changing.
The 2026/27 GP Contract, PCN DES and wider NHS planning guidance are all reinforcing a stronger focus on prevention, proactive care, population health management and neighbourhood-based working. Practices are increasingly being encouraged to move away from reactive, target-driven approaches and towards more strategic, clinically meaningful long term condition management delivered consistently throughout the year.
The Challenge with Traditional LTC Review Models
In many practices, LTC recalls are still heavily influenced by:
- annual review dates
- month of birth recall systems
- end-of-year QOF recovery work
- available clinic capacity rather than clinical need
Whilst month of birth recalls can provide a simple administrative structure, relying on this as the primary approach can unintentionally create challenges for both practices and patients.
Patients with respiratory disease may be reviewed during the peak of winter pressures rather than earlier in the year when optimisation could help prevent deterioration. Patients with cardiovascular risk factors may wait many months for intervention opportunities. Practices can also end up with significant spikes in workload as QOF deadlines approach, creating pressure on clinicians, administrators and appointment capacity.
At the same time, patients increasingly present with multiple long term conditions rather than a single isolated diagnosis. Asking patients to attend separate appointments for diabetes, asthma, hypertension and medication reviews not only increases workload for practices, but can also create frustration and unnecessary inconvenience for patients.
The National Direction of Travel
The NHS is increasingly clear about the need for a more proactive and preventative approach to care.
The 2026/27 GP Contract continues to strengthen the emphasis on:
- prevention and early intervention
- cardiovascular disease prevention
- proactive management of high-risk cohorts
- improved continuity of care
- population health management
- integrated neighbourhood working
- data-driven improvement
Similarly, the PCN DES continues to encourage practices and PCNs to work more collaboratively at scale, using shared operational approaches and multidisciplinary teams to improve patient outcomes and reduce avoidable demand.
This means moving away from simply “completing annual reviews” and towards:
- identifying the right patients at the right time
- delivering reviews when they are clinically most valuable
- intervening earlier to reduce deterioration
- coordinating care more effectively across conditions
- using workforce and digital tools more intelligently
Why Strategic Planning Matters
A more structured, year-round approach to LTC management can significantly reduce operational pressure while improving patient care.
Rather than viewing all LTC reviews as equal annual tasks, practices can begin to think more strategically about:
- which cohorts would benefit from seasonal planning
- which patients are highest risk
- where proactive intervention could reduce winter pressures or hospital admissions
- which reviews can be combined
- how different members of the multidisciplinary team can support delivery
For example:
- respiratory patients may benefit from review and inhaler optimisation during summer and early autumn before viral illnesses increase
- hypertensive patients with poorly controlled blood pressure may require earlier intervention to reduce cardiovascular risk
- frail or high-risk patients may benefit from proactive monitoring ahead of winter pressures
- diabetic patients with deteriorating HbA1c trends can be identified earlier through risk stratification rather than waiting for annual recall dates
This type of planning allows practices to spread workload more evenly across the year while ensuring patients are seen when interventions are most clinically useful.
Risk Stratification: Focusing Effort Where It Matters Most
Population health management and risk stratification are becoming increasingly important tools within primary care. Rather than treating every patient recall identically, practices can use available data to:
- identify patients at highest risk of deterioration
- prioritise poorly controlled conditions
- target patients with rising healthcare utilisation
- identify unwarranted variation
- support proactive outreach
This allows practices to focus limited clinical capacity where it is likely to have the greatest impact. Importantly, risk stratification does not always require complex systems or advanced analytics. Many practices already hold valuable information within their clinical systems, dashboards and digital tools that can help identify:
- uncontrolled hypertension
- frequent exacerbations
- medication compliance concerns
- patients missing reviews
- high-risk respiratory patients
- patients with multiple admissions or contacts
Used well, this approach supports safer, more targeted care while helping reduce unnecessary workload.
Reducing the Burden for Patients with Multiple Conditions
One of the biggest opportunities within LTC management is improving how care is coordinated for patients living with multiple conditions.
Many patients currently receive separate invitations and attend multiple appointments across the year for different conditions. This can create duplication for clinicians, repeated history taking, fragmented care and unnecessary inconvenience for patients.
A more joined-up approach allows practices to:
- combine reviews where clinically appropriate
- reduce the number of appointments required
- improve continuity
- create more holistic care plans
- reduce administrative burden
- improve patient experience
Patients may benefit far more from a coordinated review than several isolated condition-specific appointments.
This approach aligns strongly with the wider NHS shift towards neighbourhood and multidisciplinary care models, where teams work together around the patient rather than around individual disease areas.
Using the Wider Workforce More Effectively
The move towards proactive LTC management also creates opportunities to better utilise the wider multidisciplinary workforce.
Many aspects of LTC management can be supported through:
- clinical pharmacists
- pharmacy technicians
- nursing teams
- healthcare assistants
- care coordinators
- social prescribers
- health and wellbeing coaches
This allows practices to reserve GP capacity for more complex clinical decision making whilst still delivering high-quality structured care. Digital tools, messaging systems, online questionnaires and remote monitoring can also support more efficient pathways and reduce unnecessary appointments.
Moving from Reactive to Proactive Care
As practices look to move away from reactive, end-of-year recovery work, digital tools are also beginning to play a bigger role in helping teams manage LTC activity more strategically throughout the year.
A growing number of practices and PCNs are now using population health and recall planning tools to help identify outstanding reviews, prioritise high-risk patients and coordinate more structured recall programmes across multiple conditions.
For example, tools such as Suvera Planner are designed to help practices gain visibility across QOF, local and best-practice targets in one place, while supporting more coordinated patient recall workflows. The platform focuses on identifying patients who require intervention, helping practices combine multiple reviews into fewer appointments where appropriate and reducing the reliance on manual searches, spreadsheets and reactive recall processes.
Importantly, the role of these tools is not to replace clinical judgement or existing practice workflows, but to support teams in planning activity more effectively, prioritising clinical need and spreading workload more sustainably across the year.
For practices managing increasing demand alongside workforce pressures, structured planning tools may help reduce some of the operational burden associated with traditional recall models while supporting a more patient-centred approach to long term condition management.
Looking Ahead
As primary care continues to evolve, LTC management is likely to become increasingly proactive, data-driven and integrated across neighbourhood teams.
The practices and PCNs that start embedding structured planning, risk stratification and coordinated review models now are likely to be better positioned to:
- manage rising demand
- support workforce sustainability
- improve patient outcomes
- meet contractual requirements more naturally throughout the year rather
- than through reactive recovery work
The shift away from the “March scramble” is not simply about improving operational efficiency. It is about creating a more sustainable, clinically meaningful and patient-centred model of care for the future of general practice.
