A registrar survival guide... managing chronic conditions

GPs have an important role in the early detection and prevention of chronic disease as well as diagnosing, managing and treating existing chronic conditions. Therefore, it is important that we do this properly.

Keep your guidelines handy
Nationally recognised guidelines exist for all chronic conditions, so keep them close to hand.

It may be helpful to save relevant guidelines on to your computer desktop so that you can access them easily. The NICE website is also easy to use.

Read the patient's last outpatient letter
If your patient is being seen in secondary care, it is always helpful to have a quick glance at their last clinic letter.

This usually provides a comprehensive yet concise synopsis of the current state of their condition, together with advice on how they should be managed in primary care.

Utilise the team
Know your local multidisciplinary team and utilise its services appropriately. Most practices have nurse-led clinics for asthma and diabetes, and some will even have specialist nurses specifically trained to manage certain conditions.

Make a clear plan for follow-up
Give the patient clear instructions. They need to know who they will be seeing next, when, what tests they may need to have and what to do should something go wrong in the meantime.

Do not forget lifestyle measures
Smoking cessation, exercise and diet are fundamental in managing most chronic diseases. Enquire about your patient's lifestyle and reiterate the importance of basic modifications.

Essentials checklist

  • An up-to-date knowledge of the relevant guidelines.
  • A good working relationship with the multidisciplinary team and local services.
  • A clear follow-up plan.
  • Good health promotion advice.
  • Contributed by Dr Hamed Khan, a GPST3 in south London

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