People with Long-term Conditions Including Cancer

This topic covers the management of patients with chronic diseases and the recognition of cancer in primary care. It is one of the most clinically relevant AKT topics because managing long-term conditions is the core work of general practice.

Multimorbidity affects over a quarter of the UK population and is the norm rather than the exception in general practice. NICE guideline NG56 on multimorbidity recommends an approach that considers treatment burden, polypharmacy, patient priorities, and the interaction between conditions. You should understand that guidelines for individual conditions may not apply straightforwardly to patients with multiple conditions.

Cancer recognition relies on understanding NICE NG12 (suspected cancer: recognition and referral). The guideline specifies two-week-wait (2WW) referral criteria for each cancer type. High-yield cancers for the AKT include lung (persistent cough, haemoptysis, unexplained weight loss in a smoker), colorectal (change in bowel habit over 60, unexplained iron deficiency anaemia, rectal mass), breast (unexplained lump in over-30s), and skin (pigmented lesion meeting the 7-point checklist).

The safety netting approach is critical when cancer cannot be ruled out. This means giving the patient clear instructions about when to return, what symptoms to watch for, and ensuring there is a system for following up investigation results.

Palliative transitions are the shift from active management of a long-term condition to a palliative approach. The GSF (Gold Standards Framework) Prognostic Indicator Guidance helps identify patients who may be in the last year of life. The surprise question ("Would you be surprised if this patient died in the next 12 months?") is a simple screening tool.

Annual reviews for long-term conditions follow QOF and NICE guidance. For diabetes, this includes HbA1c, renal function, blood pressure, cholesterol, foot examination, and retinal screening. For COPD, it includes spirometry review, inhaler technique, vaccination status, and exacerbation history. For heart failure, it includes medication optimisation, fluid assessment, and functional status.

Cancer survivorship is an expanding area. GPs play a key role in managing the long-term effects of cancer treatment, coordinating follow-up, and detecting recurrence.