LTC and Long-Term Condition Management in Primary Care

• 13th November 2025

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Long-term condition (LTC) management in primary care is one of the most significant operational pressures facing GP practices and Primary Care Networks (PCNs). Rising multimorbidity, an ageing population, and growing clinical complexity continue to widen the capacity gap. Hypertension affects over one in four adults, type 2 diabetes prevalence has doubled in the past 15 years, and respiratory LTCs such as chronic obstructive pulmonary disease (COPD) and asthmacontribute heavily to avoidable workload across the NHS.

Clinical Pharmacists and Pharmacy Technicians working in general practice, supported through the Core Prescribing Solutions Clinical Pharmacist and Pharmacy Technician support in General Practice models, offer a structured, clinically robust way for practices to meet this rising demand. They deliver recall frameworks, evidence-based reviews, and medicines optimisation that improve outcomes while reducing GP workload. This collaborative approach is now essential for delivering safe, consistent, and high-quality LTC and long-term condition management in primary care.

This article outlines best practice for LTC management, aligned with NICE guidance and supported by measurable benefits for PCNs, practices, and patients.

Key Takeaways

• Structured LTC pathways improve safety, increase control rates, and reduce clinical risk.
• Hypertension, type 2 diabetes, lipid disorders, asthma, and COPD represent the greatest LTC pressures in primary care.
• Clinical Pharmacists lead optimisation, clinical decision-making, and high-risk medicines oversight.
• Pharmacy Technicians strengthen recall, data accuracy, inhaler technique support, and workflow efficiency.
• Standardised pathways improve QOF performance and deliver long-term value for PCNs and practices.

Hypertension Management in Primary Care

Hypertension remains a major contributor to cardiovascular disease. More than five million people in the UK are estimated to have undiagnosed hypertension, making structured identification and follow-up essential. NICE NG136provides guidance on accurate diagnosis using Home Blood Pressure Monitoring (HBPM), appropriate clinic versus home targets, and stepwise titration.

Clinical Pharmacists lead hypertension clinics, manage titration in line with NG136, and review lifestyle and adherence factors that influence control. Pharmacy Technicians support the pathway by coordinating HBPM processes, coding readings accurately, managing recall, and maintaining data quality.

A structured hypertension management model increases diagnosis rates, improves control across cohorts, and reduces variation that often emerges when practices rely solely on opportunistic reviews.

Type 2 Diabetes Management in Primary Care

Type 2 diabetes is one of the most resource-intensive LTCs. National audits suggest that up to half of patients do not receive all nine NICE care processes consistently, which increases the risk of cardiovascular, renal, and metabolic complications.

Clinical Pharmacists follow NICE NG28 to optimise HbA1c control, initiate and titrate SGLT2 inhibitors or GLP-1 receptor agonists, and ensure appropriate cardio-renal protection. They take a structured, data-driven approach that enables timely intervention for uncontrolled diabetes.

Pharmacy Technicians strengthen this work by managing recall lists, validating missing care processes, supporting lifestyle follow-up, and ensuring results are coded correctly. This blended model aligns with the NHS Type 2 Diabetespathway, improves consistency across PCN practices, and increases capacity for timely monitoring.

Lipid Management and Cardiovascular Disease Prevention

Lipid disorders are central to long-term cardiovascular disease prevention. NICE NG238 outlines the requirement for initiating high-intensity statins and reviewing non-HDL cholesterol and LDL-C to assess response.

Clinical Pharmacists review cardiovascular risk factors, optimise therapy, escalate to ezetimibe or PCSK9 inhibitors when required, and support adherence. They also initiate suitable patients on simvastatin, an HMG-CoA reductase inhibitor that lowers LDL cholesterol, total cholesterol and triglycerides while increasing HDL cholesterol. By reducing cholesterol levels, simvastatin improves long-term cardiovascular outcomes, including lower rates of heart attacks and strokes.

Although simvastatin is traditionally a moderate-intensity statin, modern NICE guidance (NG238) recommends high-intensity statins such as atorvastatin 20-80 mg or rosuvastatin 10-40 mg as first-line for most patients requiring primary or secondary prevention. Clinical Pharmacists use simvastatin appropriately for patients who require a lower-intensity option, have previously stabilised on simvastatin, or cannot tolerate high-intensity alternatives.

Pharmacy Technicians reinforce the pathway by ensuring recall is timely, lipid profiles are completed at the correct intervals, and coding is accurate. This structured model improves lipid control, enhances treatment adherence, reduces long-term cardiovascular risk, and supports QOF performance.

Further patient information is available via NHS cholesterol guidance.

Asthma and COPD: Respiratory LTC Support

Respiratory long-term conditions are a significant driver of avoidable NHS workload. COPD alone accounts for more than 115,000 hospital admissions per year, with many of these exacerbations preventable through structured primary care interventions.

Clinical Pharmacists deliver COPD reviews aligned with NICE NG115. They assess symptoms using tools such as CAT or MRC scores, review exacerbation history, optimise inhaler regimens, and create personalised self-management plans. They also manage device switches, ensure appropriate use of inhaled corticosteroids, and support smoking cessation pharmacotherapy.

Pharmacy Technicians complement this work by coordinating recall, delivering inhaler technique coaching, ensuring accurate coding of CAT scores, and supporting follow-up after device changes.

Asthma care follows similar principles, aligned with NICE NG80, with a focus on inhaler technique, personalised action plans, and consistent preventer use.

A blended respiratory pathway reduces inappropriate SABA use, improves symptom control, and strengthens QOF delivery across the PCN.

Structured Medication Reviews as a Foundation for Safety

Structured Medication Reviews (SMRs) are a core safety mechanism for patients with frailty, multimorbidity, or complex polypharmacy. SMRs identify high-risk medicines, address interactions, support deprescribing, and improve adherence.

Within Core Prescribing Solutions’ Structured Medication Reviews and Medicines Optimisation service, Clinical Pharmacists lead SMRs and manage clinical risk, while Pharmacy Technicians gather medication histories, support compliance checks, and maintain accurate coding.

SMRs remain fundamental to safe LTC delivery and complement COPD, diabetes, hypertension, and lipid management.

Integrated LTC Pathways Through Clinical Pharmacists and Pharmacy Technicians

Integrated LTC pathways require a consistent model of search, stratification, recall, review, and follow-up. A blended workforce model ensures that both clinical decision-making and workflow management are delivered effectively across all practices in a PCN.

Core Prescribing Solutions’ ARRS Workforce Support service helps PCNs deploy Clinical Pharmacists and Pharmacy Technicians in a way that increases capacity, reduces GP workload, and improves control rates across all major LTCs. Standardised pathways reduce variation, enhance clinical safety, and deliver long-term value across the network.

When LTC pathways are delivered through structured, data-driven processes, supported by both Clinical Pharmacists and Pharmacy Technicians, practices see measurable improvements in control rates, safety, and capacity. This blended model provides long-term value and is essential for managing rising demand in modern primary care.

Adeem Azhar, CEO and Co-Founder of Core Prescribing Solutions

Frequently Asked Questions

Summary

LTC and long-term condition management in primary care continues to grow in complexity and scale. A blended workforce model using Clinical Pharmacists and Pharmacy Technicians supports structured pathways that strengthen safety, improve control rates, reduce GP workload, and deliver long-term value. Through evidence-led reviews, proactive recall, and consistent optimisation across COPD, diabetes, hypertension, lipids, and asthma, Core Prescribing Solutions helps practices provide high-quality LTC care at scale.