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Optimise Chronic Disease Recall in General Practice

Dr Richard Baxter Explores Current Chronic Disease Management and Recall in Primary Care, Advocating a Proactive Approach

Read This Article to Learn More About:
  • the rising emphasis on chronic disease management (CDM) in the NHS, and its impact on primary care
  • the pros and cons of opportunistic and structured recall in the context of CDM
  • novel methods for structuring the recall of patients with chronic diseases.

Key points and implementation actions for clinical pharmacists in general practice can be found at the end of the article.

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Anyone who works in healthcare will recognise the challenges primary care faces in satisfying rising clinical demand with a limited budget and workforce.1 Coupled with this, whereas in secondary care emergency and elective care can be separated to maximise efficiency,2 patients often present to primary care with simultaneous chronic, acute, and preventative healthcare needs.

As chronic diseases become more prevalent, healthcare is becoming increasingly focused on the management of long-term conditions.3 An estimated 15 million people in England have a long-term condition, and their treatment and care is thought to account for 70% of health and social care expenditure.4 Consequently, chronic disease management (CDM) processes and interventions have increased considerably in recent decades, whereas interventions for acute attendances have remained more consistent.

In this article, I explore ways to optimise the efficiency of CDM in the context of current pressures, focusing on how practices can review their use of opportunistic versus structured approaches to CDM, and realign their processes towards a more structured model.

The History of Chronic Disease and its Management

Since Graeco-Roman times, diseases have been broadly categorised as acute (diseases that kill or run their course quickly) or chronic (diseases that linger).5 As a medical category, ‘chronic disease’ became increasingly prominent over the course of the 20th century, although the notion of chronic disease remains imprecise and elastic,5 and is used with great variation by healthcare professionals.6

Defining Chronic Disease

Chronic diseases tend to have common features, including:4,6,7

  • multifactorial causality and gradual onset
  • prolonged duration of illness
  • common adverse sequelae
  • associated functional disability
  • long-term management with drugs and other treatments.

Many conditions are categorised as chronic diseases; examples include cardiovascular disease, diabetes, obesity, asthma, and certain types of cancer.6 Certain acute illnesses can also become chronic, such as AIDS.6 As several chronic diseases involve an identifiable antecedent state (for example, factors that place people at high risk of diabetes or cardiovascular disease), it is now common to also include these cohorts in preventative activities.8,9

In the US, deaths from chronic diseases first exceeded deaths from acute illnesses in the 1950s.7 The Office for National Statistics has shown a similar trend in the UK, as the most common causes of death transitioned over the 20th century from infections to longer-term conditions, particularly heart disease and cancer.10 The gap in morbidity and mortality burden between chronic and acute diseases will further expand if the prevalence of long-term conditions continues to rise.

The Development of CDM

Deliberate approaches to managing chronic disease have been slow to develop, but are gathering pace. In 1970, only a minority of GP practices had any form of chronic disease register.11 Now, registers for many chronic diseases are ubiquitous, and the delivery of effective interventions is more widespread—if not mandatory in many cases. The 2021–2022 Quality and Outcomes Framework (QOF) guidance heavily incentivises the maintenance of patient registers for atrial fibrillation, hypertension, diabetes, asthma, and dementia, among other chronic conditions.12 The Primary Care Network Directed Enhanced Service contract also bases many of its requirements on these QOF registers.13 In my experience, systematic maintenance of these registers, alongside quality assurance of measures and interventions, are now what set practices apart.

In line with the increasing emphasis on CDM, the number of evidence‑based interventions for managing chronic diseases is rising. Figure 1 demonstrates this trend, showing the number of NICE guidelines available online each year since 2004—as more evidence-based interventions are available to clinicians, the number of guidelines increases.

Figure 1: Cumulative Number of Online Guidelines Produced by NICE, 2004–2022

Adapted from: NICE. Guidance, NICE advice and quality standards. (accessed 19 October 2022).

This trend is likely a consequence of ongoing research, which is in turn driven by the needs of funding bodies. Evidence-based interventions and guidelines have become the gold standard for decision‑making and clinical standards, and various groups—including national health systems, clinical academics, and pharmaceutical companies—emphasise their importance,14 even though their needs differ considerably. This move towards increased monitoring and management of chronic diseases is therefore likely to continue.

Although most interventions for the management of chronic disease are recommended in professional guidelines, many are also mandated or financially encouraged.12,13 Other candidate activities, with a similarly strong evidence base, compete for inclusion into routine practice, and competent and caring physicians, who are often perfectionists, can feel under pressure to implement them all. Although patients will usually benefit from such interventions, clinicians must ensure that they are being patient focused when applying them.

The Chronic Care Model

The principal model for CDM is the Chronic Care Model (CCM). Developed in 1996 in the US,15 the CCM is an evidence-based conceptual framework that sets out the essential elements of a healthcare system that need to work together to deliver effective, efficient care for chronic conditions:16–18

  • self-management support—empowering patients to manage their own healthcare
  • delivery system design—assuring effective and efficient care and support
  • decision support—promoting evidence-based, consistent care
  • clinical information systems—organising data effectively and efficiently.

The model has since been applied and validated as an effective basis for improving chronic care delivery in many developed countries.19–21 The World Health Organization adapted the CCM for global use in 2014,18 and the NHS England House of Care model was also partly based on this framework.22

In 2009, the concept of ‘minimally disruptive medicine’ was introduced within the CCM in response to the rising burden of treatment, particularly for those with multimorbidity or cognitive challenges.23,24 Despite the increasing theoretical popularity of this concept, there has been little evidence of any practical application of balancing the burden of treatment with the effective delivery of chronic care.25,26

Approaches to the Delivery of CDM

As practices aim to be more comprehensive and volumes of elective work have increased, patient recall has become necessary as part of CDM. Broadly, there are three ways to implement CDM:

  • opportunistically
  • via structured recall
  • through the use of supported self-care.

The default option tends to be opportunistic delivery of CDM, in which long-term conditions are managed as and when patients present to the practice, often for unrelated reasons. When CDM is more structured, patients are recalled at regular intervals—usually annually—and the process is more regulated.

Currently, many practices follow blended models, in which most patients are following a structured management programme and receiving regular recalls, but patients are still treated opportunistically at times because there is a perceived pressure for clinicians to capitalise on all opportunities to review patients. The Make Every Contact Count initiative emphasises that clinicians should promote behavioural change in all contacts with the public,27 and is indicative of many clinicians’ approaches to CDM.

The processes of structured recall and opportunistic treatment can become frantic and disorganised towards the end of the QOF/Quality Assurance and Improvement Framework (QAIF) year when, sadly, quality of care can be overshadowed by ‘box ticking’ and financial considerations.28,29 Any frantic rush can be evidence of insufficient structured recall at earlier times. As 100% effective recall is unlikely to be achievable, or even optimal given the constraints on most practices, a blended model of opportunism and structured recall seems inevitable.

Supported self-management, in which patients take a more active role in managing their health, also has promise for appropriately engaged individuals. Preliminary evidence has indicated the benefits of self‑management interventions on clinical outcomes,3 including for diabetes, obesity, chronic obstructive pulmonary disease (COPD), and heart failure.30 This strategy for optimising CDM therefore has potential, but needs to be explored more fully.

The structure I advocate—an optimised blend of comprehensive structured recall and judicious opportunism, culminating in a holistic medication review—aligns well with a combined model such as the CCM. It should enable practices to maximise the use of their whole workforce while minimising duplication of visits and interventions. It may also provide a useful annual focus for integration with care providers beyond the practice, and for planning multidisciplinary care. The following sections analyse the pros and cons of different approaches to CDM.

Opportunistic CDM

Opportunistic delivery of CDM can be effective, but brings with it various issues and inefficiencies. As such, it is perhaps best if it is utilised judiciously, and with an understanding of where it works well.

Clash of Agendas

A significant advantage of opportunism is that a patient is physically, or virtually, present when they may otherwise have responded poorly to being recalled. However, in this case, the patient has likely attended for a reason other than to review their chronic disease. This ‘clash of agendas’ between patient and clinician can interfere with the patient‑centred approach; in my experience, there is rarely sufficient time for proper engagement and shared ownership of an agenda that was originally introduced by the clinician, and both agendas receive suboptimal attention as a result. Such an approach can also cause needless time-based stress, as the clinician is trying to include this review in a pre-existing appointment. When opportunism is necessary, dissonance may be reduced by making patients aware of the clinician’s agenda before the consultation, just as clinicians often find it helpful when the patient shares theirs in advance.

Structural Inefficiencies

The potential for avoidable structural inefficiencies in CDM is great, and these can more easily be prevented with a planned, rather than opportunistic, approach. Incorrect sequencing of review elements (for example, failing to order blood tests before review), or incomplete review (for example, lacking information like weight or smoking status) can lead to avoidable reattendance. Unnecessary repeated phlebotomy can also be remedied through careful organisation of blood tests, particularly in patients with more than one chronic disease.31 A well-intentioned GP or advanced nurse practitioner (ANP) working opportunistically can forget, or not realise, that inefficient reviews conducted by a senior member of the clinical team may be costlier to the practice than if they occur later as part of a structured approach.

Eliminating such inefficiencies is not inevitable with a structured approach; however, in my experience, with good planning, sufficient administrative capability, and whole‑team ownership, they can be reduced. The main structural inefficiencies I have experienced with a recall‑based approach are nonresponders and nonattenders.

When Is Opportunistic CDM Worth It?

Despite the possibilities for disruption and inefficiency, there are occasions where opportunism has its advantages, particularly when a patient is not responsive to structured recall. If any review element does align well with a patient’s reason for attendance, timely reinforcement and discussion can be useful for holistic care, even if this has been done previously. This is particularly true for lifestyle elements, which are a key emphasis of the Make Every Contact Count approach.27 Obviously, any measures of a chronic condition that are out of control require more frequent management than an annual review provides. Unless there is a clear plan to address these issues, they should always be raised opportunistically.

Clinicians will likely be able to identify which patients need opportunistic intervention and which patients will return in a few months more willingly, and transparent recall processes can help them to recognise these patients. Staff at my practice have even heard that conversations in the village pub can lead to a patient’s timely presentation at reception, precluding any need for recall.

As a general rule, opportunism may be more effective in other community settings (for example, at pharmacies or supermarkets) than in general practice, and there is evidence of its success in these locations. For example, opportunistic screening for cardiovascular disease, hypertension, and type 2 diabetes in community pharmacies has been shown to work, and has the potential to reach hard‑to‑contact populations.32,33

Structured CDM

Some important facets of CDM are unavailable, or limited, unless it is structured. Utilising nonGPs at the top of their licence is substantially easier when care elements are structured and sequenced appropriately. The burden of CDM on clinicians’ time is largely predictable—it can be estimated from the number of patients on a disease register—so a structured approach allows for a better use of resources to match these demands. The primary constraints are room availability, staff mix and reliability, and how easy patients are to recall. Costs can be calculated (and matched to specific funding); capacity can be reserved; delivery can be mapped throughout the year; and contingencies can be planned appropriately by stepping elective work up or down in response to workforce fluctuations. To maximise the benefits, it is important to protect planned capacity, wherever possible, from nonelective variability.

Medication Reviews

Medication reviews, as culminations of comprehensive clinical reviews, benefit so greatly from a structured approach that they are worth discussing separately. The quality improvements and potential cost savings achieved by aligning reviews effectively can be considerable,34 even before consideration is made of any specific funding related to service delivery. Pharmacists32,35,36 and ANPs37,38 (where the scope of their practice is aligned) are well suited to overseeing both structured CDM and complete medication reviews. Some practices covered by Cardiff and Vale University Health Board have thereby managed to reduce GP input to medication reviews and repeat prescribing significantly.

Even if undertaken by a GP, medication reviews that follow a structured clinical review tend to be more streamlined than medication reviews that do not. For this reason, it is worth considering inclusion of anyone receiving regular medication in a practice’s patient cohort for structured review, irrespective of whether they are on funded disease registers (which vary considerably by borough and by nation).

How to Optimise CDM Processes

How, then, can we apply opportunism where it is most effective, and reorient our services to benefit maximally from structured CDM? Any changes to a chronic disease recall process will inevitably involve every area of a practice: how, and in what order, a practice achieves each of these key steps will vary by practice culture, but it is important that practices take sufficient time to be certain that each is covered effectively:

  • engaging executive (or partnership) support
  • understanding and accepting senior administrative and clinical leadership
  • appointing named clinical and administrative project leadership
  • achieving whole-team involvement, and ideally ownership
  • engaging and communicating with the practice’s patients.

The optimum blend of opportunistic and structured CDM will vary according to a practice’s patient demographic and workforce (including administrative capacity and competence). This balance will only become apparent as structured processes improve, but later frustrations will be better directed if it is understood at the outset what the local limitations are in terms of team skills, capacity, and patient responsiveness.

Opportunistic CDM is an important safety net for a practice’s clinical quality and financial performance. It is only as a structured approach builds that it is possible to reduce opportunism without risking both. The transparency of clinical and nonclinical staff at a practice and patient level is therefore critical to success. The focus should initially be on establishing an effective structure, and only subsequently turn to reducing opportunism.

Choice of Recall Cohorts

Recall dates for specific conditions or medications in the main clinical systems default to a fixed time (usually 1 year) from completion of the previous review. This approach does have the advantage (or disadvantage) of being hardcoded into most clinical systems, but also has significant flaws:

  • a progressive drift is inevitable that, combined with the end of the QOF/QAIF cycle, often results in everything bunching together at the end of the review year
  • reviews for multiple conditions are rarely synchronised, and patients often have several reasons for recall that could be managed together
  • it is often unclear when medication review should occur
  • it is harder to determine how successful reviews are at both a patient and a practice level.

To introduce the critical transparency needed to improve structured CDM, it is important to define cohorts of patients, and determine when each cohort is meant to receive its comprehensive clinical and medication review.

There are a number of potential approaches for determining recall cohorts. Grouping patients by condition has some advantages, and group consultations may be possible if recall cohorts are organised around particular conditions. Respiratory conditions, for example, have seasonal fluctuations; the benefits of seasonal or group activity could be delivered in addition to basic annual checks (for example, a focused prewinter phone call for patients with COPD). The rise in multimorbidity undermines this approach, however, as increasing numbers of patients now have more than one reason for recall. Indeed, an estimated 9.8% of the UK population has four or more chronic conditions, and this figure is projected to increase to 17% by 2035.39

Age is another possible determinant of recall cohort, but it carries the risk of discrimination, along with other challenges. Segmenting by patient location could also be sensible in some rural locations. Otherwise, the choice is essentially arbitrary, such as alphabetically by surname.

Birth-month-aligned Recall

Birth-month-aligned recall is an arbitrary approach that has particular benefits, and appears to be gaining in popularity. Birth months are reasonably evenly distributed across the year, and basing CDM review dates on them makes sense to patients and staff alike for this reason.

It is not easy to work out how prevalent this choice is among practices who are improving their structured model. In 2017, before I helped to develop a multipractice recall process in Hounslow, we were only able to identify and contact about seven practices in the UK who were using birth-month‑aligned review. In 2018, when this initiative was presented at the SystmOne National User Group, there was considerable interest in the concept, but few practices had already implemented it. Now, it is easy to identify over 30 practices managing CDM through birth-month-aligned cohorts. Based on a survey of the 56 practices covered by Cardiff and Vale University Health Board, five are using this method to define CDM cohorts and another five are interested in doing so. It is also possible that more practices have adopted this approach than are publicly identifiable.

Several search-and-support providers for clinical systems (for example, Ardens40) have developed resources to help practices with establishing birth‑month cohorts, but no clinical system suppliers have yet hardcoded this into their products.

Although practices seem to be working individually on birth-month-aligned recall, little has been written or shared about how it can be done, and no studies have been conducted to test its effectiveness. Anecdotally, it seems that considerable savings can be made, but the spread of these benefits is limited by the fact that a thorough evaluation has not been undertaken to date. Wisdom, but not yet concrete evidence, would suggest that a strong reason is needed to choose any other way to segment cohorts for structured recall.


The purpose of this article has been to discuss approaches to CDM in light of its growing importance in general practice. Medication review alignment, transparency, team leadership, and choice of patient cohort are emerging as probably the most critical aspects to consider when changing processes. The Cardiff and Vale University Health Board is working with practices to develop resources and evidence around this subject, and I would be happy to hear from anyone who has positive or negative experiences of such a transformation. 

Key Points
  • The number of people in the UK with one or more chronic diseases is substantial—around 70% of health and social care expenditure goes into the treatment and care of people with chronic diseases
  • Interventions for these long-term diseases represent an increasing share of the rising burden on general practice
  • There are three main ways to deliver CDM—opportunism, structured recall, and supported self-management—and their effective combination is vital for CDM
  • Structured recall has various benefits, including the optimum use of the whole MDT as well as the reduction of unnecessary reattendance and repeated phlebotomy
  • Alignment with medication reviews is an area in which structured recall is especially effective and can often be completed by pharmacists rather than GPs
  • Despite its potential for inefficiencies and disruption, opportunistic recall has its own benefits in reaching patients who are less responsive to structured recall
  • The implementation and optimisation of CDM processes at a practice or area level requires significant time, executive support, and organisation, and will vary based on the demographics of the area and the practice workforce
  • It is important that a practice decides how to organise its structured recall programme to optimise its effectiveness and distribution across the year
  • Birth-month-aligned processes for recalling patients with long-term conditions are in their infancy, but show promise.

CDM=chronic disease management; MDT=multidisciplinary team

Implementation Actions for Clinical Pharmacists in General Practice

written by Riad Choudhury, Clinical Services Pharmacist, Soar Beyond Ltd

The following implementation actions are designed to support clinical pharmacists in general practice with implementing the guidance at a practice level.

Medication reviews are a key aspect of a pharmacist’s role in any setting, and are a central element of the multidisciplinary approach to care.[A] The following implementation actions are designed to support clinical pharmacists in general practice who want to improve their medication review structures:

  • examine the PCN DES specification, which includes requirements relating to SMRs and medicines optimisation[B]
  • consider how pharmacists can support a structured approach to LTC in their practice—evidence suggests that people with long-term conditions and using multiple medicines have better clinical and personal outcomes following an SMR[B]
  • review and optimise current methods of opportunistic medication review, as these are opportunities to identify interventions, and encourage patients who may not be responsive to structured recall, to return for an SMR
  • implement supported self-management in conjunction with opportunistic and structured review
  • evaluate the current organisation of medication review recall for LTC in clinical systems, which will likely default to a fixed time (usually 1 year) from completion of the previous review
  • explore the use of birth-month-aligned recall—an arbitrary approach that is easy to remember for patients and distributes workload evenly for practitioners, as birth months are reasonably evenly distributed throughout the year.

The i2i Network has a suite of training and implementation resources, both free and bespoke, for GP clinical pharmacists, including e-learning and on-demand training delivered by experts, covering a range of long-term conditions. Become a free member at: or find out more at 

PCN DES=Primary Care Network Directed Enhanced Service; SMR=structured medication review; LTC=long-term care

[A] Royal Pharmaceutical Society website. Medication review. (accessed 30 November 2022).

[B] NHS England. Structured medication reviews and medicines optimisation: guidance. London: NHS England, 2020. Available at: