Long Term Conditions Management in General Practice
General Practice manages increasingly complex long term conditions across large populations, often through fragmented reviews, disconnected monitoring processes, and multiple separate appointments.
THS supports coordinated long term conditions management through integrated recall systems, shared clinical views, proactive monitoring, population health management, and clinical decision support.
One coordinated review for long term conditions.
Ease of use
We have templates for all key long term conditions.
They are designed to be easy to use and they all follow the same layout, so once you know one, you know them all:
- Summary first with key points at the start.
- Details in the middle if you need it
like medicines, hospital notes, guidance. - Consultation at the end with space to add your review.
Health history at a glance
Summary of the long term condition being reviewed and key diagnoses.
Key alerts and actions
Everything you need to do in one place.
Each LTC template works the same way, with actions based on evidence, safety, and national targets.
Alerts for the condition sit here. Click the arrow for details and the latest guidance. In this example, heart failure is not grouped by ejection fraction and medicines may need optimising, so a review is needed. After reviewing, right click the alert to update and clear them automatically.
Promoting Continuity
Previous entries for this condition and where your review will be visible. Click the arrow to open them quickly and continue from the last review, supporting continuity and saving time hunting throught the records.
Relevant tests
All relevant tests in one place so you can review results quickly without hunting across different systems.
Key Letters, results, and guidance
The middle section brings together useful information like medication guidance, key letters, and results in one place, so review is quick and easy.
Completion and coding
By the end of the template you will have everything you need to make a clinical decision. Add the key read codes to update the population health dashboard, track progress, and complete QOF and other work.
Once you have made your entry, you are done. Your notes will show on the summary page for the next review.
Clinical alerts that support continuity of care.
THS continuity alerts surface the key risks, recent events, and important context clinicians need when reviewing patients with complex long term conditions.
Alerts appear directly within the patient record, helping teams quickly understand recent admissions, safeguarding concerns, medication risks, missed follow-up, mental health issues, and other factors that may affect care.
This supports safer decision-making, earlier intervention, and more coordinated care across General Practice and Integrated Neighbourhood Teams.
By giving every clinician access to the same shared clinical picture, THS helps maintain continuity even when patients are seen by different professionals across organisations
Coordinated recall systems for long term conditions.
THS supports coordinated recall and monitoring across multiple long term conditions.
Coordinated annual recall
Coordinated annual recall brings together blood monitoring, medication reviews, long term conditions management, and national contract requirements into a single structured recall process across the entire year.
THS automatically synchronises monitoring intervals and review requirements across all recall pathways. When enhanced recall, cancer monitoring, or DMARD monitoring are added, everything continues to align with the core annual recall system so patients remain safely monitored through one coordinated process.
This helps General Practice manage complex monitoring programmes through one coordinated system.
Enhanced proactive recall
Enhanced proactive recall supports patients with unstable or difficult-to-control long term conditions through higher intensity monitoring and follow-up.
THS automatically increases recall frequency for patients requiring closer review, helping teams respond earlier to deterioration and maintain safer disease control.
Cancer monitoring
THS cancer monitoring templates support structured follow-up and surveillance for patients requiring ongoing blood monitoring, including PSA monitoring for prostate cancer.
Clinicians can set appropriate monitoring intervals with automated recalls for blood tests and follow-up, helping maintain safe and reliable long term surveillance.
DMARD monitoring
THS DMARD monitoring templates support safer and more coordinated blood monitoring across General Practice. Once set, the system applies the correct recall frequency and escalates monitoring when abnormal blood results are detected.
Clinicians can record clear follow-up instructions directly within the patient record, helping maintain continuity and ensuring other professionals know exactly what action is required when results return.
All DMARD monitoring automatically synchronises with the standard recall system, reducing duplication and supporting more efficient long term conditions management.
Safer prescribing for complex long term conditions.
THS supports safer prescribing for patients living with frailty and other high-risk long term conditions through proactive clinical decision support embedded directly within the patient record.
The system scans for clinically significant prescribing risks, including frailty, medication interactions, comorbidities, and other high-risk scenarios, then surfaces clear guidance at the point of prescribing.
Alerts summarise the clinical concern, explain potential consequences, and suggest safer alternatives. This helps standardise safer prescribing across teams, reduce avoidable medication harm, and support more proactive care across General Practice and Integrated Neighbourhood Teams.
Established THS practices consistently maintain low harmful prescribing rates through proactive prescribing support and continuity-aware clinical decision making.
Population Health Management. On tap.
Track QOF progress
Track QOF achievement over time through clear, practice-level performance dashboards designed for busy General Practice teams.
THS helps practices monitor progress against QOF payment thresholds, identify gaps earlier, and target improvements that support both quality outcomes and financial performance. Supporting notes, indicators, and achievement details are displayed alongside the charts for faster operational review.
Joint INT working with proven impact
Using our Population Health Management Dashboard, a THS practice and Older People’s Mental Health (OPMH) delivered a joint QI project through Integrated Neighbourhood Teams (INTs) for shared care home patients on antipsychotics.
Patients were stratified by dementia and SMI:
- OPMH led reviews for Dementia+ / SMI+ and Dementia- / SMI- groups.
- General practice led Dementia+ / SMI- and Dementia- / SMI+ groups, seeking OPMH advice where needed.
This INT approach reduced inappropriate prescribing, with current prescribing rates at around 10.5% versus ~21% in published UK care home literature.
Population insight that drives performance
Our dashboard is packed with population demographics, from condition prevalence to population pyramids. It shows you which cohorts are biggest, highest risk, or rising fastest, so you can target proactive care and QI where it will have the greatest impact. That means clearer priorities for INT work, fewer missed reviews, and stronger delivery against key indicators.
Safer blood monitoring and results management.
Blood processing templates
THS blood monitoring templates support safer and more structured review of blood results across General Practice.
Templates use a consistent clinical layout designed for faster interpretation and safer decision-making:
- Summary first with key risks and actions immediately visible
- Clinical detail in the middle, including medications, hospital correspondence, trends, and guidance
- Consultation and follow-up at the end, with space to record decisions and continuity plans
The same structured approach is used across all blood monitoring templates, helping clinicians review results faster while maintaining continuity across teams.
Summary
Summary of the key conditions that might be related to an abnormal FBC value.
Relevant tests
Abnormal results can trigger significant clinical workload. With this template, key tests are right in front of you, so a low haemoglobin, for example, can be processed quickly, saving time.
Faster clinical review
As with our long term conditions templates, previous reviews remain visible underneath the current result. Clinicians can expand earlier assessments to quickly understand previous decision-making, helping maintain continuity and support faster, safer blood monitoring.
Key Letters, results, and guidance
The middle section brings together relevant clinical information, key letters, and important results into one structured view for faster and safer review.
Supporting continuity between reviews
By the end of the template, clinicians have the information they need to make safe and informed decisions.
Once the review is completed, notes automatically appear on the summary page during future encounters, helping teams maintain continuity and making the next review faster and easier.
Digital Comprehensive Geriatric Assessment (CGA) for frailty and dementia care. Introducing iCGA 3.0.
One Team. One assessment.
One shared assessment for all teams across health, social care, and the third sector.
Healthcare useage
iCGA 3.0 shows which services a patient has been known to in the last six to twelve months and their healthcare use over the past six to eight weeks.
This helps teams spot early signs of an evolving crisis.
At a glance view
A rapid overview of the person’s frailty status, care setting, advance care planning preferences, and link to their latest care and support plan.
Superior automated recalls
Automated recalls bring patients back for the tests and reviews they need across all long term conditions, medicines management, CQC, and national requirements.
It saves time, cuts workload, and ensures nothing is missed.
Recalls can be tailored so people with complex needs are seen more often until things improve.
IT-assisted decision support
iCGA 3.0 guides INT teams through every step of a complete CGA. It flags high risk medicines, poorly controlled long term conditions, and other markers linked to poor outcomes, then provides clear guidance on what to do next.
This strengthens clinical decision making, upskills the workforce, and ensures every iCGA is thorough and consistent.
Greater efficiency
Most actions are automated, including creating and sharing the care and support plan. Duplication has also been eliminated, giving clinicians more time to focus on patient care.
Continuity with one single source of truth
iCGA improves continuity by giving all teams one shared, accurate record.
Care and support plans are generated and shared instantly with the patient and every organisation in the Integrated Neighbourhood Team (INT), so everyone works from the same information when the patient needs help.
Evidence based
iCGA 3.0 is a third generation, IT-assisted CGA with enhanced decision support. Its earlier version, iCGA 2, has been independently peer reviewed, published, and shown to improve survival.
What's the impact?
Living Longer, despite high deprivation*.
*Confirmed on independent ICB analysis
We also found better care home survival, now published.
People are living better. Older people are fitter, and frailty is less common.*
*Longitudinal analysis of frailty over time in a THS practice, based on clinician-diagnosed frailty using the Pathfields Tool.
Reduced A&E attendance*
-
25.4% fewer A&E visits in over 75s living at home
-
41% fewer A&E visits from care homes
*confirmed by independent ICB analysis
Want to find out more?
Book a Demo