Long Term Conditions

The need to improve the treatment and management of long-term conditions is the most important challenge facing the NHS. Improving care for people with long-term conditions must involve a shift away from a reactive, disease-focused, fragmented model of care towards one that is more proactive, holistic and preventive, in which people with long-term conditions are encouraged to play a central role in managing their own care.

In response to this, we have implemented a new system for calling in our patients for annual reviews of their long term conditions. The change will improve the service we offer and reduce the amount of appointments you may need, reducing duplication of tests. The system will group all your appointments into one long appointment with the Healthcare Assistant; during this appointment they will complete an array of different tests and examinations. The results will then be sent to your GP for review, should the GP feel you need to see either a Specialist Nurse or themselves this will then be arranged. You may not require to always be required to come in for a second appointment as your condition may be stable/well controlled.

You will be called each year the month of your date of birth. The appointment times will vary dependant on your long term condition but some appointments may last up to one hour.

You may have received invitations from us previously for conditions such as COPD, diabetes, hypertension ect. Previously you would have been sent an appointment in your birth month to attend the surgery. You will still be sent a letter in your birth month but instead of receiving multiple letters for different conditions you will be sent one letter. You will be asked to phone the surgery and press option one where you will be transferred to our administration team, who will book you an appointment to suit you.

Should you not book an appointment after your first invitation you will be sent another letter two months later, should you not respond to this then we will attempt to contact you one final time, this may be by phone, text, email or letter. After this invitation we will assume you do not wish attend this appointment and no further contact will be made until the following year.

Should you wish to decline these invitations then you can complete the decline slip and bring this into the surgery or you can phone the surgery and selection ‘option one’ and inform the team of your wish to dissent. We would encourage our patients to attend the surgery for these appointments as it is a good opportunity to for us to ensure your condition is being managed effectively.

Patients that will be invited for annual review

Any patients with a diagnosis of one or more of the following conditions will be invited to attend for an appointment:

  • Diabetes
  • Chronic Obstructive Pulmonary Disease
  • Chronic heart disease
  • Hypertension
  • Coeliac disease
  • Rheumatoid Arthritis
  • Atrial Fibrillation
  • Chronic Heart Failure
  • Peripheral Arterial Disease
  • Cerebral Vascular Accidents
  • Trans ischemic attacks
  • Diabetes Mellitus
  • Pre-Diabetes
  • Gestational Diabetes
  • Chronic Kidney Disease
  • Bipolar
  • Dementia
  • Learning Disability
  • Psychosis
  • Asthma (if bronchodilator issued in last year)
  • Coeliac Disease
  • Severe Frailty
  • Post-Bariatric Surgery

Please note that your letter may suggest you have Chronic Heart Disease without you being aware of this diagnosis. It may be that you do not have this diagnosis but other conditions such as heart disease, hypertension or chronic Kidney Disease then your risk of developing Heart disease is increased and we should be screening patients for this condition.

Depending on your condition you will be required to have different test and examinations.

What will be carried out in your review

Dementia  BP, bloods, height, weight, BMI, smoking status, alcohol intake, ECG, MOCA 
Dementia 3,6 or 9 month r/v BP and general wellbeing check 
Diabetes BP, bloods, foot check, height, weight BMI, smoking, alcohol intake, urine  
Learning Disabilities assessment BP, bloods, Smoking, alcohol intake, questions within the template 
Mental health medication reviews BP, bloods, height, weight, BMI, smoking status, alcohol intake, ECG
Peripheral Arterial Disease- PAD  BP, bloods
Post Bariatric Surgery BP, bloods
Severe Frailty  BP, bloods
Rheumatoid Arthritis  BP, bloods