Long Term Conditions

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 a system for calling in our patients for annual reviews of their long term conditions. The system groups 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.

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 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