Long Term Condition Reviews

From May 2021 we are aiming to proactively invite all patients who have a chronic long term condition for an annual review in their month of birth. We hope this will make it easy for you to remember and to get your health fully reviewed in a timely fashion.

Our receptionists will be able to advise you what long-term conditions you have been diagnosed with and what appointments you will require. Most conditions need annual blood tests alongside some other basic measurements, such as your hight, weight, body mass index, and blood pressure.  

We also require you to provide some other information about how you are getting on with your medications, and would be grateful if you would complete both our Medication Review form. It would also help if you could complete the Patient Activation Measure questionnaire as well.

For the majority of long-term conditions once we have all received all your results back your doctor make an assessment as to whether you need further follow-up or changes to your medications.  However – the requirements for each condition do vary so please refer to the information below for your own personal circumstance.

Asthma reviews

An Asthma Review is only indicated if you are currently on asthma medication, i.e. inhaler prescription issued by us in the last 12 months.

To help us understand how you are managing with your Asthma please also complete our Asthma Review form.

Most of our respiratory reviews are carried out by our practice Pharmacist who specialises in respiratory conditions. Please bring your inhalers to your review appointment, or for telephone reviews be prepared to demonstrate your inhaler technique via video consultation. As part of your review we will recommend a personal Asthma Action Plan so it would be useful if you give this some consideration before the appointment.

Cardiovascular reviews

A Cardiovascular health review covers one or more of the following conditions:

You will need an initial 10-minute appointment with one of our Health Care Assistant who will take a blood sample, and some other measurements such as your blood pressure and weight.

The results will be reviewed by one of our doctors to assess if any further steps are necessary.

Chronic Kidney Disease (CKD)

An annual review is advisable for Chronic Kidney Disease (CKD) however as this is often secondary to other long-term conditions such as Diabetes this will usually be covered within a Nurse Annual Review.

If you only require kidney monitoring you should book an annual Blood Test – the results will be reviewed by the GP to see if any follow-up action is needed. Prior to attending for your blood test please collect a urine sample bottle from reception and bring the sample with you to your first appointment.

Chronic Obstructive Pulmonary Disease (COPD)

Please book a Chronic Obstructive Pulmonary Disease (COPD) review appointment and bring your inhalers and completed COPD Assessment Test. For telephone reviews please be prepared to demonstrate your inhaler technique via video consultation where possible.

To help us understand how you are managing with your respiratory condition please also complete our Breathlessness Review form, and COPD Assessment form.

We also recommended that you consider a Self-Management plan – such as those recommended by the British Lung Foundation which can be found BLF: Your COPD self-management plan.

Dementia

Patients with Dementia are invited to book an annual 30-minute appointment with their Usual GP who will then advise of any further follow-up required for conditions usually covered by Nurse review.

With carer help if required, please bring a completed Dementia Care Plan to the appointment.

Diabetes

Diabetes requires close monitor throughout the year, with most patients having a comprehensive annual review and a mid-year interim review at 6 months.

For the annual review you will require an initial 10-minute appointment with one of our Health Care Assistant who will take a blood sample, and some other measurements such as your blood pressure and weight. Prior to attending for your blood test please collect a urine sample bottle from reception and bring the sample with you to your first appointment. You will then require a further appointment with a practice nurse to carry out further checks such as diabetic foot checks. Our practice nurses will also discuss your diabetic blood test results and liaise with doctors to ensure that your diabetic medications are optimised.

For your mid-year review, you will need a blood test to monitor your HbA1c (blood sugar) and the doctors will make an assessment of any further care that is required.

Hypertension (High Blood Pressure)

Hypertension monitoring involves a 10-minute HCA appointment who will take your Blood Pressure.  Your results will be reviewed by a doctor and you will be advised whether a follow-up appointment necessary.

Home blood pressure monitoring is recommended – please see guidance available in this Taking Your Blood Pressure At Home leaflet. When you do take home blood pressure readings don’t forget to let us know your results using our Blood Pressure Review form.

Find answers to the most common questions about living with high blood pressure

Learning Disabilities

A Learning Disabilities review involves a 20 min appointment with our practice nurse followed straight after by a 10 minute appointment with a doctor.

With carer help if required, please complete the Learning Disabilities Review Checklist (found here) in advance. This checklist is from Get Checked Out which has lots of resources to improve access to health care for people with a Learning Disability.

Specific Mental Health conditions

An annual health review is recommended if you have one or more of the following conditions:

You will need an initial 10 minute appointment with one of our Health Care Assistant who will take a blood sample, and some other measurements such as your blood pressure and weight.

The results will be reviewed by one of our doctors to assess if any further steps are necessary.

Rheumatoid Arthritis (RA)

Please ensure you discuss your Rheumatoid Arthritis care with your GP at a routine appointment at least annually, using your birth month as a prompt – you do not need to book a specific appointment for review.

Non-Diabetic Hyperglyceamia 

Non-diabetic hyperglycaemia (sometimes also called pre-diabetes, impaired glucose tolerance or impaired fasting glycaemia) means your blood glucose is raised beyond the normal range but it is not so high that you have diabetes. However, you are at risk of developing type 2 diabetes. You are also at risk of developing a range of other cardiovascular diseases (heart disease, peripheral vascular disease and stroke). We aim to monitor your condition and support you to try to help prevent you becoming diabetic.

You will need an initial 10 minute appointment with one of our Health Care Assistant who will take a blood sample, and some other measurements such as your blood pressure and weight.

The results will be reviewed by one of our doctors to assess if any further steps are necessary.