Long Term Conditions

As your GP surgery we play a significant role in managing your long-term condition. We believe in working with you and specialists in the community to provide holistic, personal, and high-quality care.

All patients with a long-term condition should have an annual Long Term Condition review. The first part of this is with a Health Care Assistant. At this appointment, we will take a blood sample, check your blood pressure, and update other health data. 

A Practice Nurse will review your results in Virtual Review slots, looking at your medical history and medications, and consider how together we could improve your health/management of your LTC. This may include health advice, medication changes or referrals to a community service.

If your results are all within range you will get a letter which will advise you that you will be seen again in 12 months. If you need something changing or a discussion this might be a phone call or a face-to-face appointment with a Practice Nurse.

See our NHS resources page for further details

What do I need to bring to my annual review?

• Asthma – ACT Questionnaire (this will be sent to you via text or letter)
• COPD – CAT Questionnaire (this will be sent to you via text or letter)
• Hypertension, Chronic Heart Disease (CHD), Diabetes, Stroke/TIA – Height, Weight and BP readings at least a day before your appointment and a urine sample on the morning of your appointment in a sterile container from one of our surgeries.
• Non-Hyperglycaemic Diabetes (NHD) – Nothing unless you have another condition listed above.
• Chronic Kidney Disease (CKD) - You may be required to have a urine test.

How will the recall process for routine reviews work this year?

Routine Long Term Condition Annual reviews are there for many reasons, to check you are doing well with your condition, for health education and monitoring ongoing health care. In these unprecedented times we need our patients to be responsible for their condition and to work with us to achieve the best health outcomes we can for all our patients. 

If you are unwell or symptoms of your condition are worsening you need to contact us where we can take the appropriate action to ensure you are looked after. 

My birthday is in September why have I not had a letter?

If you have not received your letter in your month of birth, this is something that one of our recall team can look into for you. If you would like to give us a phone on 01524 235 900 and press option 1, this can be looked into for you.

What do I do if my condition is worsening?

It is even more vital that you contact the practice regarding any deterioration in your condition when it happens selecting option 5 on the phone line. Our Patient Advisors will forward your details to our review nurses who will either contact you to discuss of refer you to our urgent care team who with assist you.

How can you help us help you?

There is certain information that we need to assess a patient’s progress when carrying out a review. Patients would normally be able to have their weight, height and also have their Blood pressure taken in the surgery with current restrictions we would ask our patients to try to acquire this information. We have Blood Pressure Machines at each surgeries waiting area, for this to be done before entering your appointments. 

It is as important to monitor blood pressure as it is to monitor weight.

• NHS Height and Weight Chart
• Blood Pressure Measuring at Home

A list of valid blood pressure monitors for use at home can be found on The British and Irish Hypertension Society website