Long Term Health Conditions

Long term conditions or chronic diseases are conditions for which there is currently no cure, and that are managed with drugs and other treatments. These include:

• Respiratory disease (Asthma or COPD)
• Heart disease (including Heart Failure and Atrial Fibrillation)
• Stroke
• Diabetes
• Kidney disease
• High blood pressure (Hypertension)
• Physical Health Checks for Mental health problems
• Other long term health issues that affect the health or lifestyle of a patient.

These conditions require an annual review (or Health MOT) to ensure that the condition is being managed appropriately (by you the patient and also by us as your healthcare provider), identify any problems or concerns and ensure you are confident to deal with the condition between reviews.

It is much easier for patients to remember that they will have a review of their long term condition(s) in their birthday month. It also makes it easier for the practice to align these reviews with other important events such as your medication review. This approach ensures that long term condition reviews are spread evenly through the year meaning that they impact less on urgent appointment capacity.

For your convenience and to use NHS resources wisely we will send a text message invitation with self-booking link if you have a mobile number in your record. Our software will review and record on your notes whether this message has been delivered. If it is not successful we will send you a reminder letter in the post instead.

If we have only a landline number recorded in your notes (or no number at all) we will send your invitation by second class post.

Please ensure that your address, telephone numbers and email IDs are up to date. You can update your contact details through your Online Access account or contacting the practice.

Respiratory Conditions – Asthma and COPD

If you have Asthma or COPD but no other conditions your will be invited to book a respiratory annual review appointment with a nurse.

Hypertension (High Blood Pressure)

If you have hypertension but no other conditions you will initially be invited to annual review appointment during which you will have a blood test, have your blood pressure taken and be asked some lifestyle questions.

We might ask you to submit a home readings if you are able to do so. If blood pressure is outside normal range, we will arrange follow up with one of our Clinical Pharmacists in practice.

Diabetes (and hypertension)

For diabetes care, we intend to continue providing Year of Care reviews. This involves Stage – 1 appointment for blood test, check blood pressure, check the circulation in your feet and ask you some lifestyle questions.

You will also be asked to bring early morning urine sample to send to lab so that this can be checked for traces of protein. You will then receive copy of results – preferably via email. This will be followed by Stage – 2

Annual Review Appointment with a Diabetes Nurse practitioner to review your diabetes results.

Health Checks for Serious Mental Illness

This is for patients on anti-psychotic medication and have diagnosis of long term serious mental health condition like Bipolar Disorder.

This also involves Stage 1 appointment for Blood tests, blood pressure check and some lifestyle questions. Following this you will have a telephone or face-to-face review with GP to discuss results and medication review.

Heart Failure

Initial appointment for blood test and BP check followed by face-to-face appointment with our Physician Associate for review of results and conduct physical checks.

Other Long Term Conditions

If you have other long term conditions you will initially be invited to an HCA annual review appointment before being booked in for a review with your usual GP once the results of initial tests are available.

All reviews for bloods, record blood pressures and perform some other investigations will be face to face with our team of Health Care Assistants or General Practice Associates.

Subsequent appointment with a GP, Practice Nurse, Practice Clinical Pharmacist or Physician Associate can be face to face or telephone if you prefer. Face-to-face is encouraged to allow easy discussion.

An initial assessment with one of our HCAs will last 20 minutes (30 minutes if you have diabetes to allow time for a foot examination).

Respiratory and diabetes reviews with our nurses and hypertension reviews with our pharmacist will last around 20 minutes.

GP reviews, if needed, will be 10 minutes unless you have a number of long-term conditions in which case they may be 20 minutes as well.

Most people are more tense than usual in medical settings and might not even realise it. This is called White Coat Syndrome and can mean your blood pressure is raised even if you don’t feel stressed. The term ‘white coat’ refers to the white coats traditionally worn by doctors.

It is fairly common to suffer from White Coat Syndrome.  Try and take a few minutes to relax prior to your appointment. The nurse or GP may take your blood pressure several times and record the lowest reading.

If it is higher than expected, they may ask you to record your blood pressure at home. Home BP machines are now very affordable and we would encourage all our patients to get one to help manage their condition. You can ask for printed BP diary at reception which can be filled and submitted for check by our clinicians.

If you don’t have access to Home BP monitor or if readings are not reliable – we might suggest Ambulatory 12 hour BP monitor which will be arranged at the surgery.

Patients who only have a respiratory condition (asthma or COPD) are unlikely to need a blood test but it is a necessary diagnostic tool for other long-term conditions.

It is natural to feel anxious about any medical procedure but our Clinical Team are very experienced and used to looking after patients that have a phobia of needles. Please let us know if you are scared and we can help to relax and support you. We would also suggest that you have a little something to eat as this can raise your blood sugars and help you feel stronger and less faint – none of the blood tests needed for our long-term conditions require you to fast.

In some rare cases, it might be more appropriate for blood test to be done at hospital. For St Richard’s Hospital, this will be via booking and reception team can help you with correct instructions on how to book.

We would suggest that you have a list of your medications with you at your annual review. This will help the GP to understand any issues that you have with your tablets even if you are unsure of their names.

You are advised to have your inhalers to hand when having your respiratory review so that the nurse can assess your inhaler technique and advise you on how to use them more efficiently.

If you attend for a diabetes review you will be asked to provide a urine sample. You can do this in the surgery at the time of your Stage 1 diabetic review appointment or take a sample pot away with you and return it to the practice at your convenience.

There can be a lot for the clinician to cover in your annual review appointment. Please ensure that you focus on your long term condition in your annual review appointment(s). We respectfully ask that you book a separate appointment if you have another ailment that you wish to discuss.  

We suggest that you write down any questions that you have in advance of your annual review. This will ensure that they are answered and will help the GP or nurse to tailor a management plan that best suits you.

Please be honest with the clinicians that you see so that the GP or nurse can develop a management plan in collaboration with you. For example, tell the GP if you are not taking your medication – this could save the NHS wastage or lead to your GP suggesting alternative medication or proposing a different management plan.

Most people will be fine and their condition will be well managed. However, long term conditions can cause problems very slowly over a period of time. Your body is very clever at compensating when one of your organs is struggling so it might not initially be obvious. Equally, medications that are designed to help manage your long-term condition can have side effects over time.

By checking your bloods, blood pressure, medical history, medications, and asking you questions about your lifestyle we hope to be able to identify signs of any problems before they develop. Our clinical team will review your information and consider how together we could improve your health/management of your long term condition. This may include health advice, medication changes or referrals to a specialist service.

These reviews are really important. We strongly encourage all patients with a long term condition to attend for their annual review.

Deciding what to do when people do not attend for their annual review is really challenging for us. On the one hand it is your choice as to whether you attend your review. On the other, GPs have a duty of care and we want to avoid you coming to any harm that could be avoided.

If you do not attend for your long term condition review after your first invitation we may reduce the length of your prescription from 56 days to 28 days. If you still do not attend after a second invitation we may further reduce your prescription to 14 days. Experience has shown us that reducing the duration of prescriptions dramatically increases the number of patients that attend for their annual reviews and contributes to positive long term outcomes. Please be assured we will not stop any patient’s medication.

If you do not attend after two reminders we will mark on your record that you have made an informed decision not to attend.

Please let us know if you are unable to attend for a specific reason. For example if you are unwell, in hospital or out of the country for an extended period. In these cases we may delay your review or exempt you for the current year.

For most patients your annual review process (whether this is one, two or three appointments) will be sufficient to manage your long term condition.

However some conditions and some medications need to be monitored more frequently – you may need to come for a repeat blood test after 6 months or even 3 months if your long term condition is poorly controlled.

If you have an exacerbation of your long term condition, you should contact the surgery. This should not wait till your annual review.