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Long Term Disease Clinic

A "One-Stop Clinc" for Annual Reviews

Long term disease refers to medical conditions that may have an ongoing impact on your health. In particular we use this term to refer to the following conditions:

  • Atrial Fibrillation (a condition of irregular heartbeat)* 
  • Asthma
  • Diabetes*
  • CKD (Chronic kidney disease)*
  • COPD (Chronic obstructive pulmonary disease, previously termed emphysema or bronchitis)
  • Heart Failure*
  • High Blood Pressure (also known as hypertension)*
  • Ischaemic heart disease (previous or current angina or heart attack)*
  • Mental Health conditions such as schizophrenia or bipolar depression*
  • Osteoporosis
  • Peripheral arterial disease (usually causing pain in the legs when you walk)*
  • Rheumatoid Arthritis*
  • Stroke or mini-stroke (TIA)*
  • Thyroid disease (over or underactive thyroid)*

If you have one or more of the above conditions, we recommend that you have an annual review. Some of these conditions require monitoring with blood tests or other tests such as breathing assessments or urine tests.  In addition many of these conditions require annual medication reviews.

This year (2020) we will be introducing a new process for co-ordinating these reviews. Your review will take place in the month of your birthday. This will allow us to plan our workload and spread it evenly throughout the year and it should also provide you with an easy to remember date for your review!

Why are we doing this?

We currently have approximately 4,000 patients with at least one of these conditions and so co-ordinating such reviews can be a challenge. We would like to ask for your help in this matter. By taking responsibility for your medical condition you can help ensure that you are having the best possible care.

Reviewing your condition on an annual basis will enable you to check that you are taking the correct medications. It will also give you an opportunity to ask your nurse questions about your health.

What will happen?

We will contact you in advance of your birthday month inviting you to attend for a blood test (if this is required for your condition - typically those marked with * in the list above).

This appointment will be made over the phone with a Health Care Assistant as well as an appointment with the Practice Nurse, one to two weeks later.  The length of the appointment may vary depending on your long term condition.

If you are not required to have blood tests done yearly, then an appointment with the Practice Nurse will be made directly.

Most patients with stable conditions will not need to see a GP.

In the first year

Please note that for the first year only, you maybe called in for two reviews so we can get our system in sync.

We would still like you to attend as there may be other conditions that need to be reviewed that haven’t been done at your previous appointment. 

Patients being seen in hospitals or privately

If your condition is being monitored by an NHS hospital or private consultant, this annual review will not affect you seeing them. You will be called for the blood tests at the surgery and the review with the nurse, who can then give you copies of your results to take to your consultant.

In most cases your GP will prescribe your repeat medications, not your Consultant. Your GP needs to review your blood test results annually to be able to continue prescribing your medications.

Final Comments

This review process is important and we will not be able to continue prescribing repeat medications without it.  We will sync your medication review with this annual review.

Your cooperation in this new process will therefore be very much appreciated.

We hope that this process will reduce the number of times you need to come to the surgery and therefore free up appointments for when you have more urgent problems.

Added: 28/11/2019 



 
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