Long Term Condition Reviews

The practice has currently paused delivery of routine Long Term Condition reviews due to pressures from Covid-19, including imminent commencement of Covid-19 vaccination by the practice.  Please do not automatically book for review in your birth month at this time and until further notice - the practice is working to prioritise review of patients with high clinical need who require further clinical management.

Please contact us in the month before your birthday to book all long-term conditions review appointments during your birthday month

We hope this will make it easy for you to remember and to get your health fully reviewed in a timely fashion

You may need to see more than one clinician (GP and/or Nurses) however we will combine appointments where we can

Our receptionists will be able to advise you what long-term conditions you have been diagnosed with and what appointments you will require - many conditions need annual blood tests which will be combined into one 10 minute appointment with a Health Care Assistant (HCA) approximately two weeks before your review appointment

If you are transitioning to this system from a non-birth month recall date, there may be a shorter or longer than usual gap from your last review to your birthday month.  Our receptionists will be able to advise you of the best date to book your next review, dependent on your birth month and last review date

You will be advised at your annual review to book additional appointments if your condition needs further management.  We no longer advise you to routinely book interim checks, such as mid-year checks of HbA1c for diabetics or mid-year blood pressure checks

We recommend an Annual Review if you are currently suffering from one or more of the following long-term conditions:

Asthma

Nurse Review - Asthma

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

Please bring your inhalers to your review appointment

Or for telephone reviews be prepared to demonstrate your inhaler technique via video consultation

You are recommended to agree an Asthma Action Plan at your review

Cardiovascular Disease

Nurse Review - CHD / Stroke / TIA / PAD

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

CHD (Coronary Heart Disease)

StrokeTIA ( Transient Ischaemic Attack) 

Peripheral Arterial Disease (PAD)

It involves a 10 minute HCA appointment for a blood test and Blood Pressure check then a Nurse review 1-2 weeks later.

CKD

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. 

COPD

Nurse Review - 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

You are recommended to agree a COPD Flare Up Action Plan at your review

Dementia

GP review - 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

Nurse Review - Diabetes

Regular monitoring of Diabetes is very important.

COVID-19 arrangements: you will need to attend the practice for a blood test & foot check with the remainder of your review being done with the nurse by telephone/video 1 week later

Hypertension

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 Pharmacist or Nurse and you will be advised if a follow-up appointment necessary.

Home blood pressure monitoring is recommended - see guidance available here  (1 page pdf).  

Lifestyle guidance is available on the patient.info website.

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

Learning Disabilities

GP review - Learning Disabilities

A Learning Disabilities review involves a 10 min HCA appointment for a blood test then 30 minute appointment 1 week later with a specialist GP who will then advise of any further follow-up required for conditions usually covered by Nurse review. 

With carer help if required, please complete the Learning Disabilities Review Checklist in advance - this can be completed electronically & emailed to fireclayhealth@nhs.net at least 1 working day before your appointment, or print and bring to the appointment.

This checklist is from Get Checked Out which has lots of resources to improve access to health care for people with a Learning Disability.

Covid-19 You Tube information videos designed for people with Learning Disabilities are available at the bottom of our Covid-19 information page

Mental Health

GP review - specific Mental Health conditions

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

Schizophrenia

Bipolar Disorder 

Psychosis 

It involves a 30 minute appointment with your Usual GP who will then advise of any further follow-up required for conditions usually covered by Nurse review.

Please bring with you a completed Mental Health Care Plan (PDF) Word Care Plan - this can be completed electronically & emailed to fireclayhealth@nhs.net at least 1 working day before your appointment, or print and bring to the appointment

Rheumatoid Arthritis (RA)

GP Review - 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