Long Term Condition Reviews

We will be resuming our pre-pandemic Long Term Condition review process from April 2022:

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

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 book a Respiratory Review with a Nurse or Pharmacist specialising in Asthma.  This may be a telephone appointment with a face to face follow-up if needed.  If you have recently had a course of prednisolone please do not book for review until at least 6 weeks afterwards.

You will need to 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 - this wll depend on your Asthma Control Test (ACT) score.  It would be helpful if you could complete the ACT questionnaire online in advance and tell the nurse your score at your appointment.

We advise patients with Asthma to procure a Peak Flow Meter (available as a one-off prescription) in order to better self-monitor symptoms

Cardiovascular Disease

Hypertension / CHD / Stroke / TIA / PAD

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

Hypertension (high blood pressure)

CHD (Coronary Heart Disease)

StrokeTIA (Transient Ischaemic Attack) 

PAD (Peripheral Arterial Disease) 

It involves a 10 minute appointment with an HCA for a blood test, blood pressure and urine check - please bring an early morning urine sample to your appointment if possible. 

Your results will then 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

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 a Practice Pharmacist to see if any follow-up action is needed. 

COPD

COPD

Please book a Respiratory Review with a Nurse or Pharmacist specialising in Chronic Obstructive Pulmonary Disease (COPD) 

You will need to 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 a COPD Flare Up Action Plan at your review - this wll depend on your COPD Assessement Test (CAT) score.  It would be helpful if you could complete the CAT test online (select number for each response then click on Total Score to add up total) or in paper form in advance of your appointment and bring your score with you.

Dementia

Dementia

Patients with Dementia are invited to book an annual 30 minute appointment with their Usual GP or a Nurse specialising in Dementia.  They will advise of any further review required for other Long Term Conditions.

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

Diabetes

Diabetes

Regular monitoring of Diabetes is very important.

You will need to attend the practice for an annual blood test, blood pressure & foot check with an HCA - please bring an early morning urine sample to your appointment if possible. 

The remainder of your review will be done with a nurse by telephone/video approximately 1 week later

We no longer advise routine interim checks of your HbA1c however you will be invited for more frequent follow-up if required, e.g. following treatment changes, to assess any impact on HbA1c control

Learning Disabilities

Learning Disabilities (LD)

A Learning Disabilities review involves a 10 min HCA appointment for a blood test then a 30 minute appointment 1 week later with a GP specialising in LD.  They will advise of any further review required for other Long Term Conditions.

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

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)

Rheumatoid Arthritis (RA)

Please ensure you discuss your Rheumatoid Arthritis care with your GP at a routine appointment at least annually, even if your arthritis treatment is primarily delivered in hospital.

Please use your birth month as a prompt however you do not need to book a specific appointment for review.