Long Term Conditions/ Chronic Illness Management

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.

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

All patients with a long-term condition should have an annual review (or ‘health MOT’).

Research shows that people with long term conditions who take more control of their health feel more able to cope with their health problem, have better pain management, fewer flare ups and more energy.

Self- care can help you make the most of living with your condition, rather than avoiding or missing out on things because of it. Self- care puts you in control. Therefore, we are committed to working in partnership with you to support you to be as independent and healthy as possible, with support of your careers.

Living with a long-term condition can be a daily challenge and can affect people in various ways including their physical functioning, mood and mental well-being and employment potential.

Examples of long-term conditions are:

  • Arthritis
  • Asthma
  • Chronic pain
  • COPD
  • Coronary heart disease
  • Dementia
  • Diabetes
  • Epilepsy
  • High blood pressure
  • Mental health
  • Stroke
  • Thyroid disease

How Does This Work?

  • Patients with long term conditions will be invited for their annual review within the month of their birthday. We usually will invite you by text messages if you have a mobile telephone number on your record or by letter if there is no mobile telephone number on your record.
  • Your invitation to this clinic will have a link for you to use and book directly into the clinic. This is to make it easier to book into the clinics so that you do not have to contact the surgery for appointment.
  • Depending on what long term condition you have, we may text you a link for you to give us information about your health. For example, you may receive a link to give more information on how stable your asthma has been over the year or for home blood pressure reading.
  • When we receive this information, they will be processed by one of our healthcare professionals. Depending on the information provided, you may be called in for an appointment or have your review done over the telephone.
  • Some patients have more than one long term condition. If this is the case, all relevant conditions will be reviewed within the one annual review process. This ensures that you are only attending the surgery when you need to and that we are not asking you to attend the surgery unnecessarily.
  • For some conditions, it may be necessary to have more than one appointment, for example, a blood test appointment with the health care assistant (to ensure results are available for the review) and then a review with the practice nurse or nurse practitioner. In some case, it may also be necessary to have an appointment with the GP, but most reviews will take place with our specialised Nursing team who have knowledge and experience of managing long term condition patients.
  • Some conditions may require an interim review e.g., at six months this will be discussed at the annual review where it is felt to be appropriate.
  • There are usually a maximum of 3 invites in one year. If you are unable to attend these appointments, please make us aware.

What do I need to know about my appointment?

  • Please try and arrive for your appointment about 10-15 minutes early
  • Use the check-in machine or speak to the reception to make us aware that you have arrived.
  • Use our GP Pod machine that is located in the waiting areas to measure your blood pressure, weight, height and input your smoking data
  • After this, please return to your seat to wait until you are called in.

We hope you find this new process straightforward and easy to use. If you have any questions with regard to the annual review process, please do not hesitate to contact us.

Please see below link for further information: