Long Term Conditions and Medication Reviews

The need to improve the treatment and management of long-term conditions is the most important challenge facing the NHS. Improving care for people with long-term conditions must involve a shift away from a reactive, disease-focused, fragmented model of care towards one that is more proactive, holistic and preventive, in which people with long-term conditions are encouraged to play a central role in managing their own care.

In response to this, we use a system for calling in our patients for annual reviews of their long term conditions. The system will group all your appointments into one appointment with the Healthcare Assistant for different tests and examinations. The results will then be sent to your GP for review, should the GP feel you need to see either a Specialist Nurse or themselves this will then be arranged. You may not require to always be required to come in for a second appointment as your condition may be stable/well controlled.

You will be called each year the month of your date of birth. The appointment times will vary dependant on your long term condition.

Should you not book an appointment after your first invitation you will be sent another invite one month later.  Should you not respond to this, we will assume you do not wish attend this appointment and we may make no further contact until the following year.

Patients that will be invited for annual review

Any patients with a diagnosis of one or more of the following conditions will be invited to attend for an appointment:

  • Diabetes
  • Chronic Obstructive Pulmonary Disease
  • Chronic heart disease
  • Hypertension
  • Rheumatoid Arthritis
  • Atrial Fibrillation
  • Chronic Heart Failure
  • Peripheral Arterial Disease
  • Cerebral Vascular Accidents
  • Trans ischemic attacks
  • Pre-Diabetes
  • Gestational Diabetes
  • Chronic Kidney Disease
  • Bipolar
  • Dementia
  • Psychosis
  • Asthma
  • Severe Frailty
  • Thyroid conditions

As part of your annual review you may be asked to do some home blood pressure monitoring prior to your appointment.  Click the link below to open a Home Blood Pressure Monitoring Diary to record your results.  If you are unable to print this form, please write down your results in a similar format.

You should record your blood pressure twice a day, morning and evening, for 1 week, and bring the results to your appointment.