What is a Long Term Condition?
Long term conditions or chronic diseases are conditions for which there is currently no cure, and that are managed with drugs and other treatments. These include:
- Respiratory disease (Asthma or COPD)
- Heart disease (including Heart Failure and Atrial Fibrillation)
- Kidney disease
- High blood pressure (Hypertension)
- Rheumatoid arthritis
- Mental health problems
- Other long term health issues that affect the health or lifestyle of a patient.
These conditions require an annual review (or Health MOT) to ensure that the condition is being managed appropriately (by you the patient and also by us as your healthcare provider), identify any problems or concerns and ensure you are confident to deal with the condition between reviews.
Why are you changing the recall system for long term condition reviews?
It is much easier for patients to remember that they will have a review of their long term condition(s) in their birthday month. It also makes it easier for the practice to align these reviews with other important events such as your medication review. This approach ensures that long term condition reviews are spread evenly through the year meaning that they impact less on urgent appointment capacity.
How will I be invited for my annual review?
For your convenience and to use NHS resources wisely we will send a text message invitation if you have a mobile number in your record. Our software will review and record whether this message has been delivered. If it is not successful we will send you a letter in the post instead.
If we have only a landline number recorded in your notes (or no number at all) we will send your invitation by second class post.
Please ensure that your address and telephone numbers are up to date. You can update your contact details through your Online Access account or via our website here
Who will my annual review be with?
Respiratory Conditions – Asthma and COPD
If you have Asthma or COPD but no other conditions your will be invited to book a respiratory annual review appointment with a nurse.
Hypertension (High Blood Pressure)
If you have hypertension but no other conditions you will initially be invited to an HCA annual review appointment during which you will have a blood test, have your blood pressure taken and be asked some lifestyle questions. You will then have an appointment to see a nurse (Louise) or a pharmacist (Mike) to review the management of your hypertension.
Diabetes (and hypertension)
If you have diabetes you will be booked into an HCA diabetic review appointment. The HCA will take your bloods, check your blood pressure, check the circulation in your feet and ask you some lifestyle questions. You will then have an appointment booked with a nurse or nurse practitioner to review your diabetes once your test results have been returned. If you have any additional long-term conditions you may also need a further appointment with a GP.
Other Long Term Conditions
If you have other long term conditions you will initially be invited to an HCA annual review appointment before being booked in for a review with your usual GP once the results of initial tests are available
Can I be seen face to face for my review?
All reviews with an HCA will be face to face so that they can take bloods, record blood pressures and perform some other investigations.
Subsequent appointments with a GP, nurse or pharmacist will be by telephone unless they request to see you face to face BUT you are welcome to request a face-to-face consultation if you prefer.
How long will my review last?
An initial assessment with one of our HCAs will last 20 minutes (30 minutes if you have diabetes to allow time for a foot examination).
Respiratory and diabetes reviews with our nurses and hypertension reviews with our pharmacist will last around 20 minutes.
GP reviews, if needed, will be 10 minutes unless you have a number of long-term conditions in which case they may be 20 minutes as well.
My blood pressure is often high at my review because I get anxious – what can I do?
Most people are more tense than usual in medical settings and might not even realise it. This is called White Coat Syndrome and can mean your blood pressure is raised even if you don’t feel stressed. The term ‘white coat’ refers to the white coats traditionally worn by doctors.
It is fairly common to suffer from White Coat Syndrome. Try and take a few minutes to relax prior to your appointment. The nurse or GP may take your blood pressure several times and record the lowest reading.
If it is higher than expected, they may ask you to record your blood pressure at home. Home BP machines are now very affordable and we would encourage all our patients to get one to help manage their condition. You can submit your readings via our website here.
I have a fear of having my blood taken – do I have to have a blood test?
Patients who only have a respiratory condition (asthma or COPD) are unlikely to need a blood test but it is a necessary diagnostic tool for other long-term conditions.
It is natural to feel anxious about any medical procedure but our HCAs are very experienced and used to looking after patients that have a phobia of needles. Please let us know if you are scared and we can help to relax and support you. We would also suggest that you have a little something to eat as this can raise your blood sugars and help you feel stronger and less faint – none of the blood tests needed for our long-term conditions require you to fast. You might also want to bring something, like a book, to take you mind off things if you have to wait.
Do I need to bring anything with me to my review appointment?
We would suggest that you have a list of your medications with you at your annual review. This will help the GP to understand any issues that you have with your tablets even if you are unsure of their names.
You are advised to have your inhalers to hand when having your respiratory review so that the nurse can assess your inhaler technique and advise you on how to use them more efficiently.
If you attend for a diabetes review you will be asked to provide a urine sample. You can do this in the surgery at the time of your HCA diabetic review appointment or take a sample pot away with you and return it to the practice at your convenience.
How can I get the most benefit from my annual review appointment?
There can be a lot for the clinician to cover in your annual review appointment. Please ensure that you focus on your long term condition in your annual review appointment(s). We respectfully ask that you book a separate appointment if you have another ailment that you wish to discuss with the GP.
We suggest that you write down any questions that you have in advance of your annual review. This will ensure that they are answered and will help the GP or nurse to tailor a management plan that best suits you.
Please be honest with the clinicians that you see so that the GP or nurse can develop a management plan in collaboration with you. For example, tell the GP if you are not taking your medication – this could save the NHS wastage or lead to your GP suggesting alternative medication or proposing a different management plan.
I feel fine – why do I even need a review?
Most people will be fine and their condition will be well managed. However, long term conditions can cause problems very slowly over a period of time. Your body is very clever at compensating when one of your organs is struggling so it might not initially be obvious. Equally, medications that are designed to help manage your long-term condition can have side effects over time.
By checking your bloods, blood pressure, medical history, medications, and asking you questions about your lifestyle we hope to be able to identify signs of any problems before they develop. Our clinical team will review your information and consider how together we could improve your health/management of your long term condition. This may include health advice, medication changes or referrals to a specialist service.
These reviews are really important. We strongly encourage all patients with a long term condition to attend for their annual review.
What will you do if I choose not to attend for my review?
Deciding what to do when people do not attend for their annual review is really challenging for us. On the one hand it is your choice as to whether you attend your review. On the other, GPs have a duty of care and we want to avoid you coming to any harm that could be avoided. GPs could also be held responsible if you encounter problems because the management plan that you are on has not been reviewed.
If you do not attend for your long term condition review after your first invitation we may reduce the length of your prescription from 56 days to 28 days. If you still do not attend after a second invitation we may further reduce your prescription to 14 days. Experience has shown us that reducing the duration of prescriptions dramatically increases the number of patients that attend for their annual reviews and contributes to positive long term outcomes. Please be assured we will not stop any patient’s medication.
If you do not attend after three reminders we will mark on your record that you have made an informed decision not to attend.
Please let us know if you are unable to attend for a specific reason. For example if you are unwell, in hospital or out of the country for an extended period. In these cases we may delay your review or exempt you for the current year.
Once I have had my annual review will I need to see anyone else for a year?
For most patients your annual review process (whether this is one, two or three appointments) will be sufficient to manage your long term condition.
However some conditions and some medications need to be monitored more frequently – you may need to come for a repeat blood test after 6 months or even 3 months if your long term condition is poorly controlled..
If you have an exacerbation of your long term condition, you should contact the surgery and we will arrange to see you in addition to your annual review.