Long Term Conditions

Long Term Conditions Frequently Asked Questions

We want to give our patients with long term conditions, the best outcomes and guidance that we can. To do this we need to ensure that we have an organised process of reviewing our patients on at least an annual basis. 

This new review process provides a better way of reviewing patient’s needs, especially for patients who may have more than one long term condition, which includes illnesses such as respiratory disease, heart disease, stroke, diabetes, high blood pressure, rheumatoid arthritis, etc. 

These conditions require an annual review to ensure that the condition is being managed appropriately (by you the patient and also by us as your healthcare provider), to identify any problems or concerns and ensure patients are confident to deal with their condition between reviews. 

Why are they important? 

It is essential to monitor long term conditions and if the need arises take appropriate steps to manage them as best we can. It is also an opportunity to review treatments and answer any questions you may have about your long term condition. 

How does the Process work? 

Patients with long term conditions will be invited for their annual review within the month of their birthday. Some patients have more than one long term condition. If this is the case, we will do our best to review all relevant conditions 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 and in some cases it may also be necessary to have a further appointment with the Practice Nurse or the GP, but most reviews will take place in one appointment with our specialised nursing team who have knowledge and experience of managing long term condition patients. Some conditions may also require an interim review e.g. at six months this will be discussed and agreed at the annual review if appropriate. 

We hope you find this new process straight forward and easy to use. If you have any questions with regard to the annual review process, please do not hesitate to contact us. As this is a new process we would appreciate any feedback on how the system works for you 

What if I have had my annual check-up recently? 

We appreciate that some people will have already had their annual checks done quite recently. However in order to get the new system working well and everyone having their review around their birthday, we would ask that people still arrange a Birthday Review when they receive a letter inviting them to do so. This way, the system will soon be up and running smoothly. 

Long Term Conditions (LTC) are health conditions that can impact on a person’s life, and may require ongoing care and support. We organise appointments and provide support for people who have an LTC by putting in place a way of working called ‘Care and Support Planning’.

What is care and support planning?

This way of working aims to give you the opportunity to get more out of your annual review appointments by reorganising the way things happen and giving you more information before you see one of our Nurses. It should help you talk about:

  • What support you may need
  • What is important to you
  • What you can do to look after your health and stay well

Who is it for?

Any patient who has a Long Term Condition (LTC).

The Benefits

This way of working is nearly always preferred by patients. It will help both you and our Nurse make the best use of the time you have in your care and support planning appointment. All the important tests and results needed at your appointment will be available for discussion at your second appointment.

What does this mean for me?

This means that your care and support planning review will take place over two separate appointments and you will have time to think about what you want to get out of these visits.

What happens at the first appointment?

At the first appointment, you will be asked to attend the surgery to have a number of tests done with a Practice Nurse or Healthcare Assistant. The tests may include a blood test (non-fasting), weight, blood pressure and, if you’re diabetic, a foot check. The Practice Nurse or Healthcare Assistant will either book your next appointment which will be with one of our Nurses, or ask you to arrange this appointment with the Reception desk.

What happens next?

Your test results from this appointment will be available when you attend to see the Nurse. The results of this test will be discussed with the Nurse and any appropriate action taken.

What happens at the care and support planning appointment?

At your care and support planning appointment you will be able to ask questions and talk about what’s important to you. The Nurse will raise any issues she is concerned about. Once you both agree on the main things to work on, you will get the chance to work out a plan and identify any support you need to help you look after your health.

There are a number of services that can help you when it comes to looking after yourself if you have the following Long Term Conditions – Diabetes, Chronic Heart Disease, (CHD), Cardiovascular Disease (CVD) or Chronic Obstructive Pulmonary Disease (COPD).

Further Information

Coronary heart disease (CHD) is a major cause of death both in the UK and worldwide. CHD is sometimes called Ischaemic heart disease.

Chronic obstructive pulmonary disease (COPD) is the name for a group of lung conditions that cause breathing difficulties.

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