Health Management, Reviews and Long Term Conditions

Blood pressure management clinic

Our Health Care Assistants support our patients in monitoring Blood Pressure. When appropriate they will assist you in administering 24 hour BP monitoring to give a more accurate impression of your blood pressure at different times of the day. They also complete routine BP checks that are required as part of the annual review for long term conditions. Our HCAs can provide patients with information regarding how to lower your BP and how to maintain it at a healthy level.

Diabetic management and review

Newly diagnosed patients are encouraged to attend the local diabetes education programme. This is a valuable resource for patients to learn more about this condition and how to manage it effectively. 

All diabetic patients are invited to attend an annual review appointment (or more frequently if required) with a member of the Nursing Team.   We will work with you to ensure that your progress is carefully monitored to reduce the long term risks associated with diabetes, such as heart disease and deteriorating eyesight.

Diabetic patients will be contacted  by the local screening services to invite you for Retinal screening and we strongly encourage patients to attend these.

Learning disability health managment and review

Patients who are on the Practice’s learning disability register we be invited for an annual health check. This will usually be in the same month as your birthday. This review is an opportunity for patients to discuss their health and wellbeing with the GP and, if appropriate, have any regular medications reviewed.

Medication management and review

Patients who take regular medication require an annual review (more frequent reviews may be required if the medication is new or doses have changed). These reviews will be completed by the Clinical Pharmacists, Practice Nurses or GPs. 

It is important that patients attend for medication reviews so that the surgery can continue to prescribe the medication that is required. 

Mental health management and review

Annual reviews are provided for all patients with mental health conditions. Patients will usually be invited for their review during their month of birth. This review provides an opportunity for patients to discuss their health and wellbeing with the GP and, if appropriate, have any regular medications reviewed.

Respiratory conditions management and review

Patients with Asthma or COPD are invited to be reviewed by our Nursing  and Pharmacist Teams. We will work with you to manage your condition and ensure effective medication. 

We strongly recommend that you attend your review when invited by the practice to ensure optimal management of the condition leading to minimal disruption to your daily life and lifestyle.

Long Term Conditions

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.

Further information about CHD available from NHS UK

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

Further information about COPD available from NHS UK

Useful Links

Diabetes UK

NHS UK Diabetes Information Site