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Long term disease clinic

Long Term Disease Clinic - "One Stop Clinic" - Annual Reviews

Long term disease refers to medical conditions that may have an ongoing impact on your health. In particular we use this term to refer to the following conditions:

  • High blood pressure (also known as hypertension)*
  • Diabetes*
  • Asthma
  • COPD (Chronic obstructive pulmonary disease, previously termed emphysema or bronchitis)
  • CKD (Chronic kidney disease)*
  • Mental Health conditions such as schizophrenia or bipolar depression*
  • Ischaemic heart disease (previous or current angina or heart attack)*
  • Heart Failure
  • Stroke or mini-stroke (TIA)*
  • Rheumatoid Arthritis*
  • Osteoporosis
  • Thyroid disease (over or underactive thyroid)*
  • Atrial Fibrillation (a condition of irregular heartbeat)
  • Peripheral arterial disease (usually causing pain in the legs when you walk)*

If you have one or more of the above conditions, we recommend that you have an annual review. Some of these conditions require monitoring with blood tests or other tests such as breathing assessments or urine tests.

This year we will be introducing a new process for co-ordinating these reviews. Your review will take place in the month of your birthday. This will allow us to plan our workload and spread it evenly throughout the year and it should also provide you with an easy to remember date for your review!

Why are we doing this?

We currently have approximately 5700 patients with at least one of these conditions and so co-ordinating such reviews can be a challenge. We would like to ask for your help in this matter. By taking responsibility for your medical condition you can help ensure that you are having the best possible care.

Reviewing your condition on an annual basis will enable you to check that you are taking the correct medications. It will also give you an opportunity to ask your nurse or doctor questions about your health.

The video link below helps illustrate how the Practice aims to deliver a patient centred approach in managing your long term disease.

What will happen?

We will contact you in advance of your birthday month inviting you to attend for a blood test (if this is required for your condition - typically those marked with * in the list above)

This appointment will be made over the phone with the phlebotomist, usually with Joanne or Deborah.

When you attend for the blood test, the phlebotomist will then make your appointment with the Practice Nurse 1-2 weeks later. The appointment time may vary depending on your long term condition.

If you are not required to have blood tests done yearly then an appointment with the practice nurse will be made directly.

Following on from your appointment with the Practice Nurse your medication will be reviewed by the doctor. Most patients with stable conditions will not need to see the GP and they will have an annual review in the month of their birthday.

The first year

Please note that for this year only, if your birthday falls between April and May your review will be held later on in 2016.

Patients being seen in hospitals or privately

If your condition is being monitored by an NHS hospital or private consultant, this system will not affect you seeing them. You will be called for the blood tests at the surgery and the review with the nurse, who can then give you copies of your results to take to your consultant.

In most cases your GP will prescribe your repeat medications, not your Consultant. Your GP needs to review your blood test results annually to be able to continue prescribing your medications.

This review process is important and we will not be able to continue prescribing repeat medications without it. Your cooperation in this new process will therefore be very much appreciated.

We hope that this process will reduce the number of times you need to come to the surgery and therefore free up appointments for doctors to see you when you have more urgent problems.

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