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Long term Conditions

New System for Annual Reviews


We invite all patients who live with a long term medical condition to attend for a full annual review.  The long term conditions included in this service are:


High blood pressure (also known as hypertension)



COPD (Chronic obstructive pulmonary disease, previously called emphysema or bronchitis)

CKD (Chronic kidney disease)

Mental Health conditions such as dementia, schizophrenia or bipolar disorder

Ischaemic heart disease (angina or heart attack)

Heart Failure

Stroke or TIA (mini-stroke)

Rheumatoid Arthritis


Thyroid disease (over or underactive thyroid)

Atrial Fibrillation (a type of irregular heartbeat)

Peripheral arterial disease

Learning difficulties

Multiple Sclerosis

We plan for these reviews to happen during your birthday month. This makes it straightforward for the practice to arrange to invite you for the review, and hopefully makes it easier for you to remember when the review is due. This should also reduce the number of visits to the surgery for people with more than one long term condition

What will happen?

We will contact you before your birthday month, inviting you to make your review appointment. Alternatively, you might want to contact us to make the arrangements yourself. When the review is being arranged, you will be informed of what kind of appointments you need. The types of appointment needed depend on what conditions you have. For example, you might need to have a blood test first then a nurse or GP appointment 2 weeks later. Most people with stable conditions will not need to see the GP.


Patients being seen at hospital clinics

If your condition is being monitored at the hospital, this system will not change that. You should attend hospital appointments as usual and you will be invited to come to the practice for an annual review to look at the aspects of your care not covered at the hospital.


We hope that you find that this change in our systems will improve the organisation of the care you receive from the practice.


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