Chronic Disease Management Clinics




Long Term Condition Reviews Update

We are improving our system for long term condition reviews including Diabetes, Dementia, Cardiovascular Disease, Heart Failure and Cerebrovascular Disease (strokes and mini-strokes). Our aim is for you to have all your conditions looked at together, rather than separate appointments for each condition. 

You will now have one longer appointment with a Health Care Assistant each year to have all the checks needed. This is followed up by an appointment with a Nurse to review the results and help you find the best way to manage your health.

long term condition reviews

Many of the checks that you need can be done on our ‘POD’. The POD is a computer in the first floor waiting room that is linked to a blood pressure machine and a set of scales. The POD updates your health information directly into your GP records.

You will be invited in your birthday month to:

  1. Use the POD to check your blood pressure and weight, and to answer a questionnaire about your health. Your invitation will tell you which questionnaire to complete.
  2. Book an appointment with a Health Care Assistant for a blood test and the other checks needed for your conditions.

At this appointment you will be booked in for a Nurse appointment to review the results.

NB. As we are already halfway through this year the invitations will not match exactly to your birthday month this year. From April 2025 you will be invited for your birthday month.

We plan to send your invitation by text unless you have said you do not want texts. For those without working mobile numbers a letter will be sent. If you are one of the first to be invited you will be asked to phone the surgery to make an appointment. Later text invitations will give the option to book an appointment directly from the text. You will still be able to book by ringing reception if you prefer. Please make sure that your contact details are correct so that we can make sure no one else sees confidential information about you.

If you have already had your review since 1st April 2024 you will not be invited again until next year. If you have Diabetes you are likely to need several blood tests in the year at 3-6 month points after your last review. Please continue to have the tests that your Nurse recommended at your last appointment.

If you receive a first or second invitation when you already have the relevant appointment booked with a Health Care Assistant, please ignore the invitation and keep your booked appointment. We will contact you by phone a couple of weeks after the first invitation; if you miss these contacts because you are away you can always ring reception to book at a later date.

Respiratory (breathing) conditions will still be reviewed separately.