Long Term Condition Reviews

We aim to review all long term conditions in your birthday month. We hope this is easier for you to remember and to get your health fully reviewed in a timely fashion.

Please contact us in the month before your birthday to book all long-term condition review appointments.

You may need to see more than one clinician (GP, Nurse, Health Care Assistant and/or Practice Pharmacist), however we will combine appointments where we can.

Our receptionists will be able to advise you what long-term conditions you have been diagnosed with and what appointments you will require. Many conditions need annual blood tests which will be combined into one appointment with a Health Care Assistant (HCA) approximately two weeks before your review appointment.

We recommend an Annual Review if you are currently suffering from one or more of the following long-term conditions:

Please book a face to face appointment with a Practice Pharmacist or Nurse specialising in Chronic Obstructive Pulmonary Disease (COPD) 

You will need to bring your inhalers to your review appointment.

When you receive your text invite for your review, there will be a link to a questionnaire that you need to complete prior to your appointment. Please ensure this has been completed as the clinician will need this information to complete your review.

An Asthma review is only indicated if you are currently on asthma medication, i.e. inhaler prescription issued by us in the last 12 months

If you have Asthma (and are currently prescribed inhalers), we will send you a text message at the beginning of your birth month with a link for you to complete an ACT questionnaire online. We will receive the results of this once you have completed it. If the results are within normal limits one of our Practice Pharmacists will complete an asthma action plan and send this to you - you will not need a follow-up appointment. If the results are not within normal limits you will receive a message asking you to book an asthma review with one of our Nurses.

If you have recently had a course of prednisolone please do not book for review until at least 6 weeks afterwards.

We advise patients with Asthma to procure a Peak Flow Meter (available as a one-off prescription) in order to better self-monitor symptoms.

Regular monitoring of Diabetes is very important.

You will need to attend the surgery for an annual blood test, blood pressure & foot check with an HCA - please bring an early morning urine sample to your appointment if possible. 

The remainder of your review will be done with a Practice Pharmacist or Nurse by telephone approximately 1 week later.

We no longer advise routine interim checks of your HbA1c however you will be invited for more frequent follow-up if required, e.g. following treatment changes, to assess any impact on HbA1c control

If you have Heart Failure, we will contact you in the month before your birthday to book your review appointments. We will also make sure you have appointments booked for any other long term conditions you may have.

For a Heart Failure review you will need a 30 minute appointment with an HCA for a blood test, blood pressure and an ECG. Approximately 1 week later you will need a 20 minute face to face appointment with one of our Practice Pharmacists or Specialist Heart Failure Nurse.

A Cardiovascular health review covers one or more of the following conditions:

Hypertension (high blood pressure)

CHD (Coronary Heart Disease)

Stroke / TIA (Transient Ischaemic Attack) 

PAD (Peripheral Arterial Disease) 

You will need a 10 minute appointment with an HCA for a blood test, blood pressure and urine check - please bring an early morning urine sample to your appointment if possible. 

Your results will then be reviewed by a Practice Pharmacist or Nurse and you will be advised if a follow-up appointment is necessary.

Lifestyle guidance is available on the patient.info website.

Find answers to the most common questions about living with high blood pressure

An annual review is advisable for Chronic Kidney Disease (CKD) however as this is often secondary to other long-term conditions such as Diabetes or Hypertension, this will usually be covered within your annual review for another condition.  

If you only require kidney monitoring you should book an annual appointment with an HCA for a blood test, blood pressure and urine check. The results will be reviewed by a Practice Pharmacist to see if any follow-up action is needed. 

You may need interim reviews depending on your CKD category but you will be invited separately for these.

We have a Care Coordinator dedicated to ensuring that patients with Dementia have all necessary appointments booked for their annual review. The Dementia review itself is a 30 minute face to face appointment with a Nurse specialising in Dementia. Your Carer should attend with you for this appointment.

Your Care Coordinator will advise and book any appointments needed for other Long Term Conditions.

With carer help if required, please bring a completed Dementia Care Plan to the appointment

We have a Care Coordinator especially for our patients with Learning Disabilities. They will contact you or your carer to help you to book your annual review as well as any other apppointments you may need.

A Learning Disabilities review involves a 10 minute appointment with a Health Care Assistant (for a blood test) and approximately 1 week later a 30 minute appointment with a Nurse specialising in LD.  

You will be sent a checklist to be completed before your appointment which you can ask your carer to help you with.

An annual health review is recommended if you have one or more of the following conditions:

Schizophrenia

Bipolar Disorder 

Psychosis 

We have a Care Coordinator who will contact you to book annual review appointments for your mental health in your birth month, as well as book any appointments needed for other Long Term Conditions.

Your mental health review itself involves a 20 minute appointment with a Health Care Assistant for some physical checks (including a blood test, blood pressure, height & weight) and approximately 1 week later a 30 minute appointment with your Usual GP. Some patients may need an ECG at the HCA apointment, dependent on what medication is being taken.

Please bring with you a completed Mental Health Care Plan (PDF) / Word Care Plan - this can be completed electronically & emailed to fireclayhealth@nhs.net at least 1 working day before your appointment, or print and bring to the appointment

Please ensure you discuss your Rheumatoid Arthritis care with your GP at a routine appointment at least annually, even if your arthritis treatment is primarily delivered in hospital.

Please use your birth month as a prompt however you do not need to book a specific appointment for review.