Long Term Condition Management

A “birth month recall system” is used by many GP practices in the UK to remind patients with long-term conditions to book their annual reviews during their birthday month. This aims to make it easier for patients to remember their appointments, improve efficiency, and ensure consistent monitoring of their conditions.

If you are living with any of the following conditions – we will be contacting you just before, and during, your month of birth to come in for your annual review:

  • Asthma
  • Atrial Fibrillation
  • Coronary Heart Disease
  • COPD
  • Diabetes
  • Dementia
  • Heart Failure
  • Hypertension
  • Non-Diabetic Hyperglycaemia
  • Peripheral Artery Disease
  • Severe Mental Health
  • Stroke/TIA

Here’s how it generally works:

1. Invitation:

Patients receive an invitation to book their annual review during their birth month, usually by text, email, telephone call or letter. Please make sure your contact details are up to date.

If a patient does not respond to the 1st invitation, we will send 1 more invite. This might be by a different communication method.

We will try to send 1 invite just before your birth month, and 1 invite during your birth month.

2. Booking:

Patients will usually be sent a self-booking link or they can contact the practice to book their appointment, and our patient advisors will identify the necessary appointments and tests.

3. Combined Reviews:

This system often encourages consolidating multiple tests and checks into a single appointment, minimising the number of visits for patients. If you have more then one Long Term Condition, then we will call you to try and arrange the appointments for you in less visits.

4. Benefits:

It is very important you attend for an annual review of your condition. We would encourage you to attend these appointments and not decline. Attending your long-term health condition review is important for several reasons:

Monitoring your condition: Regular reviews allow healthcare professionals to track the progression of your condition, assess how well treatments are working, and make adjustments if needed.

Preventing complications: Many long-term conditions can lead to complications if not properly managed. A review helps identify any potential issues early, so they can be addressed before they become serious.

Optimising treatment: Your healthcare provider can ensure that you’re receiving the most appropriate medications, therapies, or lifestyle advice based on your current condition. If there are newer, more effective treatments or guidelines, the review is a chance to update your care plan.

Personalised care: Your health needs can change over time. Regular reviews provide an opportunity to discuss any new symptoms, concerns, or lifestyle changes that might affect your condition, helping tailor your care to your current situation.

Support and education: Health condition reviews are also a great time to ask questions, clarify doubts, and receive guidance on managing your condition day-to-day. This can give you a better understanding and more control over your health.

Building a relationship with your healthcare team: Regular check-ins help foster communication with your doctors, nurses, or other specialists, allowing them to better understand your unique health needs.

Missing these reviews can lead to undiagnosed changes in your health, missed opportunities for better management, and potentially preventable complications. It’s all about staying on top of your health to live a longer, healthier life!

GP Review Types and what to expect:

Asthma

  • 30 minute appointment with a nurse annually. The appointment will involve a questionnaire and a discussion about inhaler technique, a peak flow test, how to manage your exacerbations and your care plan.

COPD

  • 30 minute appointment with a nurse annually if symptoms are not controlled. The appointment will involve a questionnaire to help identify how often your COPD flares up and your level of breathlessness to help optimise your treatment. If symptoms are well controlled with your current treatment then a face-to-face appointment is not necessary.

Pre-diabetes (non-diabetic hyperglycaemia)

  • Annual blood test to check your HbA1c (blood sugar levels) – Any abnormal results will be followed up
  • Annual blood pressure reading
  • Annual Urine ACR test

Hypertension

  • Annual blood pressure reading – any out of range readings will be followed up by a home BP diary or 24 hour BP machine
  • Annual blood test to check your kidney function, liver function and cholesterol levels
  • Annual Urine ACR test

Coronary Heart Disease

  • Annual blood pressure reading
  • Annual blood test to check your kidney function, liver function and cholesterol levels
  • Annual ACR test

Peripheral Artery Disease

  • Annual blood pressure reading
  • Annual blood test to check your kidney function, liver function and cholesterol levels
  • Annual ACR test

Atrial Fibrillation

  • Annual blood test to check your kidney function, liver function and cholesterol levels
  • Height and weight measurements to allow your kidney function to be measured
  • Review of your stroke risk (CHA2DS2-VASc score)
  • Annual ACR test

Severe Mental Health

  • 20 minute appointment with a HCA annually to take your Height and Weight, Blood Pressure, Smoking and Alcohol status and a blood test to check your cholesterol and Hba1c (blood sugar levels)
  • 20 minute follow up with a clinician to discuss your results and review your care plan

Stroke / TIA

  • Annual blood pressure reading
  • Annual blood test to check your cholesterol levels

Heart Failure

  • Annual blood test. This will be a full blood count and kidney function check
  • Annual Blood Pressure reading
  • Annual Urine ACR
  • A follow up with a clinician involving a discussion about your breathing and medication.

Dementia

  • Annual 20 minute telephone call with a clinician (can request face to face appointment if preferred) discussing symptoms and care plan review

Diabetes

  • Blood test every 6 months to check your HbA1c (blood sugar levels).
  • 30 minute appointment with a nurse annually. This appointment will include a foot check, blood pressure measurement and HbA1c, cholesterol, kidney and liver function blood test and a urine ACR test. The Nurse will arrange a follow up call with you to go through your results and review your care plan.