Long Term Conditions

Long-term conditions, or chronic diseases, are conditions for which there is currently no cure, and which are managed with medications and other treatments.

National and local healthcare priorities include that people with long-term conditions are supported in managing their condition and are aware of treatments and resources to help them do so. LTCs differ from person-to-person and can range from mild, well-controlled Asthma to patients with several, sometimes conflicting, conditions which affect their quality of life.

Patients with long-term conditions will be invited to the Practice for an ‘annual review’, with additional appointments arranged depending on their clinical needs and personal preferences. Those with Diabetes will be invited to a ‘Diabetes Review Pre-assessment’ appointment and those with other LTCs will be invited to a CDM1 appointment (chronic disease monitoring). The content of the review will depend on the patient’s condition and current treatment but could include blood tests, blood pressure assessment, weight and lifestyle questions. Patients will receive an explanation of their treatment, shared decision-making and a review of their medication. We will signpost the patient, and carers, towards other sources of information, or support, which will help them manage their condition. We will refer to other services within the practice, and in the wider healthcare team, as required.

Wherever possible, we aim to look after all aspects of the patients care in one go, avoiding multiple, unnecessary appointments with different clinicians. Appointments will be arranged for the patients’ convenience including accommodating the needs of their carers and relatives, if appropriate. The surgery offers early morning and late evening appointments to maximise the patients’ choice, and the use of telephone consultations, email, and text communications will help us be more flexible.

Where appropriate, the patients’ decisions regarding their healthcare needs and preferences, including management of acute illness, will be documented in the clinical record, a copy shared with the patient and the appropriate outside services kept informed (i.e. the ambulance service, the community nursing teams etc).

Our aim is to offer a holistic, patient-centred LTC service for our patients whilst accommodating their needs and preferences wherever possible.

LTC Team Profiles

Long Term Conditions – Profiles

Asthma Questionnaire

Asthma Questionnaire

Links to local services/self-help resources