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
Home Blood Pressure Monitoring
A blood pressure test is a simple way of checking if someone’s blood pressure is too high or too low. Blood pressure tests can be carried out at a number of places, including at home – using a patient’s own digital blood pressure monitor, a local pharmacy and GP practice, at an NHS Health Check appointment (offered to adults in England aged 40-74), or even in some supermarkets. Sometimes your blood pressure readings in the GP Surgery may be high due to the stress of being in a medical setting, often called ‘White Coat Syndrome’. If this happens, your doctor may ask for you to take readings using a home blood pressure monitor twice a day over 7 days as this will give a more accurate result.
There are a variety of low-cost blood pressure monitors available that patients can buy to use at home. It’s important that any equipment has been properly tested. The British and Irish Hypertension Society (BHS) has information about validated blood pressure monitors.
Download our Home Blood Pressure Monitoring sheet here to log your blood pressure readings. Make sure you hand these readings in to either Helme Chase or Maude Street for them to be analysed.
Links to local services/self-help resources
- Atrial fibrillation
- Chronic kidney disease
- Chronic obstructive pulmonary disease (COPD)
- Coronary heart disease
- Heart failure
- High blood pressure (hypertension)
- Peripheral arterial disease (PAD)
- Rheumatoid arthritis
- Stroke & Transient ischaemic attack (TIA)