Chronic Disease Monitoring
An Annual review is required for all patients with a chronic disease.
The practice continues to invite patients for annual review when they are due. The invite may include a questionnaire to complete and return prior to your review. This will allow the clinician to review and possibly send you a text to either advise that:
- No further review is necessary as we have all the information we need to authorise issue of repeat medication for a further period of 6 to 12 months.
- We will complete the reminder of your annual review virtually (either by a telephone or video call to avoid the need for you to come to the surgery.
- We will need to complete the remainder of your annual review face2face. This is because we need to carry out physical elements to your review, e.g. check your blood pressure, which we cannot do without seeing you.
The review may include lifestyle, medication review to optimise the treatment of the condition, blood tests, urine samples and monitor for any complications.
Not all chronic diseases are reviewed by the doctors. The majority of reviews are more appropriately carried out by the practice Pharmacist or the Practice Nurse. The reception team will book your appointment with the most appropriate clinician.
Asthma clinics are run by our Practice Nurse where we will assess your treatment and inhaler therapy to ensure you are on the correct medication to help keep your asthma in control.
If you suffer from Atrial Fibrillation, our Pharmacists and Nurses will regularly monitor you with necessary tests, such as ECG, anticoagulation and blood tests and will help you manage your symptoms.
Patients who are diagnosed with cancer will be monitored and followed up by our Primary Care Team who are here to help, offer advice, and treat your general health as well as any cancer related problems.
There are various organisations who are working to help support those with cancer. More information can be found in the Self Help & Care section of our website.
A spirometry test is carried out by our Healthcare Assistant to determine if there is any deterioration in patient's lung function. The review is carried out by the Practice Nurse.
Annual reviews are carried out by the Advanced Nurse Practitioner. Support for carers will also be discussed and provided.
One in every give people in the UK is diagnosed with depression. Our team is able to help by providing friendly advice and the team can also refer you for the best choice of therapy to help with your condition.
The Practice invites patients with Chronic Mental Health problems for a general health check, where they have a thorough consultation to discuss concerns with the patient and/or their carers and a review of their general health.
The Practice offers routine diabetic reviews at a special appointment each year, where we will discuss with the patient their diabetes management and go through any concerns they may have.
Diabetes Annual Review Questionnaire
Our Doctors and Pharmacist are able to help patients who have suffered, or who are suffering, with drug and alcohol misuse, often in co-ordination with other specialist healthcare professionals.
E-DAS Entry into Drug & Alcohol Services
Epilepsy is a chronic condition that needs frequent review and our patients are managed and closely monitored by the Practice Pharmacist, whether for urgent ailments or for regular health checks.
Patients with heart disease should have annual medication review and blood tests, which will be reviewed at your appointment with a member of the team.
Patients will be reviewed by the Advanced Nurse Practitioner. Patients are seen for blood pressure monitoring and medication checks.
Annual checks are carried out by our Pharmacist or Advanced Nurse Practitioner which will include the necessary measurements and blood tests to make sure that patients are treated optimally for thyroid problems.
Patients with Chronic Kidney Disease or acute kidney injury are monitored with regular blood tests and general health reviews in the practice to help prevent any further deterioration in the condition.
People with learning disabilities often have poor physical and mental health than other people, and are therefore reviewed at least annually in the Practice, with up to date blood pressure monitoring and medication reviews.
You can self-refer for help and advice about losing weight safely and eating a healthy, balanced diet and regular physical activity.
Patients who have previously suffered a Stroke or Transient Ischaemic Attack (TIA) will be asked to attend for regular review with the Advanced Nurse Practitioner or Pharmacist, so that we monitor your condition and perform any relevant health checks.