Annual Reviews: Long Term Conditions



Improving how we support your Long Term Conditions

If you have certain ongoing health conditions like diabetes or heart disease, we’re here to make a positive change in how we work with you. We want to ensure that you receive the best care possible to manage these conditions and enjoy a healthier life.

At our practice, we have a team of healthcare professionals ready to support you. Our focus is on what matters most to your well-being, not just your medical needs. This includes things like the right treatment for your condition, as well as broader aspects like your job, where you live, and your mental health.

Our goal is simple: to empower you to take control of your health. By working together to plan your care, we want to help you manage your health effectively, lower your chances of needing hospital care, and enhance your overall quality of life.

What are Long-Term Conditions?

Long-term conditions are health challenges that stick around for a while, such as diabetes and heart disease. We understand how these conditions can affect your daily life, and we’re dedicated to helping you navigate them with confidence.

Who is this for?

Initially, we’re targeting nine specific long-term conditions:

  • Diabetes (Type 1 and Type 2)
  • Heart diseases (including strokes, heart failure, and more)
  • High blood pressure
  • High cholesterol
  • Non-alcoholic fatty liver disease
  • Atrial fibrillation
  • Chronic kidney disease
  • Asthma
  • Chronic obstructive pulmonary disease

What can you expect?

1. Attend your Check and Test Appointment

In your Check and Test Appointment, a health professional will carry out all the checks and tests you need to monitor and manage your long-term condition. You may be sent for a blood test and have other checks like a blood pressure check and weight check. We may discuss lifestyle factors such as smoking and exercise with you too.

2. Receive your test results and your Care Plan

After two to four weeks, you will receive your test results (by post, text, or email, however you prefer). We will also send a blank document called a Care Plan.

A Care Plan is an agreement between you and your healthcare professional to help manage your health and support day to day. In your Care Plan, you can record things that are important to your health and wellbeing. This can include anything from your life, like employment, housing, or mental health.

A Care Plan covers:

  • What is important to you and the goals you have
  • How to get the most out of your medication
  • The care and support you need from others

A healthcare professional will review your Care Plan with you in your Discussion Appointment. You can start filling out your Care Plan before your appointment or you can fill it during your appointment.

3. Attend you discussion appointment

You will then be invited to a Discussion Appointment with a healthcare professional. This may be another team member (such as a nurse, health care assistant, pharmacist, social prescriber link worker) who is best placed to support your care and can spend more time with you. This appointment will take around 30 minutes.

You can discuss your long-term conditions, test results, treatment, and anything else that is affecting your health, from housing to employment. Together we will look at what matters most to you and agree some goals. Your Care Plan will be updated with what has been agreed.

4. Attend your follow-up appointment

Three to six months later, you will be invited to a Follow-Up Appointment. This will last up to 15 minutes and is an opportunity to update your Care Plan with a healthcare professional, considering what is going well and where you may need more support. You may have more than one Follow-Up Appointment in a year

How will we contact you?

Don’t worry if you don’t hear from us right away. We’ll reach out to you via text, phone call, or letter to arrange your appointments throughout the year. And if you have any concerns or questions, please feel free to get in touch with us.

Your well-being is our priority, and we’re here to support you every step of the way.


High blood pressure (hypertension)

Keeping track of your health

If you have high blood pressure, ensure see our nurses once a year. They’ll check your medication’s effectiveness and make necessary adjustments and update your management plan accordingly.

Check Your Blood Pressure Anytime

In our waiting room, you’ll find a machine to check your blood pressure anytime you want. It’s easy to use, and our friendly staff will assist you if needed.



Diabetes care

woman injecting woman's arm carrying child

Taking Control of Diabetes

You play an important role too! Keep track of your blood sugar levels every day. It will show how food, activity, and medicine affect your body. Our team will help you understand when to check your blood sugar and what levels are healthy for you.

Healthy Eating and Exercise

Embrace a healthy diet with fruits, vegetables, whole grains, and proteins. Limit sugary and processed snacks. Stay active too! Our healthcare professionals will create a plan tailored to you, with exercises to keep you strong and healthy.

Using Insulin Safely

If you require insulin, we’ll show you how to use it safely. We’ll teach you about injection sites, proper dosage, and precautions to take. We will also guide you on the importance of rotating injection sites to prevent complications.

Join the NHS Diabetes Prevention Programme

If you are at risk of Type 2 diabetes, consider joining this program. Our team will educate you on staying healthy and reducing the risk of diabetes.


Asthma care

Stay Healthy with Asthma

We prioritize your health and well-being if you have asthma. Come see us every year for an asthma check-up. Our nurses and pharmacists will review your medications and create a personalized management plan.

woman in white vest and black bikini with hand on chest

Keep Asthma Under Control

By attending these check-ups, you can effectively manage asthma and lead a healthier life, reducing the risk of severe attacks.

Remember, we’re here to support your well-being and provide comprehensive care.


Chronic obstructive pulmonary disease (COPD)

Taking Care of Your Lungs

If you are 35 or older, a smoker, experience breathing difficulties, or have a persistent cough, see our nurses. They will perform lung function tests for COPD screening.

Annual Reviews: What to expect

If you have COPD and haven’t undergone pulmonary rehabilitation yet, make an appointment with us. Our specialized service, led by physiotherapists, aims to manage and improve COPD symptoms, enhancing your quality of life.

Our dedicated team is committed to supporting your lung health and ensuring you receive the appropriate medication and personalized management plan. Annual review appointments with our nurses are available to ensure optimal COPD care. To book an appointment, simply call the practice or use our online services.


Chronic heart disease (CHD)

Come for a special check-up every year if you have chronic heart disease! Our experienced pharmacists and nurses will give you advice and support to help you stay healthier. During these check-ups, we’ll look at your condition, review your medicines, and help with things like eating healthy, staying active, not smoking, managing stress, and taking your medicines the right way. We want to help you feel in control of your health. Call our staff to make an appointment for your yearly check-up and get the support you need to manage your heart disease well.

woman wearing silver-colored ring