Long term conditions or chronic diseases are conditions for which there is currently no cure, but can be managed over a long time. These include:
These conditions require an annual review (or Health MOT) to ensure that the condition is being managed appropriately (by you the patient and also by us as your healthcare provider), identify any problems or concerns and ensure you are confident to deal with the condition between reviews.
Sometimes people may not have a long term condition yet but could be at risk of developing a condition. For example, some people may be considered to be pre-diabetic. We may also need to monitor these people annually.
| Blood Pressure + Pulse: | Hypertension (HTN), Atrial Fibrillation (AF) |
| Cardiovascular: | Coronary Heart Disease (CHD), Chronic Heart Failure (CHF), Peripheral Arterial Disease (PAD), Transient Ischemic Attack (CVA/TIA), CVD-Primary Prevention (on statin or QRISK2/3 >10%), Familial Hypercholesterolaemia |
| Diabetes: | Diabetes Mellitus Type 1 (DM1), Diabetes Mellitus Type 2 (DM2), Non-Diabetic Hyperglycaemia (NDH)/Pre-Diabetes, Gestational Diabetes |
| Endocrine: | Hyperthyroidism, hypothyroidism, primary hyperparathyroidism |
| Renal: | Chronic Kidney Disease (CKD) (Stages 1-5) |
| Mental Health: | Severe Mental Illness (SMI) |
| Haematology: | Monoclonal Gammopathy of Unknown Significance (MGUS) |
| Liver: | Non-Alcoholic Fatty Liver Disease (NAFLD + NASH) |
| Respiratory: | Asthma (if bronchodilator issued in last year), Chronic Obstructive Pulmonary Disorder (COPD) |
| Liver: | Non-Alcoholic Fatty Liver Disease (NAFLD + NASH) |
| MSK: | Gout + on Urate Lowering Therapy (ULT) |
| Other: | Rheumatoid Arthritis, Epilepsy (if antiepileptics issued in last year), Frailty, Certain Medications, Other Personalised Care |
Managed Separately
| Conditions | Dementia, Learning Disability (LD), Cancer (CA) |
| Housing | Care Home Resident or Housebound |
| End of Life | Advanced Care Planning |
| Time-Sensitive Medication Reviews | Diseases-Modifying Antirheumatic Drugs (DMARDs), Anticoagulation Medication, Vitamin Deficiencies |
People who are aged 40-74 who do not have a pre-existing qualifying condition can have an NHS Health Check every five years. Please contact the practice on 0161 3048009 to check if you are eligible and book in for a NHS Health Check.
Many people who have a long term condition or are at risk of developing a long term condition will need to be invited for an annual review. Patients who have certain conditions, or who are taking certain medications may require more frequent additional reviews. Some conditions may require reviews with different clinicians which may mean more than one appointment, however for many people the annual review may just involve one appointment.
To ensure that everyone who is eligible gets invited for an annual review the practice will send patients at least 3 invitations each year from April to April. For most people the practice will use the month of month as the “deadline” to receive 3 invites. For example if your birthday is in Augst, you can expect to receive your first invite in June, your second invite (if you have not already had your appointment) in July, and your third invite (if needed) in August. Unless you have a condition or risk which needs to monitored more frequently and providing everything was satisfactory during your annual review, you are completed for the year and will be invited again the following year.
My Birthday is in April or May
To allow the practice to structure invites within an annual period, we reset the invites at the start of each April. Whilst most patients can expect up to 3 invitations before their birthday month, patients who have a birthday in April and May are slightly different – They can expect their first invitation in April, second in May and third in June.
Full Schedule of Invites
| Birth Month | 1st Invitation | 2nd Invitation | 3rd Invitation |
| April | April | May | June |
| May | April | May | June |
| June | April | May | June |
| July | May | June | July |
| August | June | July | August |
| September | July | August | September |
| October | August | September | October |
| November | September | October | November |
| December | October | November | December |
| January | November | December | January |
| February | December | January | February |
| March | January | February | March |
Table of when to expect invites
For your convenience if you have a mobile number or email address recorded we will send you a sms message or email inviting you to contact the practice to book in. Our software will review and record whether this message has been delivered. If it is not successful we will send you a letter in the post instead.
If we have only a landline number recorded in your notes (or no number at all), or we do not have consent to send you sms messages we will send your invitation by post.
Please ensure that your address and telephone numbers are up to date. You can update your contact details through your Online Access account or via our website here.
When you receive an invitation to book in for a review you make an appointment be calling the practice on 0161 3048009, visit us in person, or book a long-term condition review appointment online here.
Most review appointments will either be with a healthcare assistant (HCA) or nurse. Depending on what type of review you need you may need first need an appointment with a HCA and then a follow up appointment with a nurse or GP.
All reviews with an HCA will be face to face so that they can take bloods, record blood pressures and perform some other investigations if applicable.
Subsequent appointments with a GP or nurse may be conducted by telephone unless they request to see you face to face BUT you are welcome to request a face-to-face consultation if you prefer.
An initial assessment with one of our HCAs will usually last between 20-30 minutes depending on what tests are needed.
Depending on what conditions or risk you have the healthcare professional may carry out a number of tests as well as ask you general lifestyle and personal questions to assess how your condition or risk is currently being managed.
Some common tests we may carry out include:
Most people are more tense than usual in medical settings and might not even realise it. This is called White Coat Syndrome and can mean your blood pressure is raised even if you don’t feel stressed. The term ‘white coat’ refers to the white coats traditionally worn by doctors.
It is fairly common to suffer from White Coat Syndrome. Try and take a few minutes to relax prior to your appointment. The healthcare professional may take your blood pressure several times and record the lowest reading.
If it is higher than expected, they may ask you to record your blood pressure at home.
I need a blood test but am afraid of needles – what can I do?
This is very common. Our team are very experienced and the procedure is most often quick and painless. You are welcome to bring someone with you to your appointment for support. We will not force anything so even if you come to the appointment but decide you do not want have blood taken at that time, we can rearrange and try again a different time.
If you are particularly nervous just speak to the team and we will make you feel comfortable and at ease.
Do I need to bring anything with me to my review appointment?
If you use inhalers please bring these with you when having your respiratory review so that the nurse can assess your inhaler technique and advise you on how to use them more efficiently.
If you attend for a diabetes review you will be asked to provide an early morning urine sample. You can do this in the surgery at the time of your HCA diabetic review appointment or take a sample pot away with you and return it to the practice at your convenience.
Sometimes you may be asked to complete a questionnaire before your review.
There can be a lot for the clinician to cover in your annual review appointment. We suggest that you write down any questions that you have in advance of your annual review. This will ensure that they are answered and will help the us to tailor a management plan that best suits you.
Please be honest with the clinicians that you see so that the healthcare professional can develop a management plan in collaboration with you. For example, tell the GP if you are not taking your medication – this could save the NHS wastage or lead to your GP suggesting alternative medication or proposing a different management plan.
Most people will be fine and their condition will be well managed. However, long term conditions can cause problems very slowly over a period of time. Your body is very clever at compensating when one of your organs is struggling so it might not initially be obvious. Equally, medications that are designed to help manage your long-term condition can have side effects over time.
By checking your bloods, blood pressure, medical history, medications, and asking you questions about your lifestyle we hope to be able to identify signs of any problems before they develop.
These reviews are really important. We strongly encourage all patients with a long term condition to attend for their annual review.
It is your choice as to whether you attend your review. On the other, GPs have a duty of care and we want to avoid you coming to any harm that could be avoided. GPs could also be held responsible if you encounter problems because the management plan that you are on has not been reviewed.
If you do not attend for your long term condition review we may reduce the length of your prescription for safety. Please be assured we will not stop any patient’s medication.
Please let us know if you are unable to attend for a specific reason. For example if you are unwell, in hospital or out of the country for an extended period. In these cases we may delay your review or exempt you for the current year.
For most patients your annual review process (whether this is one, two or three appointments) will be sufficient to manage your long term condition.
However, some conditions and some medications need to be monitored more frequently – you may need to come for a repeat blood test after 6 months or even 3 months depending on your situation. The care is personalised to each patient.
If you have an exacerbation of your long term condition, you should contact the surgery and we will arrange to see you in addition to your annual review.
If you have had tests such as blood tests, you will often receive a SMS message with a short description if the results were satisfactory, normal, abnormal or need repeating. If you have had a number of tests you may receive a number of results and messages. Some blood tests are broken down into several tests so although you have had just one blood sample taken, the sample may be broken down into a number of tests.
If further action is required, such as a repeat test, a change in medication or if an appointment with a GP is required, the practice team may contact you to arrange this. Result may also be discussed if you have a follow-up appointment booked.
If you have online access to your GP record, such as through the NHS App, you may also be able to view your results.
To view more information on common blood tests and what results mean click here.