Long Term Conditions

We are improving the way we work with patients with long-term conditions

Non-urgent advice: Patients living with certain long-term conditions will be encouraged to attend a Yearly Health Check.

Long-term conditions are those that impact over a long period of time, such as diabetes and heart diseases. Our goal is to provide patients that have a Long-term condition with personalised care from their general practice and support from healthcare professionals. This will cover things that patients say matter most to their health and wellbeing, from the best treatment for their condition, to wider things like employment, housing, and mental health. We hope that by planning care together with patients, they will have the confidence to manage their health, reduce their risk of being admitted to hospital, and have a better quality of life.

What Does This Mean For Me?

Patients that do have a long-term health condition will be encouraged to attend at least three check-ins per year. There are 4 key stages patients can expect throughout this process please note however that the goal of this service is to provide personalised care so there may be more appointments or stages that are needed to suit the specific requirements of the patient.

See Below The 4 Key stages throughout this process or see the video to see an example of a patients journey through these key stages.

Patient Attends 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.
If you need an interpreter, please let us know so we can arrange one for your appointment.

Test results and 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

You can start filling out your Care Plan before your appointment or you can fill it in during your discussion appointment.

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. 

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.

Non-urgent advice: How will I be contacted if this is for me?

We will contact you via text, phone call, or letter to organise your appointments. We will contact patients over the year so please do not worry if you do not hear from us right away. If you are concerned or have questions, please contact us