Long-term conditions

A long-term condition is managed in the months between appointments, by you. Our job is to make sure you have the right medicines, the right numbers, a plan you understand, and a person to ring when something changes. About a third of our patients have at least one, so it is most of what the nurses do.

Every patient on a long-term condition register is invited for a review in their birthday month: bloods and measurements with the healthcare assistant first, then thirty minutes with the nurse who looks after that condition to go through results, medicines, symptoms and what you want to be able to do this year. Diabetes reviews include foot checks and a referral for eye screening; asthma and COPD reviews include an inhaler technique check and a written action plan.

Between reviews you can ring the nurse directly on the number on your care plan. The practice pharmacist adjusts blood pressure and diabetes medicines under a shared protocol, so changes do not wait for a GP appointment. The social prescriber, Hannah, helps with the things that make conditions worse but are not medical: money, housing, loneliness, getting back to activity. A first-contact physiotherapist runs clinics here on Mondays and Wednesdays for joint and back problems, bookable without seeing a GP.

What is included

• Named nurse or GP for each condition
• Annual review in your birthday month, thirty minutes
• Written care plan and action plan
• Direct number for your nurse between reviews
• Social prescriber and in-house physiotherapist
• Medication changes by the practice pharmacist without waiting

How to book, and when

Annual review booked by the practice in your birthday month; blood tests first, then thirty minutes with the nurse. Reviews by phone or video if you prefer. Everything is free on the NHS unless it says otherwise. How each kind of appointment works is on the appointments page; the full list of clinics is on the clinics page.