Chronic Disease Annual Review Information

In 2022-23 we introduced a new system for chronic disease annual review appointments.

With our new and improved system, we hope to:

  • Offer all our patients face to face appointments
  • Improve the uptake of annual reviews
  • Improve the pathway of care for patients - patient seeing the right clinician, first time
  • Improve the quality of review for patients 
  • Improve access and flexibility of bookings for patients

  • Improve patient access for patients to self book by SMS
  • Improve access for our nursing team - patient seeing the right clinician, first time

All patients with a chronic disease are required to have an annual review. The purpose of the review is to ensure patients are taking the right medication and their condition is being managed.

Annual reviews are conducted for a range of conditions including, but not limited to:

  • Asthma/Chronic Obstructive Pulmonary Disease (COPD)
  • Cardiovascular/Heart Disease including Atrial Fibrillation, Heart Failure and High Blood Pressure (Hypertension)
  • Chronic Kidney Disease (CKD)
  • Diabetes
  • Dementia
  • Learning Disabilities
  • Mental Health
  • Rheumatoid Arthritis
  • Stroke and Transient Ischaemic Attacks (TIAs)

We encourage our patients to take an active role in helping to manage their own conditions, but it is helpful to attend the practice at least once a year for a review.

The majority of annual reviews are normally carried out by our nursing team. You may need two appointments; one with a Healthcare Assistant and one with a Practice Nurse or Pharmacist.

Your annual review will be due one year from your last review.

If you have not had an annual review in the last year, you will be called for your review from the 1st April of each year. 

Chronic disease review - Level 1 

Appointment type - 20 minute appointment with our Healthcare Assistant, including blood test, blood pressure and lifestyle advice. 

  • Atrial Fibrillation

  • Chronic Heart Disease

  • Chronic Kidney Disease

  • Heart Failure

  • Hypertension

  • Learning Disabilities - GP appointment after appointment with HCA

  • Mental Health - GP appointment after appointment with HCA

  • Peripheral Arterial Disease

  • Pre-Diabetes

  • Stroke/TIA

Chronic disease review - Level 2

Appointment type - 20 minute appointment with one of our Practice Nurses, if you have any Level 1 conditions, you will be invited for a 5 minute blood test at least 1 week before your appointment. 

  • Asthma 

  • COPD

  • May have any Level 1 conditions above

Chronic disease review - Level 3

Appointment type - 5 minute appointment with our Healthcare Assistant for a blood test, then a 25 minute appointment with one of our Practice Nurses at least a week later. 

  • Diabetes 

  • May have any Level 1 and/or Level 2 conditions above

If you suffer from diabetes, pre-diabetes, kidney disease, heart disease or hypertension please make sure you bring a urine sample to your appointment. Specimen bottles can be picked up from reception if needed.

It is important to attend your review appointment so we can ensure your condition is properly controlled and managed. If you run out of your repeat medication and have not had a review, we may not be able to re-authorise your repeat medication.

At your appointment the Health Care Assistant (HCA) or Practice Nurse will do any tests and checks that may be needed for your review. These may involve:

  • Body Mass Index (Height and weight)
  • Blood tests
  • Blood pressure and pulse
  • Cholesterol
  • Diabetic foot check
  • Inhaler technique
  • Lifestyle and dietary advice
  • Medication review

The HCA/Nurse will then inform you of the next steps, which may involve a follow-up appointment with a practice nurse, pharmacist or GP.

Some patients are seen by a consultant at the hospital for more specialised management of their chronic condition. Attending for your annual review at the practice may feel like a duplication, however Primary Care annual reviews and Secondary Care reviews are not the same and do not replace each other.

Your consultant may recommend some changes in medication or some new medication to help manage your condition and will often request for your GP practice to prescribe this medication. The practice as the prescriber of your medication, has a responsibility to make sure checks take place to make sure your medication can be prescribed safely and is effective. This is also an opportunity for the patient and practice to make sure patients have access to and are taking the right medication as prescribed by their GP and/or Consultant. 

Patients do have the right to decline their annual review, see more information below. 

Patients can decline to attend for their annual review. If you do not wish to attend for your annual review, please contact our administration team on 01925 650226 (option 7). The administrator will add a note to your record to document your wishes. 

Please be aware that the practice will then review any medications you are taking and your medication supply maybe be reduced to 1 months' supply for prescribing safety purposes. 

The practice will attempt to invite all patients on three occasions for their annual review with reminders approximately one month apart.

If a patient has not booked their annual review after the third reminder, the patients medical records will be reviewed and your medication supply will be reduced to 1 months' supply for prescribing safety purposes. 

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