Clinics and Services

Long Term Condition management in the NHS refers to the ongoing care and support provided to patients living with chronic health conditions such as;

• Cardiovascular/Heart Disease including Atrial Fibrillation, Heart Failure and High Blood Pressure (Hypertension)
• Chronic Kidney Disease (CKD)
• Diabetes
• Stroke and Transient Ischaemic Attacks (TIAs)
• Peripheral Arterial Disease
• Rheumatic Arthritis

The goal is to help individuals manage their condition effectively, improve quality of life, and reduce hospital admissions.

Regular LTC reviews are a key part of this care. These reviews are usually conducted annually (or more frequently if needed) by GPs, nurses, or other healthcare professionals. They involve:

• Monitoring symptoms and disease progression
• Reviewing medications and treatment effectiveness
• Offering lifestyle advice and support
• Setting personal health goals with the patient
• Coordinating with other services as needed

The NHS promotes a personalised, patient-centred approach, encouraging self-management and shared decision-making to empower patients in managing their own health.

The majority of our annual reviews are carried out by our nursing team and takes between 15-30 minutes.

During your review, the Practice Nurse or HCA will;

• Take a non-fasting bloods sample checking: U&E, LFT, Lipid profile, and Hb1ac, FBC. - They may require other blood samples too, depending on your individual health needs.
• Check your blood pressure and pulse
• May check your height and weight
• May take a urine sample

Your review appointments can be booked;

• Online via TPP SystmOnline / Airmid App,
• The NHS App,
• By phone: 01243 826541
• or the direct booking link you may have received by text message.

Have no online access to your medical record?

• Sign up for the NHS APP
• More info about the NHS App

Please note review appointments are bookable between 8:30am an 1:00pm Mondays to Fridays.

Please make sure you drink plenty of water before your blood test.

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.

Diabetes management in the NHS focuses on helping people with diabetes (Type 1, Type 2, or other forms) live healthier lives by controlling blood sugar levels and reducing the risk of complications. Care is delivered through regular monitoring, education, and support from healthcare professionals including GPs, nurses, dietitians, and diabetes specialists.

Diabetes reviews are usually carried out annually (or more often if needed) and involve:

• Checking blood glucose control (e.g. HbA1c levels)
• Monitoring blood pressure, cholesterol, and kidney function
• Reviewing medications and insulin (if used)
• Foot checks to prevent complications
• Lifestyle advice (diet, exercise, smoking cessation)
• Discussing mental wellbeing and self-management support

These reviews aim to ensure the condition is well-managed and to personalise care based on the patient's needs. Patients are encouraged to take an active role in managing their diabetes through structured education (like DESMOND) and support from their care team.

Our initial Diabetic Annual Reviews are carried out face-to-face with a Health Care Assistant and take 30 minutes. 

We ask patients to bring an early morning urine sample and if available a blood glucose diary with them to the review.

Urine specimen bottles can be purchased from the pharmacy at a low cost.

During your initial review, Our Health Care Assistant will;

• Take a non-fasting bloods sample checking: U&E, LFT, Lipid profile, and Hb1ac, FBC , may take a TSH and Vitamin 12 samples too - They may require other blood samples too, depending on your individual health needs.
• Take you height and weight
• Take your blood pressure
• Carry out an annual diabetic foot check.

Once your test result received our nurse will arrange for a follow up appointment which can be face to face or over the phone to;

• Review your HbA1c and cholesterol levels
• Review your blood glucose control
• Discuss any issues you have with your diabetes or health in general
• Advise any change in regimen, lifestyle or medication – including any side effects
• A care plan containing your test results will be sent to you prior to this follow up appointment

Your review appointments can be booked;

• Online via TPP SystmOnline / Airmid App, 
• The NHS App,
• By phone: 01243 826541
• or the direct booking link you may have received by text message.

Have no online access to your medical record?

• Sign up for the NHS APP
• More info about the NHS App

Please note

• Initial review appointments are bookable between 8:30am and 12:00noon Mondays to Fridays.
• Follow up appointments can be booked between 8:30am to 12:00noon and 2:00pm to 4:00pm  Monday to Fridays

Please make sure you drink plenty of water before your blood test.

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.