Chronic Disease Monitoring

An annual review is required for all patients with a chronic disease.

The practice invites patients with a chronic disease e.g. Diabetes, COPD/Asthma, Hypertension, Epilepsy etc. for an annual review of their general health and current medications. Patients are invited for the appropriate monitoring and health review via letter, which is sent the month of their birth.

This invite may include a health questionnaire to be completed and returned prior to a review. This will allow the clinician to review your current health status and advise one of the following outcomes for management of your chronic disease:

• No further review is necessary as we have all the information we need to authorise issues of repeat medication for a further period of 6 to 12 months.
• We will complete the reminder of your annual review virtually (either by a telephone or video call to avoid the need for you to come to the surgery.
• We will need to complete the remainder of your annual review face2face. This is because we need to carry out physical elements to your review, e.g. check your blood pressure, which we cannot do without seeing you.

The review may include lifestyle, medication review to optimise the treatment of the chronic health condition, blood tests, urine samples and other monitoring for any complications. Not all chronic diseases are reviewed by the doctors. The majority of reviews are more appropriately carried out by the practice Pharmacist, Advanced Nurse practitioner or the Practice Nurse. The reception team will book your appointment with the most appropriate clinician.