New Long Term Condition recall system from April 2025

Posted by: rebeccaclegg - Posted on:

We have recently reviewed how we manage patients with Long Term conditions as we found our current system meant some patients are having to come in multiple times for different conditions and we wanted to improve this so that patients can have all conditions reviewed together where possible. We are therefore changing our recall processes for patients with Long term conditions from the 1st April 2025.

This will mean any patients with the below conditions, will be picked up in the new recall system:

  • Epilepsy + on antiepileptics
  • Best Practice (Polycystic Ovary Syndrome, Bronchiectasis, Gout + on Long Term urate-lowering therapy, Hypothyroidism, Hyperthyroidism, frailty severe (not housebound or care home), Familial Hypercholesterolaemia, Cardiovascular Disease Pathogenicity Predictor (CVD-PP) and on statin or QRisk is 2 or 3, Coeliac disease, Bariatric surgery, Primary hyperparathyroidism, Rheumatoid Arthritis)
  • Respiratory (COPD and Asthma)
  • Chronic Kidney disease stages 1-5
  • Mental Health
  • Hypertension and Atrial Fibrillation
  • Diabetes
  • Diabetes Gestational
  • Prediabetes
  • Cardiovascular disease (Heart Failure, Chronic Heart Disease, Peripheral Arterial Disease (PAD) and Stroke/TIA)

Some of the conditions above were not included in our previous Long Term Condition recall system, therefore some patients may now be invited in for a Long term Condition review when they have not been before.

As part of the new recall system, patients will be invited in around their birthday month.

Patients will be invited to book in for a Part 1 Long Term condition review with a Health Care Assistant which will be 20 or 30 minutes long depending on what condition(s) you have. At that appointment, the Health Care Assistant will review your alcohol status, smoking status, check your weight, take your bloods, complete a Blood pressure check. Additionally, depending on what condition you have they may ask you to bring in a urine sample and may complete a diabetes foot check.

Certain Long term conditions will require a Part 2 Long term condition review with either a Nurse, GP or ACP that specialise in that Long Term Condition(s). The Health Care Assistant at the part 1 appointment will book you in for the part 2 appointment. The Health Care Assistant will also book you in for a telephone medication review with the Practice Pharmacist if this is due.

The part 2 Long Term Condition review appointment may be longer than you previously had as we are trying to reduce multiple visits to the Practice.

We are introducing the use of questionnaire’s for both Asthma & COPD to improve information gathering. If you get sent a text message with a link to complete a questionnaire, please ensure you complete this as the completed answers will be sent back to the Practice to review. Paper copies of the questionnaire will be available at the front desk if you are unable to open the text message link.

If you cannot attend your appointment, please ensure you contact the Practice to cancel so that we can release the appointment or others to use.

This new process is a big change for staff as well as patients so please bear with us over the next couple of months as everyone gets used to the new system and slight changes to the process may be required.