Long Term Disease Management

We offer an annual review with the nurse practitioner or practice nurse for all patients with long term conditions. This is an opportunity to ensure that the condition is managed appropriately and to discuss any concerns that you may have about your condition.

You will be invited by letter on or around your birthday. Some patients will also require blood tests before attending for annual review. Time taken may vary according to condition (s) but usually lasts from 15 to 45 minutes.

Anti-Coagulation Monitoring

The practice offers a monitoring service for patient taking warfarin.

The Surgery staff will ring you between 5.30pm and 6.00pm with the results of your INR test.

It is very important that we give you your results. If we cant contact you for any reason you must contact us.

Please ensure that your telephone contact details are kept up to date with us.

Asthma

The asthma review is for patients who are using inhalers to control asthma. The aim of the review is to achieve and maintain good asthma control.

Any problems or concerns will be addressed, height and weight will be measured, peak flow respiratory rate will be measured, asthma medication and compliance will be reviewed, inhaler technique will be assessed, an asthma management plan will be given and guidance will be given regarding lifestyle.

COPD Clinic

The COPD review is for all patients with various stages of COPD. The aim of the review is to offer support and guidance in achieving and maintaining good quality of life and avoiding exacerbations.

Any problems or concerns will be addressed, lung function tested, level of breathlessness assessed, statistics measured such as weight and oxygen saturation, medication will be reviewed, inhaler technique assessed and guidance will be given regarding lifestyle.

Coronary Heart Disease

The coronary heart disease annual review is for patients who have had a heart attack, angina, coronary stent, bypass surgery, narrowing of
arteries in the leg, stroke or transient ischaemic attack.

The aim of this review is to the offer support and guidance to enable you to manage your condition and to prevent further incidents from occurring.

Any problems or concerns will be addressed, statistics such as weight and blood pressure will be measured, blood results will be explained, medication will be discussed and guidance will be given regarding lifestyle.

Diabetec Care

The diabetes annual review is for patients with all types of diabetes mellitus but management of some patients will be shared between the Diabetes Centre at the hospital and here.

The aim of the review is to assist you in achieving and maintaining good control of blood sugar to avoid the complications that sometime occur when control is consistently poor.

Any problems or concerns will be addressed, statistics such as weight and blood pressure will be measured, urine will be tested, feet will be examined, blood results will be explained, medication will be discussed including titration of insulin if appropriate and guidance will be given regarding lifestyle.

Hypertension

The hypertension annual review is for patients treated for high blood pressure. The aim of the review is to maintain good blood pressure control and prevent the problems that sometimes occur with poorly controlled high blood pressure.

Any problems or concerns will be addressed, statistics such as weight and blood pressure will be measured, urine will be tested, blood results will be explained, an assessment will be made of the risk of developing cardiovascular disease, medication will be discussed and guidance will be given regarding lifestyle.

Healthy Heart (CVD)

Patients aged 40 to 74 years and who have no pre- existing condition such as coronary heart disease, hypertension or diabetes or who are not taking medication for high cholesterol will be invited to attend for a healthy heart check.

The purpose of this is to identify those with a high risk of developing cardiovascular disease (angina, heart attack and stroke) within a 10 year time frame so that interventions can be offered to reduce this risk.

Fasting blood samples will be taken with a follow up appointment with a nurse when statistics will be measured, family health history identified, lifestyle assessed and blood results discussed.

A risk score will be calculated from this information and appropriate interventions offered. Patients identified as high risk will be offered annual reviews whereas and patients identified as moderate or low risk will be offered 5 yearly reviews.