Patients with Long Term Conditions

If you suffer from any of the following long term conditions, you can expect a regular review with health care staff and, in some cases, special investigations to help in diagnosis and monitoring:

  • asthma_inhaler_5Asthma – you will be offered an annual check which will include monitoring of your peak expiratory flow and medication review.
  • Atrial Fibrillation – (an arrhythmia or ‘irregularity’ of the heart) all patients will be offered regular monitoring of anticoagulants and an annual check which may include ECG and blood pressure measurement.
  • Coronary Heart Disease – patients with a suspected diagnosis will be sent for fast track testing which will include exercise ECG and any further tests which are deemed appropriate. You will be offered an annual check to include monitoring of weight, blood pressure, blood testing for cholesterol and other measures of health
  • Heart Failure – annual check and monitoring of your condition.
  • Cancer – we will refer people with suspected cancers to a consultant within two weeks of being seen by the GP. We will co-ordinate care and review the condition within the first 6 months of hospital treatment.
  • Chronic Obstructive Pulmonary Disease (chronic bronchitis, emphysema) - you will be offered monitoring of your condition annually, including spirometry when necessary.
  • Dementia – patients with a form of dementia will be offered a care plan to include social and psychiatric care. They will be regularly monitored.
  • Depression – all patients with a chronic disease will be monitored for depression. Patients will be asked to complete a questionnaire which will help with the monitoring of the condition.
  • Diabetes – you will be offered an annual review which will include checks on vision, blood and foot check as well as checks on circulation and nerves and digital photography of the retina. Patients will also have a six monthly interim review. A useful link is:
  • Epilepsy – you will be offered an annual assessment of your condition and medication. Additional checks will be undertaken if necessary.
  • Hypertension – all hypertensive patients will be offered a blood pressure check and medication review every 6-9 months.
  • bp_at_homeHypothyroidism – you will be offered an annual blood test and medication review.
  • Learning difficulties – patients will be offered an annual physical health check.
  • Mental Health – patients with severe and long term mental health problems will be offered a psychiatric care review, an annual health check to include physical and mental health and a medication review.
  • Stroke & TIA – if your GP suspects this condition you will be referred to a fast track clinic and offered CT brain scan and ultra sound of the neck arteries. Annual checks of blood pressure and cholesterol are recommended.
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