Long Term Condition & Medication Reviews

Quote / Testimonial:

We are aiming for everyone to have their annual reviews in the month of their birthday – this would include annual blood tests, HCA, nurse and doctor reviews.

This may mean that this year some patients are called earlier than a year after their last review and some slightly later.

We however need your help for this to run effectively.

Non-urgent advice:

If your birthday is coming up you are welcome to pre-empt and call to arrange your reviews.

If you get sent a reminder please follow the instructions – we spend a lot of time chasing patients to book appointments, share BPs, have their annual blood tests etc. and this takes us away from other clinical work.

Please try to find out what routine follow up you require for your condition and share the responsibility of managing your health with us.

What does your review entail?

The below doesn’t cover all conditions and medications but it covers the majority and what your annual requirements would be.

ConditionBlood testsAnnual appointmentsOther
HypertensionAnnual 6 monthly BP readings with annual early morning urine  
Heart failureAnnualReview with clinical pharmacist   
Stroke/Transient ischaemic attack (TIA)  Annual 6 monthly BP readings  
Asthma Text review  Telephone call or face to face with asthma nurse if concerns raised on text  
Chronic obstructive pulmonary disease (COPD) Face to face with COPD nurse   
DiabetesAnnualFace to face with Health Care Assistant or telephone call with diabetes nurse  Frequency of assessment may be shorter if poor control or complications, will be advised individually
Dementia Care Coordinator review   
Depression 6 monthly text review2 yearly face to face or telephone call with doctor, more frequent if concerns raised in text response or more complex case  
Other mental health conditionAnnualQuestionnaire completion Health Care Assistant review/ Doctor review   
Rheumatoid arthritisAnnualTelephone call with nurse   
Chronic kidney diseaseAnnual Annual early morning urine 6 monthly BP  
EpilepsyAnnualText questionnaire   

MedicationBlood testAnnual appointmentsOther
StatinAnnual   Annual BP
Disease modifying ant rheumatic drugs (DMARDs)  Frequency varies    
Direct Oral Anticoagulants (DOAC) – rivaroxaban, edoxaban, apixaban, dabigatran  Frequency varies 3 monthly review needs a routine blood test.
6 & 12 monthly reviews needs a 20min HCA appointment.
Hormone Replacement Therapy 1st review 3 months after starting – telephone call with nurse  
Annual reviews thereafter via text   
Annual BP & weight
Contraceptive pills 1st review 6 months after starting  
Annual reviews thereafter via text   
Annual BP & weight
Eplenerone/spironolactone6 monthly    
Lithium3 monthly    

  • We are aiming to do all your blood tests at the same time so you only have to come in once for all your conditions rather than multiple trips to monitor each condition/drug separately.
  • Please help us by being aware of your medication and if you are having blood tests for one condition check with the phlebotomist about adding others at the same time, we will also be working hard to do this from our end too.