Long Term Condition Monitoring

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What are Long Term Conditions?

Long Term Conditions are health conditions that can impact on a person’s life, and may require ongoing care and support.

 These include:

  • Asthma
  • Atrial Fibrillation
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Chronic Kidney Disease (CKD)
  • Coronary Heart Disease (CHD)
  • Diabetes
  • Heart Failure
  • High Blood Pressure (Hypertension)
  • Stroke
  • Thyroid

If you have a Long Term Condition, you will likely be contacted by the practice on the month of your birthday to have a review of your condition(s). This can be by telephone or text message. 

If you are required to have bloods taken as part of your Long Term Condition monitoring, you will likely be asked to make an appointment to have them done via the Care and Treatment Service. You can contact them by calling  01382 496717

Non-urgent advice: Asthma

What is Asthma?

Asthma is a long-term condition caused by inflammation of the airways in the lungs.

You can develop asthma at any age. 

Symptoms include:

  • coughing
  • wheezing
  • chest tightness
  • breathlessness

Symptoms can vary from person to person. They’re often worse at night and early in the morning, or with certain triggers.

What is an Asthma Review?

On the month of your birthday, the practice will send you out a 'Medlink' via text message. A medlink is a review survey designed to find out how you are managing your asthma and inhalers. Depending on those answers, the practice may invite you to make an appointment with our Asthma Nurse to discuss your codition. 

Why do I fill out the medlink?

Not all patients are required to come into the practice for a review and some do not feel they need to. The Medlink Survey will provide you with guidance and the opportunity to feed back to our Asthma Nurse. 

 

Non-urgent advice: Atrial Fibrillation (AF)

What is Atrial Fibrilation?

Atrial fibrillation (sometimes called afib or AF) is a type of heart rhythm problem where your heartbeat is not steady.

The main symptoms of atrial fibrillation are:

  • an irregular heartbeat, where your pulse is not steady
  • suddenly feeling like your heart is pounding, racing, fluttering, skipping or missing a beat (heart palpitations) – this may last for a few seconds up to a few minutes
  • a heartbeat faster than 100 beats per minute
  • feeling very tired
  • finding it harder to exercise
  • chest pain or tightness
  • feeling short of breath, lightheaded, dizzy or like you might faint

Sometimes there are no symptoms, and atrial fibrillation is found as part of a routine check-up or when you're having tests for something else.

What is an Atrial Fibrillation Review?

On the month of your birthday, you will be invited to make an appointment with one of our clinicians who will discuss your symptoms, review your medication, sound your heart and optimise treatment options for you. Reviews are crucial for managing AF. 

 

 

Non-urgent advice: COPD

What is COPD?

Chronic obstructive pulmonary disease (COPD) is a collection of lung diseases. It includes chronic bronchitis, emphysema and chronic obstructive airways disease.

The main symptoms of COPD are:

  • shortness of breath, particularly when you're active
  • a persistent chesty cough with phlegm – some people may dismiss this as just a "smoker's cough"
  • frequent chest infections
  • persistent wheezing

 

COPD does not usually become noticeable until after the age of 35. Most people diagnosed with the condition are over 50 years old.

What is a COPD Review

On the month of your birthday, you will be invited into the Practice to have a COPD review with one of our clinicians. It involves discussing symptoms and social circumstances, checking your inhaler technique, monitoring oxygen levels, and reviewing lifestyle factors like smoking and vaccinations. The goal is to ensure your treatment is effective and to make any necessary adjustment with clinical support.

Non-urgent advice: Chronic Kidney Disease (CKD)

What is Chronic Kidney Disease?

Chronic kidney disease (CKD) is a long-term condition where the kidneys do not work as well as they should.

It's a common condition often associated with getting older. It can affect anyone, but it's more common in people who are black or of south Asian origin.

There are usually no symptoms of kidney disease in the early stages. It may only be diagnosed if you have a blood or urine test for another reason and the results show a possible problem with your kidneys.

At a more advanced stage, symptoms can include:

  • tiredness
  • swollen ankles, feet or hands
  • Shortness of breath
  • feeling sick
  • blood in your pee (urine)

What is a Chronic Kidney Disease review?

On the month of your birthday, you will be asked to attend the Community Care and Treatment Centre to have a blood sample taken.

The results of these tests are sent to one of our clinicians who will review them. If they think you need a face to face / telephone appointment, they will ask the admin team to contact you to arrange this. If you do not hear from us, then this means that the results of the test were satisfactory.

If you have not heard from us and would like to confirm this, please contact the practice between the ours of 11am and 5pm.

Non-urgent advice: Coronary Heart Disease

What is Coronary Heart Disease (CHD)? 

Coronary heart disease is the term that describes what happens when your heart's blood supply is blocked or interrupted by a build-up of fatty substances in the coronary arteries.

The main symptoms of coronary heart disease are:

  • chest pain (angina)
  • shortness of breath
  • pain in your neck, shoulders, jaw or arms
  • feeling faint
  • feeling sick (nausea)

But not everyone has the same symptoms and some people may not have any before coronary heart disease is diagnosed.

What is a Coronary Heart Disease (CHD) review?

On the month of your birthday, you will be sent out a 'Medlink' via text message. A medlink is a review survey designed to find out how you are managing your condition. 

You will also be asked to attend the Community Care and Treatment Centre to have a fasting blood sample taken and a Blood Pressure / Pulse check.

The results of these tests and the Medlink survey are then sent to one of our clinicians who will review them. If they think you need a face to face / telephone appointment, they will ask the admin team to contact you to arrange this. If you do not hear from us, then this means that the results of the test were satisfactory. If you have not heard from us and would like to confirm this, please contact the practice between the ours of 11am and 5pm..

Non-urgent advice: Diabetes

What is Diabetes?

Diabetes is a condition that causes your blood glucose (sugar) level to become too high. There are 3 main types of Diabetes: 

  • Type 1 Diabetes

    This type is often diagnosed in childhood, but you can get it at any age. It cannot be prevented.

  • Type 2 Diabetes

    Some people are at higher risk due to ethnicity, age, living with obesity or overweight. It can sometimes be prevented or stopped with lifestyle changes and treatment.

  • Gestational Diabetes

    Can happen during pregnancy. You can reduce your risk with lifestyle changes. Gestational diabetes usually goes away after you've given birth.

What is a Diabetes review?

There are 2 types of reviews for people with Diabetes:

Yearly Review

On the month of your birthday, you will be asked to attend the Community Care and Treatment Centre to have a blood sample taken.

The results of these tests are sent to a clinician who will review them. If they think you need a face to face / telephone appointment, they will ask the admin team to contact you to arrange this. If you do not hear from us, then this means that the results of the test were satisfactory.

If you have not heard from us and would like to confirm this, please contact the practice between the ours of 11am and 5pm.

6 Monthy Review

You require to have 2 checks per year. Usually this will be your birthday month and then 6 months thereafter. Your 6 month review will be undertaken by the practice.

 

Non-urgent advice: Heart Failure

What is Heart Failure?

Heart failure means that the heart is unable to pump blood around the body properly. It usually happens because the heart has become too weak or stiff. Heart failure does not mean your heart has stopped working. It means it needs some support to help it work better.

The main symptoms of heart failure are:

  • breathlessness after activity or at rest
  • feeling tired most of the time and finding exercise exhausting
  • feeling lightheaded or fainting
  • swollen ankles and legs

Some people also experience other symptoms, such as a persistent cough, a fast heart rate and dizziness.

 

What is a Heart Failure Review?

On the month of your birthday, you will be asked to attend the Community Care and Treatment Centre to have a fasting blood sample taken, blood pressure check, weight and lifestyle questions.

The results of these tests are sent to one of our clinicians who will review them. You should receive an invitation for face to face / telephone appointment to review your heart failure symptoms. The admin team to contact you to arrange this.

 

Non-urgent advice: Hypertension

What is Hypertension?

Hypertension (High Blood Pressure) is a condition where the force of blood against your artery walls is consistently too high. This constant strain can damage your heart and blood vessels and significantly increase the risk of serious health problems like heart attacks and strokes. You are highly recommended to have your own blood pressure monitor when you are prescribed blood pressure medication. 

Many people have it without realising it.

Rarely, high blood pressure can cause symptoms such as:

  • headaches
  • blurred vision
  • chest pain

What is a Hypertension Review?

On the month of your birthday, you will be asked to attend the Community Care and Treatment Centre to have a fasting blood sample taken and an early morning urine sample. If you have your own blood pressure monitor, please bring along some recent readings to assist the healthcare team. 

The results of these tests are sent to one of our clinicians who will review them. If they think you need a face to face / telephone appointment, they will ask the admin team to contact you to arrange this. If you do not hear from us, then this means that the results of the test were satisfactory.

If you have not heard from us and would like to confirm this, please contact the practice between the ours of 11am and 5pm.

Non-urgent advice: Stroke

What is a Stroke?

A stroke is when blood stops flowing to a part of your brain. It can affect things like speech and movement, and take a long time to recover.

The main symptoms of a stroke can happen suddenly. They may include:

  • face weakness – one side of your face may droop (fall) and it might be hard to smile
  • arm weakness – you may not be able to fully lift both arms and keep them there because of weakness or numbness in 1 arm
  • speech problems – you may slur your words or sound confused

What is a Stroke Review?

On the month of your birthday, you will be asked to attend the Community Care and Treatment Centre to have a blood sample taken, blood pressure test, weight and lifestyle questions. 

The results of these tests are sent to one of our clinicians who will review them. If they think you need a face to face / telephone appointment, they will ask the admin team to contact you to arrange this. If you do not hear from us, then this means that the results of the test were satisfactory.

If you have not heard from us and would like to confirm this, please contact the practice between the ours of 11am and 5pm.

 

Non-urgent advice: Thyroid

What is a Thyroid Condition?

The thyroid is a small butterfly-shaped gland in the neck, just in front of the windpipe (trachea). It produces hormones that affect things such as your heart rate and body temperature.

An overactive thyroid, also known as hyperthyroidism or thyrotoxicosis, is where the thyroid gland produces too much of the thyroid hormones. 

An underactive thyroid (hypothyroidism) is a common condition where the thyroid gland in your neck does not make enough hormones. This can cause symptoms like tiredness and weight gain.

What is a Thyroid Review?

On the month of your birthday, you will be asked to attend the Community Care and Treatment Centre to have a blood sample taken.

The results of these tests are sent to one of our clinicians who will review them. If they need to modify your thyroid medication, they will prepare a prescription and a member of the admin team will contact you. If you do not hear from us, then this means that the results of the test were satisfactory.

If you have not heard from us and would like to confirm this, please contact the practice between the ours of 11am and 5pm.

Page last reviewed: 28 October 2025
Page created: 15 September 2025