Long Term Conditions

A long term condition is a health problem that requires ongoing management over a period of years.

These include diabetes, hypertension (high blood pressure), chronic kidney disease, stroke, atrial fibrillation and heart failure.

The way we are carrying out our reviews is changing. We have listened to patient feedback on how it can be challenging for you to find an appointment that fits in with you or your carer’s schedule. As a practice, we want to provide a more efficient and effective service for all of our patients with long term conditions so you can stay well for years to come. 

The aim is that all patients with any of the above conditions are reviewed annually, around their birth month, and once their review has been completed their medication (where appropriate) is authorised for another 12 months. 

We have invested in a self- screening pod, the Monitor Me Pod (MMP), which can be used to measure height, weight, blood pressure and pulse and also answer health questionnaires. All of this information is then saved directly into your medical records. This means that you don’t need to be tied to an appointment time - just turn up and use the MMP at a time that suits you in our opening hours.

View a demonstration video on the MMP so that you know what to expect the first time you use it. It really is very straight forward!

It is important that we review your condition annually to ensure we are keeping you as healthy as possible and to make sure we are prescribing you the appropriate medication. Regular monitoring of your medication and bloods are essential for your safety. Unfortunately if you do not attend for your annual review this may affect your repeat prescriptions.

The patient journey

Your Roadmap to Long Term Health

1. Preparing for your MOT

8 weeks before month birth

Our team will be reviewing your record to make sure we are prepared for your annual MOT, including any safety alerts from our systems.

2. Inviting you to your MOT

6 weeks before month birth

You'll get a letter introducing you to the new process with a link to our website page for more details.

Next, you'll get a text message with a link to book your blood test appointment at Landseer Road Blood Test clinic.

3. Getting your information together

During month birth

You'll get your blood tests done at Landseer Road.

You get to book in to our brand new Monitor Me Pod (MMP) to get your numbers and questionnaire completed.

(Foot checks for diabetics will be arranged separately).

4. Reviewing your information

During month birth

Our Clinical Team will review your results and check again for any safety alerts.

If everything is ok, we will renew your medications for another year and send you a congratulatory SMS.

If we need to make amendments to your treatment plan, we will contact you to arrange this.

5. Making sure no one is left out

During month birth

We will arrange to review our housebound patients and anyone who is unable to access this new service.

6. Final Safety Check

Within 2 weeks of month birth

Our Clinical Team will do one final check to make sure we have covered all the aspects of your health that need review and that your medications can be continued safely.

a patient

Step by Step:

1. Please book an appointment for your blood tests at Landseer Road – if we have a mobile number for you we will have sent you a text for this with a link to book online.

2. Please pop into the Surgery at a convenient time for you to use the Monitor Me Pod which is situated in a private room off our main waiting room. If you have diabetes or chronic kidney disease (your conditions will be listed on your invite letter), please also bring an early morning urine sample with you and hand it in over reception. If you do not have a urine bottle there will be some in the kiosk room and you can take one away with you and take your sample to Landseer Road when you have your blood tests or drop it back into the Surgery.

3. Once we have your blood results back and have evaluated your Monitor Me Pod health information our clinical team will review the information and your medication and communicate the outcome to you.

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