Long Term Condition Recall System

New Long-Term Condition (LTC) Care and Recall System from April 2025

At Capelfield Surgery, we are improving how we support patients with long-term conditions (LTCs). Our goal is to streamline care, reduce unnecessary visits, and ensure patients receive a more comprehensive review tailored to their needs.

What is a Long-Term Condition?

Long-term conditions are ongoing health issues that require regular monitoring and management, such as diabetes, high blood pressure, and heart disease. It is recommended that individuals with LTCs attend an annual review to optimize their care and overall well-being.

Changes to the LTC Annual Review Process

From 1st April 2025 we are introducing a new recall system. This means:

  • Patients with one or more LTCs will be invited for a review around their birthday month to help structure and simplify appointments.
  • Where possible, reviews will be combined to minimize multiple visits to the practice.
  • Some patients who were not previously included in our LTC recall system may now be invited for an annual review.

Conditions Included in the New Recall System

Patients with any of the following conditions will be included:

  • Respiratory: Asthma, Chronic Obstructive Pulmonary Disease (COPD)
  • Cardiovascular: Heart failure, Ischaemic heart disease, Peripheral arterial disease (PAD), Stroke/TIA
  • Diabetes: Type 1, Type 2, Gestational diabetes, Prediabetes
  • Kidney Disease: Chronic Kidney Disease (CKD) Stages 1-5
  • Metabolic Conditions: Hypertension, Hyperlipidaemia (high cholesterol)
  • Other: Atrial fibrillation, Mental health conditions

What to Expect from Your LTC Review

  1. Part 1 – Health Care Assistant Appointment
    • A 20-30 minute appointment depending on your condition(s).
    • Checks will include blood tests, blood pressure measurement, weight assessment, alcohol and smoking status review.
    • Additional tests may be required, such as a urine sample or a diabetes foot check.
    • If needed, a medication review with the Practice Pharmacist will be scheduled.
  2. Part 2 – Specialist Review
    • Certain conditions require a follow-up appointment with a Nurse/Pharmacist/GP
    • The Health Care Assistant will book this appointment if needed.
    • This review may take longer than previous ones as we aim to provide more comprehensive care in fewer visits.

Additional Changes

  • Asthma & COPD Questionnaires: Patients with respiratory conditions may receive a text with a link to complete a questionnaire before their appointment. If you cannot access it digitally, paper copies will be available at reception.
  • Cancellations: If you cannot attend your appointment, please inform the Practice so the slot can be offered to another patient.

This new system is a significant change for both staff and patients. We appreciate your patience and cooperation as we transition to this improved approach. Our aim is to provide better, more efficient, and patient-centred care that helps you manage your health with confidence.

Published on 17 March 2025