Long Term Conditions (LTC)

The Long Term Medical Conditions Clinic is an innovative approach to the way the practice cares for its patients with long term conditions (asthma, diabetes, stroke, hypertension, COPD, cononary heart disease). It allows us to recall patients to have their conditions and medication reviewed in a more effcient way. The clinics were set up to reduce the need for patients to make mulitple visits to see the practice nurse or doctor. The LTC clinics are run by the Heath Care Assistants (HCA), Practice Nurses and Doctors all working together.


The practice has over 4500 patients with one or more long term conditions (LTCs) and we have a responsibility to see all of these patients at least once per year (more often in some cases) to check that everything is going well with the management of their condition, each patient needs to be reviewed for each condition and this represents about 30% of the entire workload of the practice. By carrying out these reviews more efficiently we hope to achieve the below objectives.


  • Reduce the need for patients to make multiple visits to the practice . We do this by combining where possible, multiple tests in one appointment (depending on the nature of the tests the appointment time maybe slightly longer) This allows a more joined up approach to the care of patients with more than one LTC.
  • Arranging annual automatic recalls for reviews around the month of birth so patients know when they are likely to be called for their review by the practice.
  • Following tests being carried out, results are then reviewed by the specialised clinican, this could be either a Practice Nurse or GP.
  • Patients will not be contacted routinely about their results unless abnormalities are present and then the appropriate clincian will contact the patient. The patient will only be invited for a face to face appointment if it is deemed clinically necessary and not upon request. If a patient wishes to know their results these can be viewed via online access or by telephoning the reception after 2pm.
  • Better allocation of the practice resources so that we have more time for providing good quality health care for all of our patients.


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