Long Term Conditions

September 2023

A long-term condition (LTC) is a condition that cannot, at present, be cured but is controlled by medication and/or other treatment/therapies.

Across North Central London GP practices are adopting a new model of care for managing LTCs. For many of our patients at River Place the process is similar to the way in which we have provided care to people with diabetes. Going forward, we will be using a similar two-step approach for the annual review of people with a wider range of LTCs, including people with:

  • Cardiovascular Disease (CVD) -ischaemic heart disease, stroke, peripheral arterial disease and heart failure
  • High blood pressure
  • High cholesterol
  • Atrial Fibrillation
  • Diabetes (Type 1 and 2)
  • Non-alcoholic fatty liver disease (NADLF)
  • Chronic Kidney Disease (CKD)
  • Asthma (adults and children)
  • Chronic Obstructive Pulmonary Disease (COPD)

We will also be offering annual reviews for all patients that we consider to be at high risk of developing these conditions.

Patients will receive personalised care and support from the surgery team. This will cover things that patients say matter most to their health and wellbeing, from the best treatment for their condition, to wider things like employment, housing, and mental health.

Our goal is that by planning care together patients will have the confidence to manage their health, reduce their risk of being admitted to hospital, and have a better quality of life.


What can you expect?

Check and Test Appointment:

Each year during your month of birth you will be invited to a face-to-face appointment at the surgery with a member of our healthcare team. At this appointment we will complete tests including blood and urine tests (if needed), blood pressure, height and weight, and peak flow for those patients with asthma. We will aim to address all of the LTCs that may be affecting you in this appointment, to help us care for you as a whole person, rather than a collection of different medical diagnoses. At your check and test appointment you will be booked a follow up within the next 2-4 weeks to discuss your results.  

This appointment will take around 30minutes. If you need an interpreter, please let us know so we can arrange one for your appointment.

Multi-disciplinary Team (MDT) Review

Following the Check and Test Appointment those patients who we feel are at high risk of complications from their LTC will be discussed by our in-house MDT, consisting of a senior pharmacist and advanced nurse practitioner, with input from your named GP. We may ask for advice and input from other members of the wider healthcare team, including social prescribers and hospital specialists. 

Receive your test results and care plan

You will be sent a copy of your results by post within a care plan called MYCaW, for you to review before your discussion appointment.

A Care Plan is an agreement between you and your healthcare professional to help manage your health and support you day to day. In your Care Plan, you can record things that are important to your health and wellbeing. This can include anything from your life, like employment, housing, or mental health. 

A Care Plan covers:

  1. What is important to you and the goals you have
  2. How to get the most out of your medication
  3. The care and support you need from others

Discussion Appointment

You will then have your discussion appointment with a member of our heath care team. This appointment can be in person or over the phone depending on your preference. At this appointment we will discuss your results, treatment and goals, and update your MYCaW care plan together.

Your discussion appointment may take between 15 minutes to one hour, depending on the number of LTCs you have.

Follow-up Appointment

You may be offered one or more follow-up appointments throughout the year until your next annual review. Again, these may be over the phone, or in person. At these appointments we will review your treatment and goals together, considering what is going well, and where you may need more support.


How will I be contacted if this is for me?

We will contact you via text, phone call, or letter to organise your appointments. We will contact patients over the year so please do not worry if you do not hear from us right away. If you are concerned or have questions, please contact us.


Care for Children and Young Persons (CYP) with Asthma

Annual review:

All children and young people with asthma will have a review of their asthma each year. The first part of this will take place as a review of their notes by a trained member of our healthcare team.

The CYP will then be invited for a review within their month of birth.

At this appointment we will review:

  • Asthma control
  • Any related conditions such as hayfever that may be impacting it
  • Triggers for asthma
  • Exposure to smoke
  • Inhaler technique and compliance

At the end of this appointment we will produce a child Asthma Action Plan.

Post-Attack Review:

  • All CYP will be offered a review within 48h of an acute exacerbation of their asthma (‘asthma attack’) to ensure it is resolving. 
  • A further review will be scheduled within six weeks of the exacerbation, to review and understand the reasons for it.

Interim Review

Those CYP considered to be at high risk of a further asthma attack may be invited in again throughout the year to review their asthma and treatment.