Management of Chronic Disease

Annual Reviews /Chronic Disease Management

The management of patients with Chronic Diseases involves GPs, Advanced Nurse Practitioner, Practice Nurses and Healthcare Assistants.

If you are diagnosed with any of the following conditions,you are offered a structured review annually by appointment (usually with a practice nurse – unless arranged otherwise with your GP). You will need to make this routine appointment with reception:

Vascular’ diseases:

Ischaemic (coronary) heart disease  eg. angina, or post heart attack.

Hypertension (raised blood pressure)

Peripheral vascular (arterial) disease

Stroke or TIA

Respiratory’ diseases:

Chronic Kidney Disease (CKD)



We have made some changes:

1.    Your review will be carried out by the Advanced Nurse Practitioner or Practice Nurse, followed by blood testing on the same visit ( if indicated).

2.     You may not need to have blood testing every year e.g. lipids (cholesterol)*

3.     All relevant reviews (e.g. asthma and hypertension) will be carried out at the same visit.

4.     Abnormal blood results (only) will be communicated to you, preferably by text. You are welcome to telephone us for results if you wish, in addition. 

Why have we made these changes?

1.     To reduce unnecessary visits to surgery for you  (and us)

2.     To reduce unnecessary blood testing (for you and the NHS)

3.    To ensure our practice meets with current clinical guidelines

4.     To ensure a clear review date is in place for yourselves and us

If you are Diabetic –you will be invited to Diabetes clinic in the usual way by post.  The Nurse will carry out any other relevant reviews at this appointment eg. COPD.

*Note: why have we reduced some blood testing ?

In some stable chronic disease e.g. hypertension, peripheral artery disease (but not if you already have a diagnosis of heart disease or stroke), we are interested in looking at future cardio-vascular disease risk for prevention purposes. We use a computerised tool called QRISK. This looks at several parameters  including, age, sex, blood pressure, Body Mass Index, cholesterol readings, family history etc. The result indicates the percentage risk of developing a vascular problem such as heart attack or stroke over the next 10 ears.

This is more useful than looking at e.g. a cholesterol result in isolation. Year on year, QRISK results do not alter dramatically. Therefore, checking cholesterol annually may be excessive and not needed. NICE asks us to advise you when your QRISK result is equal or higher than 10%, so that we can offer statin treatment. We also screen for diabetes in vascular at risk patients every 2 years. Some drug treatments eg. Ramipril (ACE Inhibitor) or Indapamide, Bendroflumethazide (diuretic) require monitoring of kidney function every year. We will tailor your annual review plan to your own requirements. Respiratory conditions do not require blood testing.

The doctors and nurses.

Brig Royd  Surgery.