ANNUAL FOLLOW UP INFORMATION
We are looking to revamp our system for monitoring patients with long term conditions to try to reduce repeat appointments, multiple trips to the surgery and time spent chasing patients for reviews.
In turn we hope this will free up appointments for other issues and improve everyone’s access to care.
We are aiming for everyone to have their annual reviews in the month of their birthday – this would include annual blood tests, HCA, nurse and doctor reviews.
This may mean that this year some patients are called earlier than a year after their last review and some slightly later.
We however need your help for this to run effectively.
If your birthday is coming up you are welcome to pre-empt and call to arrange your reviews.
If you get sent a reminder please follow the instructions – we spend a lot of time chasing patients to book appointments, share BPs, have their annual blood tests etc and this takes us away from other clinical work.
Please try to find out what routine follow up you require for your condition and share the responsibility of managing your health with us.
Please note that this is a new process which we only started in April therefore there may be some duplication in communication. This process is new to all clinicians and the administration team. There is a manual element to this process to remove patients from recalls after reviews have been done so if you have had all your reviews and tests but are still receiving messages, please kindly inform the reception team and we will review your notes as we may just need to manually tick a box. We understand this may be frustrating, however this new way of working will help everyone involved, and will have many long term benefits.
The below doesn’t cover all conditions and medications but it covers the majority and what your annual requirements would be.
|Condition||Blood tests||Annual appointments||Other|
|Hypertension||Annual||6 monthly BP readings Annual early morning urine|
|Heart failure||Annual||Review with clinical pharmacist|
|Stroke/Transient ischaemic attack (TIA)||Annual||6 monthly BP readings|
|Asthma||Text review||Tel call or face to face with asthma nurse if concerns raised on text|
|Chronic obstructive pulmonary disease (COPD)||Face to face with COPD nurse|
|Diabetes||Annual||Face to face with Health Care Assistant Tel call with diabetes nurse||Frequency of assessment may be shorter if poor control or complications, will be advised individually|
|Dementia||Care Coordinator review|
|Depression||6 monthly text review||2 yearly face to face or tel call with doctor, more frequent if concerns raised in text response or more complex case|
|Other mental health condition||Annual||Questionnaire completion Health Care Assistant review Doctor review|
|Rheumatoid arthritis||Annual||Tel call nurse|
|Chronic kidney disease||Annual||Annual early morning urine 6 monthly BP|
|Medication||Blood test||Annual appointments||Other|
|Disease modifying ant rheumatic drugs (DMARDs)||Frequency varies|
|Direct Oral Anticoagulants (DOAC) – rivaroxaban, edoxaban, apixaban, dabigatran||Frequency varies||3 monthly review needs a routine blood test.|
6 & 12 monthly reviews needs a 20min HCA appointment.
|Hormone Replacement Therapy||1st review 3 months after starting – tel call with nurse Annual reviews thereafter via text||Annual BP & weight|
|Contraceptive pills||1st review 6 months after starting Annual reviews thereafter via text||Annual BP & weight|
We are aiming to do all your blood tests at the same time so you only have to come in once for all your conditions rather than multiple trips to monitor each condition/drug separately.
Please help us by being aware of your medication and if you are having blood tests for one condition check with the phlebotomist about adding others at the same time, we will also be working hard to do this from our end too.
Cuckfield Medical Practice & The Vale Surgery