Managing Chronic Diseases

We offer a range of clinics and services here at West End Surgery to help manage chronic diseases.

If you have a longterm (chronic) condition, you should make sure that you attend a review of your condition. This will prevent your condition deteriorating and make sure you are taking the best medications.

Please note that if you do not attend a review, we may not be able to give you your medications because we cannot know if it is safe to continue the medications.

Please note that you may still need to see the GP if you are being seen by the hospital specialist because the GP does additional checks.

We always try to remind you when you are due a review by calling you, sending a letter, sending a text message, or putting a reminder on your repeat prescription script.

We also rely on you to take responsibility for your own health-if you have noticed you have not had a review and think you need one, please make a routine appointment.

Below is a list of longterm (chronic) conditions, when you should come for a review, and what the review involves. This is not a full list and a doctor will advise you.

Diabetes ·       Blood test every 6 months. This may need to be done more frequently if you condition is not controlled.

·       Urine test every year.

·       Blood pressure check every every year.

·       Eye test (“retinal screening”) every year.

·       Annual check with the nurse every year- this will include a check of your feet. Please note that you still need this check if you are being seen by the hospital specialist because this includes additional checks.

Pre-diabetes (“borderline” diabetes) ·       Blood test every year.

·       Annual check with the nurse every year

Cancer ·       We would like you to see the doctor within 6 months after first diagnosis.
COPD ·       Annual check with the nurse every year- this will include a breathing test called spirometry.

·       The doctor may want to see you more frequently if your condition is not controlled.

Asthma ·       Annual check with the nurse or doctor every year.

·       The doctor may want to see you more frequently if your condition is not controlled.

Hypothyroidism ·       Blood test every year.
Subclinical hypothyroidism (“borderline” hypothyroidism) ·       Blood test every 1-2 years (the doctor will advise you).
Rheumatoid arthritis ·       Annual check with the doctor every year. Please note that you still need this check if you are being seen by the hospital specialist.

·       You may need regular blood tests if you are on special medication (“DMARDs”). The doctor will advise you.

Mental health problems such as bipolar, schizophrenia or other psychoses (NOT depression or anxiety) ·       Annual check with the doctor every year. Please note that you still need this check if you are being seen by the hospital specialist because this includes additional checks.

·       Blood test every year.

·       Blood pressure check every year.

Pill/oral contraception ·       Review after 3 months after starting, review every 6 months thereafter with the doctor or nurse.
Coil ·       You should have the coil removed after a period of time, usually 5 years (the doctor will advise you).
Ring pessary ·       Review and change every year.
Depot (injection) contraception ·       Remember to book the injection every 12 weeks.
Vitamin B12 deficiency ·       Injection with the nurse every 3 months. There is no benefit of having an injection earlier or having a repeat blood test.
Depression ·       We would like you to see the doctor within 2-8 weeks after the first diagnosis or as agreed by the doctor.  We will not be able to give you further medication if you do not see a doctor for a review.

·       On longterm antidepressants- review with the doctor every year.

Kidney disease ·       Blood test every year.

·       Blood pressure check every 6 months.

·       Urine test every year.

Heart disease including previous heart attacks, angina ·       Blood test every year.

·       Blood pressure check every year.

·       Annual check with the doctor every year.

Stroke, TIA (transient ischaemic attack or “mini-stroke”) ·       Blood test every year.

·       Blood pressure check every year.

Peripheral vascular disease ·       Blood test every year.

·       Blood pressure check every year.

HRT (hormone replacement therapy) ·       Blood test every year.

·       Blood pressure check every year.

·       Annual check with doctor or nurse every year.

Hypertension (high blood pressure) ·       Blood test every year.

·       Blood pressure check every year

Glaucoma ·       You should have a review by a hospital specialist every year who will advise the GP on what medications you should be taking.
Epilepsy ·       You should have a review by a hospital specialist or GP every year.
Dementia ·       Annual check with the doctor every year.
Hepatitis B ·       Blood test every 6 months to 1 year (as advised by the hospital specialist).