How We Review Your Long Term Conditions

Our goal is to help you to optimise your long term health, making sure you are booked in with the most appropriate clinician in the right timeframe. 



Who is involved in my care?

There are many people involved in ensuring you get the best care for your long term condition. 

Recall Team Patient Services Team Nurses and Allied Health Team

Including Pharmacists, Paramedics, Nurses, Healthcare Assistants and Nursing Associates. 

We have a dedicated Recall team who are there to ensure patients are invited for their annual reviews and booked with the appropriate clinicians. 

Our Recall team will remind you if your Annual Review is due so that we can help you manage your condition. 

If you haven't responded, we will send you reminders. This is because we want to make sure:

  • Your medication is safe to prescribe
  • You are on the appropriate medication
  • Your condition is not deteriorating

It is important that your contact details are up to date, so that we can reach you to book your reviews. If your details have changed, you can inform the practice via our online form Update Contact Details


Text Messages

Our Recall team send text messages to patients with a mobile number who have consented to recieve text messages. This allows you to recieve a message with a link to book your own appointment at a time and date that is suitable for you, without having to queue on the phones! The link on this text expires after 7 days, but you can still call the surgery to book your appointment, rather than waiting for another invite. 

If you do not want to recieve text messages from Moatfield Surgery, please let us know so we can update your consent preferences. You can find out more about how we use your mobile number and email address on our website page Your Mobile Number & Email Address

How will I be invited for my Annual Review and What is involved?

Your Annual Review will look different depending on your condition. Some of the most common conditions we review are listed below: 

Mental Health

You will be sent a text message link, or will be called to book a blood test and to provide your Weight, blood pressure, BMI, Alcohol intake and Smoking status. 

Your blood test will be done with one of our healthcare assistants and your GP will review your results. 

Why Do I Need an Annual Review?
  • To check you are on the correct treatment plan
  • To assess risk of and prevent other conditions such at Diabetes, High Blood Pressure and Heart Attacks.
  • To make sure you are getting the appropriate support. 


We will send you a text message link to ask about your asthma, or send an asthma questionnaire in the post. 

Our clinical team will review your answers.

If everything is okay, you will receive a message. 

If you have identified concerns, or if we think there is a better treatment plan, we will offer you an appointment with an asthma trained clinician to:

  • Check your peak flow
  • Go over Inhaler technique
  • Review your Self Management Plan
  • Discuss any concerns
Why Do I Need an Annual Review?
  • To reduce Asthma attacks, which could be life threatening
  • Reduce asthma symptoms
  • Check your inhaler technique
  • Have a plan to manage your symptoms
  • Keep prescription costs lower
  • Ensure you are on the most efficient and convenient inhaler. 


You will recieve a text with a link, or a call to book in for blood tests to check your blood sugars. 

During your blood test, we will also check your feet, blood pressure, weight, smoking status and alcohol intake. 

Patients with Type 2 Diabetes will be invited to a Group Clinic for a review. 

Patients with Type 1 Diabetes will be invited for a 1-1 review with a clinician, unless they are under secondary care. 

Why Do I Need an Annual Review?
  • Reduce your risk of a heart attack, stroke, foot problems, kidney problems, sight problems & sexual dysfunction. 
  • Discuss your concerns
  • Check your medication is safe and appropriate
  • Share your experience and learn from others. 


We will invite you to a Group Clinic where we will discuss:

  • COPD Exacerbations
  • Inhaler technique
  • Self Management Plan / Better Treatment Plan
  • How to manage breathlessness
  • discuss any concerns
  • consider pulmonary rehab
  • support in stopping smoking
  • sharing experience with others
  • check your oxygen levels
Why Do I Need an Annual Review?
  • Try to reduce COPD Exacerbations, which could be life threatening
  • Check Inhaler technique
  • Discuss rescue packs
  • Manage COPD Symptoms
  • Check you are on the most efficient and convenient inhaler
  • Know the normal oxygen level for you
  • Have a plan to manage symptoms

Hypertension (High Blood Pressure)

We will send you a link to ask for your blood pressure. You can take a reading at home, or use the Blood Pressue Pod at the Surgery. 

Our clinical team will review your reading. 

If everything is okay, we will send you a message. 

If your blood pressure is slightly too high, we will ask for a 7 day diary so that our clinical team can review your average blood pressure. 

You will be invited to a Group Clinic where we will discuss:

  • Blood Pressure targets
  • Risk of Kidney Problems
  • Heart Risk
  • Medication
  • Care plans
  • Share your experience with others
Why Do I Need an Annual Review?
  • Reduce your risk of a heart attack, stroke and kidney failure
  • Check your medication is safe and appropriate
  • Get your blood pressure to target. 






Last Reviewed 20/05/2024