Chronic Disease Monitoring
Our Clinicians have a variety of experience in long term conditions and run daily chronic disease clinics including cardiovascular, respiratory, diabetic care and chronic kidney disease.
We have built a suite of searches to create our own registers of long term conditions or those on long term medication that requires regular monitoring, above those set by QOF standard, to ensure safe prescribing.
We aim to offer annual medication and blood test reviews where necessary, to support patients better manage their health.
The clinical staff undertake regular training to keep up to date with guidance
We have an in-house dietician who helps patients manage their diet
We have given education talks to groups of patients about their condition
It is essential for you to have regular follow-ups, blood tests and review of medication, where appropriate.
Once you have had your blood tests, please book an appointment with the Health Care Advisors who will complete your annual diabetic review, and explain management changes as a result of your blood results.
QOF data for Hillingdon in 2016 shows that we are achieving the lowest average HBA1c for our Diabetic population.
For Diabetics who require more specialist input we offer this service through our Network.
Pre-Diabetes & Diabetes Education for patients:
NDH (Non-Diabetes Hyperglycaemia) patients
DESMOND (within first 12 months of diabetes diagnosis)
MyDesmond (online - ANY duration since diabetes diagnosis)
MyHealth - Managing diabetes workshop
The practice recommends that all adult patients have their blood pressure checked annually.
Please ask the receptionist for a blood pressure check form. Please use the blood pressure machine in the main reception. Follow the instructions and take two readings a few minutes apart. Complete the form and hand the form back to the receptionist. The nurse will record your readings and contact you if you need to be followed up.
If you have been asked to review your blood pressure from home, please use our eConsult to submit your BP readings.
Sometimes the clinician seeing you may need to refer you for a 24 hour blood pressure monitor. More information about this is given in this document -
If you have asthma or use inhaled medications we expect you to have regular reviews. Please complete our Asthma Review Questionnaire (below) as part of your annual review.
This is run by our Clinicians who is highly experienced and trained in the management of asthma. Regular review of your asthma is important to ensure that you understand how to manage your condition and to assess the suitability of your medication.
Asthma Care Plan
Adult Asthma Action Plan
Chronic Kidney Disease
Kidney disease is a very general term used by healthcare professionals to suggest that the kidneys are not functioning in an adequate way. 'Chronic' means a condition that does get completely better. It sounds intimidating but often CKD is only a very slight abnormality. Patients who are diagnosed with CKD are able to receive treatment to prevent other serious conditions from developing. Many people live an active and full life. See the leaflets below for more information.
CKD information leaflet -
Managing CKD -