If you live with a long-term condition, having one team that knows you makes a real difference. We set up a written care plan with you, book regular reviews, and coordinate with specialists, pharmacists and allied health so everyone is working from the same page.
What it includes
- A written care plan, reviewed every six months with you
- Diabetes: blood sugar, foot and eye checks, medication review
- Heart disease, high blood pressure and cholesterol
- Asthma and COPD, including action plans
- Arthritis, osteoporosis and chronic pain
- Referrals to dietitians, physiotherapists, podiatrists and diabetes educators
- Nurse-led reviews between doctor appointments
Who it is for
Anyone with a condition expected to last six months or more. Care plans may also unlock subsidised allied-health visits depending on your coverage.
How to book
Ask reception for a care plan appointment. The first one is a long appointment, often with the practice nurse first and then your doctor.
Common questions
What is a care plan?
A written summary of your conditions, your goals, the treatments and checks you need, and who is responsible for each. You get a copy and we review it together regularly.
Do I need to see my usual doctor?
Ideally, yes. Continuity matters for long-term conditions, so we will try to book you with the same doctor each time.