NCL Long-Term Conditions Case Finding

As part of the NCL LTC LCS programme, practices will identify and support patients at risk of long-term conditions. Eligible patients will be invited for review every three years, excluding those already diagnosed or recently reviewed.

Conditions & Eligibility Highlights:

• Diabetes Risk: Elevated HbA1c, history of gestational diabetes, or high BMI (especially in BAME groups).
• Raised Blood Pressure: BP >140/90 without a hypertension diagnosis.
• Cardiovascular Risk: QRisk ≥10% and not on statins or not on high-intensity statin.
• Chronic Kidney Disease (CKD): Abnormal eGFR/uACR results or at-risk due to comorbidities.
• Atrial Fibrillation (AF): No AF code but on relevant medications or aged 65+ without recent pulse check.
• Asthma in Children/Young People: Prescribed inhalers/steroids or codes for suspected asthma with no diagnosis.
• Heart Failure: On heart failure-related medications or raised NTproBNP without HF diagnosis.

What Patients Can Expect:

• Invitation for Check and Test appointment  relevant tests (bloods, BP, ECG, etc.)
• Diagnosis and coding where needed, review with clinicians
• Lifestyle advice and appropriate referrals (e.g. NDPP, statins, social prescribing)

Please complete the collaboRATE form