Proactive chronic disease management for GP practices, PCNs, Federations and ICBs across England, structured reviews, medication adjustments, lifestyle advice and reliable follow-up that keep patients well and out of crisis.
Structured reviewse.g. hypertensionGP-led oversightYour pathwaysReliable follow-upPatients on track
Review → adjust → follow up → keep patients stable
ProactiveStructured reviews
GP-ledGoverned & indemnified
Proactive chronic disease management
Long-term condition clinics that keep patients well
NovaClinic long-term condition clinics give your practice dedicated clinical time for the patients who need regular, structured care. Our clinicians proactively manage chronic conditions such as hypertension, reviewing each patient, checking how well their condition is controlled and acting before problems escalate. Our DM037 and diabetes care-process guide covers a related recall and recording challenge.
Proactive review keeps patients stable and out of crisis, easing the pressure that unmanaged long-term conditions place on your appointment book and on urgent care.
Each clinic is built around structured, personalised care that fits your existing pathways. Rather than a one-off appointment, patients receive a clear plan: a review of their condition, any medication adjustments that are clinically indicated, practical sick-day guidance for when they are unwell, and lifestyle advice tailored to them. Reliable follow-up arrangements keep them on track between reviews.
Structured reviews of chronic conditions such as hypertension.
Medication adjustments where clinically indicated.
Sick-day guidance and clear, personalised lifestyle advice.
Reliable follow-up arrangements to keep patients on track.
“Client testimonial
Our hypertension reviews are finally proactive rather than reactive, and the register data has never looked cleaner.
Long-term condition management only works when it is consistent, so our clinicians follow your protocols for reviews, recall and referral and record everything in your clinical system. That keeps your GPs in oversight, supports accurate recall and helps with data quality for chronic disease registers, all under GP-led governance.
The clinic runs as a seamless extension of your team, not a detached service.
Works to your existing protocols and clinical system.
Supports accurate recall and chronic disease register data quality.
Delivered under GP-led governance with your GPs retaining oversight.
“Client testimonial
Follow-up actually happens now. Patients stay on track between reviews and we see far fewer crises.
PPriyaNurse Team LeadVerified NovaClinic client
Who it's for: GP practices, PCNs, Federations and ICBs across England that want proactive, structured chronic disease management delivered to their own pathways.
70%*
Needs resolved remotely
Across NovaClinic, around 60–70% of patient contacts handled without a face-to-face slot
25k+
Appointments saved
Kept free for the practice each year through proactive review
*Based on real-world results achieved at some GP practices. Actual figures vary by list and case mix.
Questions
Long-term condition clinic FAQs
Which long-term conditions can NovaClinic clinics manage?
NovaClinic runs proactive clinics for chronic conditions such as hypertension, with structured reviews, medication adjustments, sick-day guidance and lifestyle advice. Clinics are designed around your practice's priorities and pathways, so we focus on the long-term conditions where you most need capacity.
How do long-term condition clinics fit into our existing pathways?
Each clinic is built around your existing pathways and clinical system rather than replacing them. Our clinicians follow your protocols for reviews, recall and referral, and record everything in your system, so care stays consistent and your GPs retain oversight under GP-led governance.
Do patients get proper follow-up after their review?
Yes. Reliable follow-up is central to the service. After each review our clinicians arrange the next steps, repeat monitoring, medication changes or a further appointment, so patients stay on track and are less likely to reach crisis, keeping them well and out of urgent care.
Tell us which chronic disease registers need capacity and we'll design proactive clinics around your pathways. Please share business information only. Do not include patient-identifiable details. Every analysis includes a written report from a Lead Clinician, free, with no obligation.