Long-term condition clinics
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.
reviews
indemnified
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.
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.
Personalised care that fits your practice
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.
Who it's for: GP practices, PCNs, Federations and ICBs across England that want proactive, structured chronic disease management delivered to their own pathways.
*Based on real-world results achieved at some GP practices. Actual figures vary by list and case mix.
What practice teams tell us
"The service and support received has helped us out greatly whilst we were short staffed."
"Our hypertension reviews are finally proactive rather than reactive, and the register data has never looked cleaner."
"Follow-up actually happens now. Patients stay on track between reviews and we see far fewer crises."
Long-term condition clinic FAQs
Which long-term conditions can NovaClinic clinics manage?
How do long-term condition clinics fit into our existing pathways?
Do patients get proper follow-up after their review?
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Manage long-term conditions with NovaClinic
Tell us which chronic disease registers need capacity and we'll design proactive clinics around your pathways. All enquiries are completely confidential and never shared with third parties. Every analysis includes a written report from a Lead Clinician — free, with no obligation.