Standard operating procedure

Recall & Long-Term Condition Monitoring Procedure

How [Organisation Name] maintains disease registers, recalls patients for structured reviews, monitors high-risk medicines and operates a failsafe so that no patient's monitoring is missed.

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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Disease registers
  • 6. Procedure
  • 7. Coding and data quality
  • 8. Records
  • 9. Audit
  • 10. Related documents
  • 11. Review and version control
  • 12. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 - Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance)
  • National Institute for Health and Care Excellence (NICE) guidance on the relevant long-term conditions (for example type 2 diabetes in adults NG28, hypertension in adults NG136, asthma NG245, chronic obstructive pulmonary disease NG115, and chronic kidney disease NG203)
  • Quality and Outcomes Framework (QOF), as set out in the applicable primary medical services contract for the relevant year
  • General Medical Council, Good practice in prescribing and managing medicines and devices (2021)
  • Data Protection Act 2018 and the UK General Data Protection Regulation

Who it applies to

All staff at [Organisation Name] involved in the care of patients with long-term conditions, including GP partners, salaried and locum GPs, advanced nurse practitioners, practice nurses, healthcare assistants, clinical pharmacists and pharmacy technicians, the long-term condition / recall lead, and the administrative, data quality and reception staff who run searches, send invitations and code activity.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Albumin:creatinine ratio (ACR)
A urine test that detects small amounts of protein, used to check for early kidney damage.
Amiodarone
A heart-rhythm medicine that needs regular monitoring because it can affect the thyroid, liver and lungs.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Chronic kidney disease (CKD)
A long-term condition in which the kidneys gradually work less well over time.
Chronic obstructive pulmonary disease (COPD)
A long-term lung condition that makes breathing difficult, usually caused by smoking.
Clinical coding
Recording a diagnosis or activity in the patient record using a standard code so it can be searched and counted.
Data Protection Act 2018
The UK law that governs how organisations collect, store and use people's personal information.
Disease register
A searchable list of patients recorded as having a particular long-term condition, used to plan and monitor their care.
Disease-modifying anti-rheumatic drug (DMARD)
A medicine used to control conditions such as rheumatoid arthritis, requiring regular blood monitoring because of its side effects.
DNA (did not attend)
A record that a patient missed a booked appointment without cancelling it.
Estimated glomerular filtration rate (eGFR)
A blood-test result that estimates how well the kidneys are filtering, used to stage kidney disease.
Failsafe
A backstop process that catches patients who remain overdue a review or monitoring so that nobody is missed.
Full blood count
A common blood test that measures red cells, white cells and platelets to check general health.
General Medical Council (GMC)
The body that registers doctors in the UK and sets the standards they must follow.
General Medical Services (GMS) contract
A standard national contract under which many general practices provide primary medical services.
HbA1c
A blood test showing average blood sugar over the past two to three months, used to monitor diabetes.
High-risk medicine
A medicine that needs defined blood or other monitoring to be used safely, such as methotrexate, lithium or amiodarone.
Housebound patient
A patient who cannot attend the practice and is reviewed and monitored at home.
Lithium
A medicine used in some mental health conditions that needs regular blood monitoring because the safe and harmful doses are close together.
Long-term condition
A health condition that cannot currently be cured and is managed over time, such as diabetes or asthma.
Methotrexate
A disease-modifying medicine used for conditions such as rheumatoid arthritis that requires regular blood monitoring.
National Institute for Health and Care Excellence (NICE)
The body that produces evidence-based guidance on treatments and care for health and social care in England.
Near miss
An event that could have caused harm but did not, by chance or because it was caught in time.
Non-medical prescriber
A trained health professional, such as a nurse or pharmacist, who is qualified to prescribe medicines.
Phlebotomy
The taking of a blood sample for testing.
Quality and Outcomes Framework (QOF)
A national scheme that rewards general practices for managing long-term conditions to defined standards.
Recall
The process of inviting a patient to attend for a review that is due.
Records Management Code of Practice
National guidance setting out how long health and care records should be kept and how they should be managed.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Renal function
How well the kidneys are working, measured through blood and urine tests.
Risk assessment
A structured check identifying what could cause harm and what is being done to prevent it.
Safeguarding
Protecting people's health, wellbeing and rights and keeping them safe from abuse, harm or neglect.
Secondary care
Specialist hospital or clinic services that a patient is usually referred to, rather than the general practice.
Shared-care agreement
A written arrangement setting out how a hospital specialist and the general practice share responsibility for prescribing and monitoring a medicine.
Spirometry
A breathing test that measures how much air a person can move in and out of their lungs.
Standard Operating Procedure (SOP)
A written, step-by-step instruction setting out how a particular task is to be carried out consistently.
UK General Data Protection Regulation (UK GDPR)
The UK's main data-protection law governing how personal information is collected and used.

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