Last review date 03/02/2023

LTC Reviews


Setup (Legacy Only)

Setup (QOF & Best Practice / QOF Only)

Sending Invitations

Booking Appointments

Sending Reminders

Pre-assessment Questionnaires

Initial Review & Tests

Follow-Up Review

Interim Reviews

Exception Reporting

LTC Reporting

LTC Review - FAQ

Ardens offers a comprehensive approach to Long Term Conditions Reviews. Clinical reports & months of birth are used to send invitations to patients and a single template can then be used to record the review. Watch the overview video below for a brief summary of the LTC Review process and then also watch the full video below too. The online resources here should guide you through the LTC process but we also advise you to book some LTC Review training at your surgery for all your staff too.

PLEASE NOTE:  Due to the recent QOF Invitation changes made by NHS England for 2023/24, please see our Changes to the LTC QOF Invitation Codes Support Article for more details.

!!NEW - LTC Review Conditions Included 

For 2023/2024, additional conditions have been included. The existing 'Legacy' group of reports and conditions still remains for practices to still use if they wish. Practices can now however:

  • Manage separately dementia, LD, care home & housebound patients
  • Choose between recalling just QOF or QOF + Best Practice conditions

Please note that just the updated invitation reports have been published for sending invites in March for reviews in April. The updated LTC review template will be published for the start of April.


Conditions Dementia, Learning Disability
HousingCare home resident or housebound




HTN + Pulse:    HTN, AF
Cardiovascular:CHD, CHF, PAD, CVA/TIA
Diabetes:DM1, DM2, NDH/Pre-Diabetes, Gestational Diabetes
Renal:CKD 1-5
Mental Health:SMI
Respiratory:Asthma (if bronchodilator issued in last year), COPD
Other:Rheumatoid Arthritis, Epilepsy (if antiepileptics issued in last year)


Cardiovascular:CVD-Primary Prevention (on statin or QRISK2/3 >10%), Familial Hypercholesterolaemia
Endocrine:Hyperthyroidism, hypothyroidism, primary hyperparathyroidism
Gastrointestinal:Coeliac Disease, Post-Bariatric Surgery
Haematology:Monoclonal Gammopathy of Unknown Significance (MGUS)
Liver:Non-Alcoholic Fatty Liver Disease (NAFLD + NASH)
MSK:Gout + on ULT


HTN+ Pulse:    HTN, AF
Cardiovascular:CHD, CHF, PAD, CVA/TIA
Diabetes:DM1, DM2, NDH/Pre-Diabetes, Gestational Diabetes
Renal:CKD 1-5
Mental Health:Bipolar, Dementia, Learning Disability, Psychosis
Respiratory:Asthma (if bronchodilator issued in last year), COPD
Other:RA, Coeliac Disease, Severe Frailty, Post-Bariatric Surgery

To view our recent Live webinar explaining the new LTC Process in more detail, please click on the below video:

LTC Pre-Appointment Tests Included 

For a summary of the pre-appointment tests that are requested, please see here.

Sending Invitations Using Reports

Ardens use reports, not recalls, for sending invitations as reports are not reliant on users adding/superseding/removing recalls. They also do not require time to maintain if a new patient registers or a practice merges. Reports also ensure only a single invitation is sent to a patient with multiple co-morbidities.

Please note:

• A new patient must be reviewed at the time of registration. 

• A new diagnosis must be reviewed at the time of diagnosis. 

• Good data quality is required for new & resolved diagnoses (see here

• The system is reliant on a single read code Xaagy – Chronic disease management annual review completed being added after the annual review is completed. This is to ensure that 2nd or 3rd invites are not sent out. 

• Whilst invitations are only sent annually, some conditions require more frequent review. Additional reviews should be booked at the time of the previous appointment. 

• This is not an all-encompassing solution for every condition & circumstance. Clinical expertise and judgement is still required at all stages. It is the practice’s responsibility to check the reports/templates/alerts prior to commencing the LTC review process.

NEXT: Setup