Chronic Disease
Chronic Disease Management
Compassionate, ongoing support for long-term conditions.
If you are experiencing a diabetic emergency, severe chest pain, difficulty breathing, or any life-threatening symptoms, please call 999 immediately. For urgent but non-life-threatening concerns, contact NHS 111.
Quick answer
Chronic disease management at AtWell provides structured, proactive support for conditions including diabetes, asthma, COPD, hypertension, heart disease, thyroid disorders, and autoimmune conditions. Regular reviews, medication management, lifestyle guidance, and specialist referrals — all with a GP who knows you.
About this service
Living with a long-term condition is a lifelong commitment, and you shouldn’t have to navigate it alone. Our chronic disease management service provides consistent, proactive care for conditions including diabetes, asthma, COPD, hypertension, heart disease, thyroid disorders, and autoimmune conditions. We don’t just manage your condition — we work with you to understand it, adapt to it, and live well alongside it. Through regular structured reviews, careful medication management, personalised lifestyle support, and specialist referrals when needed, we keep you ahead of your condition rather than reacting to it.
Who is this for?
Anyone living with a long-term condition who wants consistent, proactive care — whether newly diagnosed or managing a condition for years. No referral needed.
What to expect
Regular structured reviews to monitor your condition and adjust your care plan. Medication reviews to ensure you’re on the most effective regimen with minimal side effects. Lifestyle planning tailored to your condition, covering nutrition, activity, stress, and sleep. Specialist referrals when needed, with supporting documentation and clear communication.
Your journey, step by step
Initial assessment
A thorough 30-minute consultation to understand your condition history, current medications, lifestyle, and goals. We review any recent test results and establish a baseline.
Personalised care plan
We create a structured care plan tailored to your specific condition, setting clear review intervals, monitoring targets, and lifestyle goals.
Regular structured reviews
Scheduled appointments to monitor your condition, review blood results, adjust medications, and assess how you’re feeling. Frequency is tailored to your needs.
Medication management
Careful, ongoing review of your medications — checking effectiveness, managing side effects, and coordinating with any specialists or your NHS GP.
Lifestyle & specialist support
Personalised lifestyle guidance and referrals to specialists when your condition requires additional expertise, with clear communication at every step.
Conditions we treat
Hover to learn more about each condition.Tap a condition to learn more.
Diabetes (Type 1 & 2)
Blood glucose monitoring, HbA1c targets, medication review, dietary guidance, and complication screening.
Asthma
Inhaler technique review, trigger management, action plans, and lung function monitoring.
COPD
Symptom management, inhaler optimisation, pulmonary rehabilitation referrals, and exacerbation planning.
Hypertension
Blood pressure monitoring, medication adjustment, lifestyle guidance, and cardiovascular risk assessment.
Heart disease
Ongoing monitoring, medication management, secondary prevention strategies, and cardiology liaison.
Thyroid conditions
Hypothyroidism and hyperthyroidism monitoring, dose optimisation, and symptom management.
Autoimmune conditions
Ongoing support for conditions including rheumatoid arthritis, lupus, and inflammatory bowel disease, with specialist co-management.
Our services
Book an appointment to see pricing and availability.
“I’ve had type 2 diabetes for six years, and my appointments at AtWell are the first time I’ve ever felt genuinely in control of it. My GP takes the time to explain everything, adjust my medication when needed, and actually asks how I’m feeling as a person — not just as a patient.”
Frequently asked questions
Yes. Many of our patients see us alongside their NHS GP for more frequent reviews, longer appointments, or faster access. We can communicate with your NHS practice with your permission, ensuring your care is joined up.
This depends on your condition and how well it is controlled. Some patients benefit from monthly reviews; others are well-managed with quarterly check-ins. We agree the right frequency with you at your initial appointment and adjust it as your condition evolves.
Absolutely. Many people live with multiple conditions, and we take a holistic view of your health. Your care plan will address all your conditions together rather than treating them in isolation.
If your condition requires specialist input, we will provide a detailed referral letter and, where possible, recommend both NHS and private pathways so you can choose the route that suits you best.
Yes. We can prescribe, adjust, and manage medications for your condition. Electronic prescriptions are sent to your chosen pharmacy. For controlled medications, paper prescriptions are available from reception.
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Learn moreReady to book your chronic disease appointment?
Available regular reviews. No referral needed.