How to build a monthly LTC recall plan

Start with clinical priorities and a dated list

A birth-month recall system can help organise routine reviews, but it should not decide when a particular patient needs care. Use the appropriate clinical guidance, local protocols and individual care plan to establish what is due. Urgent concerns need the practice’s usual escalation process, outside the monthly planning cycle.

Choose a named owner for the plan and a clinical lead for questions about priority or suitability. Record the extract date so everyone knows how current the worklist is. Separate due work, overdue work and records needing clarification; a missing code may need checking before another invitation is sent.

Look at the whole patient before booking

Bring the person’s outstanding tasks together. Check what can reasonably be done in one visit, what needs results first and which reviews require another professional. Confirm suitability and the patient’s preferences before combining appointments.

NICE’s multimorbidity guidance asks professionals to consider treatment burden, including appointments, and agree an individualised plan. It does not mean every review should be combined or delayed until a convenient clinic. Read NICE NG56.

• Check whether the task has already been completed or arranged elsewhere.
• Identify prerequisites, such as results needed before a review.
• Flag housebound patients and people who need a different appointment setting.
• Keep a visible route for a clinician to resolve uncertain or conflicting information.

Match invitations to real capacity

Count the work by role, then estimate appointment time using your practice’s agreed durations. Include administrative contact work, clinical review of results and follow-up. An available blood-test appointment does not automatically mean there is capacity for every later step.

Agree an invitation batch that the team can support, keeping capacity for urgent and unexpected work. Review any gap between demand and available time with the practice lead. The purpose is to make the gap visible early, rather than hide it by moving clinically necessary due dates.

See how AegisRX presents practice capacity, including a clearly labelled worked example.

Give contact and non-response a clear owner

Before contacting someone, check current contact details, communication needs and recent invitations. Avoid sending another message just because two separate condition lists contain the same person.

Use an accessible contact route. NHS England’s Accessible Information Standard describes how services should identify and meet information and communication needs related to disability or sensory loss. Read the standard.

Record who follows up an unanswered invitation, a declined appointment or failed contact, and when. Follow the practice’s approved clinical and recall policies; there is no universal number of messages that makes every unresolved case safe to close.

Check recorded care, not just messages sent

Keep invitation, booking, attendance and completed care as separate states. The responsible professional should record the care delivered and any agreed next step in the clinical record. A sent message is evidence of contact activity; it does not demonstrate that monitoring happened.

At the next review, reconcile the fresh extract against outstanding work. Investigate items that remain open: the patient may still need care, a result may be outstanding, or the recording may need correcting. Review exceptions with the appropriate professional.

Track a small set of consistent measures: outstanding patients and tasks, overdue work, completed recorded care, unresolved contact attempts and staff time. Keep the date, scope and denominator alongside each figure so changes are interpretable.

Your monthly planning checklist

1. Owner: a named person coordinates the plan and a clinical lead resolves concerns.
2. Scope: the list has an extract date, agreed pathways and checked exclusions.
3. Priority: safety concerns follow the appropriate escalation route.
4. Appointments: suitable tasks are grouped and matched to available roles and time.
5. Contact: accessible invitations and non-response follow-up have owners.
6. Completion: recorded care is reconciled with the next list and unresolved work stays visible.

In AegisRX, pharmacist-run EMIS searches support a weekly or monthly reporting cycle. Your practice uses the lists, contacts patients and records care; the service reads the records without writing back. See the service workflow.