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Doing things differently to help GPs transform care and reduce demand

1 November 2021 | Dr Matt Kearney
Matt Kearney on supporting primary care to do things differently and at scale as we emerge from the pandemic. Discussing the expansion of NHS Proactive Care @home, and how the UCLPartners Proactive Care Frameworks assist to deliver optimised care for long term conditions.

This month sees a major expansion of NHS Proactive Care @home. This national support offer provides a systematic framework for the transformation of long-term condition management in primary care as local systems build their post-COVID recovery. The offer is built around the UCLPartners Proactive Care Frameworks that adopt a population health management approach — with risk stratification and prioritisation, and support for the wider primary care workforce to personalise and optimise care. Proactive Care @home has been adopted in four integrated care systems (North East London, North Central London, Cheshire and Merseyside, and Leicester, Leicestershire and Rutland), and is now extending to nine further ICSs in wave 2.

The COVID-19 pandemic brought an unprecedented overnight change in primary care with a widespread shift to remote management and necessarily reduced face-to-face access, together with surging clinical demand linked to coronavirus infection. This has caused severe disruption to routine proactive care in high impact conditions such as cardiovascular disease, hypertension, diabetes and COPD, with patients missing out on the regular assessment, testing and adjustments to treatment that keep them well and minimise exacerbations and complications. These are the conditions that drive emergency admissions to hospital and premature mortality from heart attack, stroke, and respiratory disease. While also dealing with the current pressures in primary care, GPs are concerned that this persisting disruption to long-term condition management will fuel further waves of demand for urgent care in the coming months.

The Proactive Care Frameworks are being welcomed in general practice because they help GPs to restore routine long-term condition management and free up capacity while also responding to COVID surges and delivering the vaccination programme. The frameworks support practice teams to do things differently and at scale in the new world of primary care post COVID. Six conditions are included: atrial fibrillation, hypertension (supporting Blood Pressure @home), cholesterol, type 2 diabetes, asthma and COPD.

Core components of the frameworks are:

  • Comprehensive search and stratification tools embedded in EMIS and SystmOne to risk stratify patients – this allows GPs to prioritise and phase their workload, answering the question: ‘who do we need to prioritise now, who can we safely phase to later?’
  • Systematic use of the wider workforce to deliver structured support for education, self-management and behaviour change, with training and a range of practical resources and digital tools that support multi-morbidity care.
  • Pathways that utilise pharmacists and nurses to optimise clinical care, and additional roles such as healthcare assistants, health and wellbeing coaches and social prescribing link workers to support remote delivery of care and self-care.

Opportunity to reverse historic undertreatment

Doing things differently as we restore services post COVID also brings the opportunity to reverse the historic under treatment seen in long-term conditions. For example, before the pandemic, despite robust evidence that much cardiovascular disease could be prevented by optimal management of the high-risk conditions, a third of people with diagnosed hypertension were not treated to target; an estimated 50 per cent of people with the pre-existing cardiovascular disease were on sub optimal or no lipid lowering treatment; and one in five people with atrial fibrillation were not anticoagulated. And in each case, there is substantial geographical variation contributing to health inequalities.

Size of the Prize modelling by UCLPartners for two of the pilot ICSs shows what is feasible. In both North East London and North Central London, improving blood pressure management from current levels to the NHS long-term plan ambition level of 80 per cent would prevent up to 250 heart attacks and strokes in each ICS in three years – and every subsequent three years.

Focusing on the “How To” in real world primary care

In looking for solutions, it is critical to recognise that much suboptimal care in long-term conditions happens because their management is difficult in complex, time-pressured GP consultations where most patients have multiple problems to discuss. The UCLP Proactive Care Frameworks focus less on reiterating the ‘what needs to be done’ and more on the “how to” of delivering optimal management and personalised care in real world primary care.

Taking blood pressure as an example, a practice or primary care network runs the UCLP search tool for hypertension in EMIS or SystmOne. This stratifies patients into four priority groups based on blood pressure level, co-morbidity, age and ethnicity.

A health care assistant (or another of the new additional roles in primary care) uses the framework resources to consult with the patient by text, video or face-to-face as needed, shows where to obtain a valid and affordable blood pressure monitor, helps them understand their condition by signposting to education and shared decision-making information on the British Heart Foundation website, shares a video on how to use the blood pressure monitor correctly, and offers brief interventions and signposting for smoking cessation, physical activity and diet. Taking a holistic approach, the health care assistant can also refer to the social prescribing link worker or care coordinator where appropriate to help meet the patient’s wider health and social needs. In a separate consultation, focusing first on the high priority groups, the clinical pharmacist, nurse or GP checks the blood pressure readings and blood test results, reviews co-morbidities, and optimises the patient’s medication.

This framework approach to proactive care ensures safe prioritisation of patients, improves the personalised care offer with structured support for education, self-management and behaviour change, and releases clinician capacity in this very challenging time for primary care. A number of early adopter ICSs are building the Proactive Care Frameworks into their long-term condition and workforce transformation programmes, supporting local clinical leadership around new models of care and aligning incentives. Adopting a population health management approach, implementation of the frameworks can also be focused across an ICS to target health inequalities by prioritising areas of deprivation and highest risk of poor health outcomes.

By supporting primary care to do things differently and at scale as we emerge from the pandemic, and by transforming delivery of care to address historic barriers to optimal management in these high impact conditions, implementation of the Proactive Care Frameworks will help local systems deliver a central NHS long-term plan ambition: prevention of 150,000 heart attacks, strokes and cases of dementia by optimising treatment in atrial fibrillation, blood pressure and cholesterol (the ABC of CVD prevention).

All of the Proactive Care Framework resources are free and can be accessed at

This blog was first published in the HSJ.