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How can GPs effectively care for patients with long-term conditions in the current climate?

20 January 2022 | Dr Matt Kearney and Helen Williams
UCLPartners has built a suite of comprehensive search tools for EMIS and SystmOne that help primary care to safely prioritise care for patients with long term conditions at the same time as responding to the COVID surge and the vaccination programme.

A spotlight on cardiovascular disease prevention

Primary care is under huge pressure, with unprecedented demand driven by the latest wave of coronavirus infection. At the same time GPs and their teams are having to divert substantial staff time to delivering the booster vaccination programme. To try and ease some of the pressure, the Quality Outcomes Framework (QOF) has been partially suspended until April 2022. This of course will release some capacity by freeing staff from non-urgent or lower priority work, but there is also understandable concern at the potential impact of this further disruption on the delivery of routine care.

We know that many patients with long term conditions such as hypertension, CVD, atrial fibrillation and high cholesterol have not received their usual regular review appointments or had their blood pressure checked and may have avoided attending the surgery even when they were unwell. This routine proactive care and timely intervention is what keeps patients well and prevents the deterioration and exacerbations that drive further demand for acute care (e.g. heart attacks and strokes) and worsens patient outcomes.

So, we are acutely aware in general practice that while focusing our resources on responding to the latest surge and delivering the vaccination programme, we also need to look after our patients with long term conditions, initially by identifying those at greatest risk and finding ways to provide the care they need.

Starting with patients with the greatest need

The UCLPartners Proactive Care Frameworks provide search and stratifications tools that GP practices across the country are using to help prioritise patients with the greatest need. The stratification tools have been developed by primary care clinicians using NICE guidance and clinical consensus to stratify patients into high, medium, and lower priority groups. The stratification tools are not just lists of criteria to inform clinical judgement but are comprehensive coded search files that automate the process and produce lists of patients in priority groups. They are free to download and run easily in EMIS and SystmOne. The tools are comprehensive and pragmatic and allow us to answer the question: which of our patients need more urgent review by a clinician in this time when our capacity is so limited? Detailed information about the search tools and prioritisation criteria can be found here.

Supporting proactive care for all patients

Of course, all of our patients, whether at higher or lower risk, need ongoing care. In addition to the stratification tools, the frameworks also include a range of free resources to support self-management and remote management – both for patients who need more urgent appointments and for all other patients whose clinician reviews are less urgent. For example, high quality resources that staff such as health care assistants (HCAs) and care coordinators can use to help a patient to understand their conditions, access an NHS blood pressure monitor or buy a clinically validated and affordable monitor of their own, and to support patients to measure their blood pressure accurately.

Benefits for patients and practices

Taking hypertension as an example, we ran the search in GP systems covering about 500,000 people in London. In this population, over half of patients had normal blood pressure monitored in the last 18 months and so do not need to be seen urgently by a clinician.  18% had blood pressure above 160/100mmHg or above 140/90mmHg with significant related co-morbidities and therefore do need more urgent review. 15% had no record of a blood pressure check in 18 months, and an HCA could contact these patients, help to access a BP monitor if needed and support them to submit blood pressure readings. A further 15% of patients had a blood pressure above 140/90mmHg (but below 160/100mmHg) and their appointments can be scheduled over a manageable time period. And for all patients, proactive care consultations with staff such as the HCA can be provided over time to support self-care and remote care.

GPs are finding that the value of this approach is that it helps greatly to manage workflow at a time when we have such limited capacity, it provides reassurance that we are reaching the patients who most need treatment optimisation, and it offers a structured way to ensure that all patients receive care in an appropriate time frame.

In addition, by focusing first on those in greatest need of treatment optimisation, this approach helps us to improve the quality of patient care, meet our QOF and other targets, and reduce demand for urgent and emergency care – both in hospitals and in practices.

Useful links:

Proactive care frameworks

Our online support package contains tools and resources to help primary care teams to continue to effectively deliver proactive care for patients with CVD and respiratory conditions.

View the frameworks