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Post-COVID recovery: proactive care, self care and CVD prevention

15 February 2021 | By Dr Matt Kearney and Laura Boyd
A major concern for general practice is how to continue with the essential covid response while providing proactive care to patients who are at highest risk of deterioration.

Last year, the arrival of coronavirus transformed primary care overnight. GPs and their teams now deliver care in very different ways, much of it remotely. The latest covid surge and the vaccine programme has placed huge new demand on practices and primary care networks.

Much staff time is now diverted to managing patients with coronavirus and to delivering the vaccine roll out.

This is the right emergency response, but there is a high risk that continued disruption to routine proactive care in conditions such as diabetes, hypertension, cardiovascular disease, COPD and asthma will drive a big increase in exacerbations and complications. Patients with these conditions depend on regular review and optimisation of treatment to keep them well and to prevent deterioration.

It is likely that disruption of clinical pathways will drive further waves of demand over the coming months both in primary care and in hospital admissions for heart attacks, strokes, heart failure, asthma and COPD exacerbations.

A major concern for general practice is how to continue with the essential covid response while providing proactive care to patients who are at highest risk of deterioration.

Frameworks and practical support for the primary care workforce

To help primary care to manage this challenge, UCLPartners has developed a series of proactive care frameworks for the management of long-term conditions in this new world of primary care. The frameworks focus on how to do things differently at scale: they enable practices to prioritise clinical activity by stratifying patients who are at highest risk; they deploy the wider workforce to reduce the workload for GPs; and they improve the personalised care offer for patients.

The frameworks cover four cardiovascular conditions (atrial fibrillation, high blood pressure, high cholesterol and type 2 diabetes) and two respiratory conditions (asthma and COPD). They are built around four key principles: virtual by default; mobilisation of the wider workforce; a step change in support for self-management; and underpinning by digital and other resources.

For each condition, the framework includes:

  • Comprehensive GP search tools to stratify patients into risk cohorts.
  • Pathways for local adaptation that prioritise high risk patients for follow up, maximise remote delivery of care, and distinguish the elements of proactive care that can be delivered by staff such as clinical pharmacists, healthcare assistants, social prescribers, nursing associates and others with appropriate training.
  • Scripts and protocols to guide these staff in consultations to deliver patient education, self-management support and brief interventions for lifestyle change.
  • Training that includes health coaching and motivational interviewing to equip the workforce to support more personalised care.
  • Digital resources and technologies that support remote care and self-care.

How do these work in the real world?

How do the frameworks work in practice? If we take blood pressure as an example, patients with hypertension are automatically stratified according to their last blood pressure into priority groups that indicate who needs to consult a GP, pharmacist or nurse soon, and whose follow-up can safely be phased to later months.

In their consultations (virtual by default), the clinicians optimise blood pressure control, manage co-morbidities and address broader cardiovascular risk.

The healthcare assistant, social prescriber or nursing associate has a separate video consultation with the patient and shows them where to buy a valid and affordable blood pressure monitor (or to access a free monitor if available) and how to use it correctly. If the patient does not have digital access or is unable to measure their blood pressure, arrangements are made for face-to-face consultations.

To support the clinician’s consultation, the healthcare staff collate key information such as blood pressure, weight, and smoking status. They arrange routine blood tests and run automated risk scores such as QRisk2.

They share excellent patient resources from the British Heart Foundation website to help the patient understand blood pressure and cardiovascular risk. If needed they can teach them how to test their urine for protein using a smartphone and digital app. And they provide brief interventions and signposting for smoking cessation, alcohol, diet and physical activity.

Protocols to support staff in delivering these personalised care consultations have been developed for each of the six conditions. A unified protocol has also been developed for atrial fibrillation, blood pressure, cholesterol and type 2 diabetes so that patients with multiple cardiovascular conditions can have a single consultation.

Gaining traction across England

The UCLPartners Proactive Care Frameworks have been widely welcomed by GPs and primary care networks, with growing uptake in North London, Yorkshire, Cheshire and Merseyside, East Midlands, East of England, Wessex, West of England and other areas.

UCLPartners, the Innovation Agency and East Midlands Academic Health Science Network are now working with the NHS@Home programme and with NHSX to test a structured roll out of the frameworks across four integrated care systems.

One reason for this rapid traction is that the frameworks are visibly grounded in primary care, with development led by GPs and pharmacists. They also address an urgent and pressing question for GPs: how do we provide essential and urgent care to our high-risk patients with long-term conditions while responding to the covid surge and delivering the vaccination programme?

These frameworks go beyond guidance and dashboards – they focus less on the what to do and more on the how to do it in real world, with practical systematic support to overcome entrenched barriers to optimal care.

Empowering the primary care workforce

GPs across the country are rising to the challenges of the pandemic, and they are rising to the new opportunities to transform the way care is delivered. The UCLPartners Proactive Care Frameworks are helping primary care to restore services that have been disrupted by the covid-19 response.

But by supporting workforce transformation and providing a comprehensive structure for “doing things differently” they enable practices and networks to focus on optimising clinical care and self-care in long-term conditions and reducing unwarranted variation.

Despite the disruption caused by the pandemic, this approach provides a major new platform for delivering the NHS long-term plan priority for cardiovascular disease prevention to prevent heart attacks and strokes at scale.

This blog was first published in the HSJ.