Skip to content
This website uses cookies to help us understand the way visitors use our website. We can't identify you with them and we don't share the data with anyone else. If you click Reject we will set a single cookie to remember your preference. Find out more in our privacy policy.

Support for long-term condition management during and after COVID-19

9 June 2020 | Dr Matt Kearney

As a result of COVID-19, the way we deliver primary care has changed dramatically. Almost all consultations are done by phone or video. Very few of our patients now come to surgery to see a clinician in person. This overnight change has been an essential response to the pandemic to minimise risk of infection for patients and staff. When the pandemic is over there will inevitably be some increase in face to face consultations, but it is likely that the majority will remain virtual. This is the new normal in primary care.

So, what does this mean for the care of long-term conditions like asthma, COPD, diabetes and hypertension? Proactive management with regular reviews and optimisation of treatment are essential to help patients remain in good health. For many, this comprehensive care has been put on hold. Without structured follow up patients with long-term conditions are more likely to experience deterioration and exacerbations that put them at risk and increase the demand for reactive emergency care. How are we going to maintain high quality long-term condition management in the new world of health care where remote consultation is the norm? Certainly, this overnight transformation presents us with significant challenges. But it also offers opportunities to improve care for our patients as we are forced to innovate and rethink our approach.

To help support this transformation, our primary care team of GPs and pharmacists at UCLPartners have launched a framework to help primary care teams deliver comprehensive proactive care to people with long-term conditions.

To help us adapt to new realities as we respond to and emerge from the pandemic, we have based the framework on four key principles. Firstly, virtual first will be the norm in interaction between patient and clinician. Secondly, the evolving primary care workforce can contribute substantially to ongoing proactive care for patients with long-term conditions. Thirdly, we should use this transformation to achieve a step-change in support for self-management. And fourthly, these new ways of working should be underpinned by digital technologies for the benefit of patients and clinicians.

What is the framework? Starting with asthma and COPD, we have built downloadable search tools for GP systems that stratify patients into high, medium and low risk cohorts. This is achieved by grouping clinical features that are associated with risk of deterioration. The stratification is then used to match a patient’s level of risk to care that is provided. For example, certain clinical features and levels of complexity would indicate that a patient is at inherently high risk and needs to be seen by a GP or clinician with specialist skills, for example a respiratory nurse or pharmacist.  In contrast, patients who are very stable and at low risk of exacerbation may only require support with self-management and lifestyle change. This level of care could be provided by health care assistant, nursing advisor or pharmacy technician with appropriate training.

Self-management support delivered by these staff will include using online videos to demonstrate and check inhaler technique and to teach peak flow measurement; brief interventions and signposting for smoking cessation and physical activity; and using online and digital resources to help patients understand their condition and recognise and respond to deterioration. New staff members currently being recruited to primary care teams around the country – assistants, advisors, technicians etc – will be well placed to deliver these interventions to patients at lowest risk. But they can also deliver these core elements of holistic care to patients in the higher risk groups, thus releasing the time of clinicians to focus on the clinical.

The UCLPartners framework is not fixed. It is designed to be flexed and adapted locally to suit local circumstances and priorities. It is also critical to recognise that new frameworks and technologies alone do not deliver innovation at scale. So UCLPartners is offering to work in partnership with local teams in primary care networks and boroughs to deliver comprehensive implementation support. This will include search and stratification tools built for EMIS and SystmOne; protocols and scripts to guide consultations especially by staff such as health care assistants, nursing advisors, pharmacy technicians etc;  bespoke education and training, including appropriate clinical skills, motivational interviewing and health coaching; development support for pharmacists, nurses and others taking on new roles through professional communities of  practice; and identification and validation of emerging digital resources to support remote monitoring and self-management.

The frameworks for asthma and COPD, together with a range of supporting resources have now been published on the UCLPartners website. Type 2 diabetes, hypertension and other cardiovascular conditions will follow soon.

Dr Matt Kearney

GP and Programme Director, Primary Care Innovation, UCLPartners