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.

How to use the frameworks

Proactive care frameworks

We have developed a series of proactive care frameworks to restore routine care by prioritising patients at highest risk of deterioration, with pathways that mobilise the wider workforce and digital/tech, to optimise remote care and self-care, while reducing GP workload.

The frameworks include atrial fibrillation, high blood pressure, high cholesterol, type 2 diabetes, asthma and COPD.

The frameworks are comprehensive and include:

  1. Comprehensive search tools to risk stratify patients – built for EMIS and SystmOne.
  2. Pathways that prioritise patients for follow up, support remote delivery of care, and identify what elements of long-term condition care can be delivered by staff such as Health Care Assistants and link workers.
  3. Scripts and protocols to guide Health Care Assistants and others in their consultations.
  4. Training for staff to deliver education, self-management support and brief interventions. Training includes health coaching and motivational interviewing.
  5. Digital and other resources that support remote management and self-management.

The frameworks are being implemented by GPs across the country, helping practices to identify who needs priority care, and those whose care can safely be delayed.

These frameworks are designed to be adapted to local context and preferences and have been created following patient and public consultation.  In March 2020 we held a patient and public involvement event, attended by approximately 30 people with high risk CVD conditions, and carers.  The aim of this consultation was to gather insights and information to enable better identification and treatment of people with high blood pressure, atrial fibrillation and high cholesterol in the primary care setting.  Read the feedback from patients in our report.

The CVD LTC and stratification tools are wonderful…super-easy to upload and already in a few days making a difference to patient care and staff resilience in my PCN. Picked up some quick wins and new determination to get things right.

Dr Hannah Morgan, GP and Clinical Director for Hayling Island and Emsworth PCN, South East Hampshire

Download slides describing the support available for all six conditions in detail

The UCLPartners’ tools give us a clear mechanism of risk stratifying patients with long-term conditions, developing the wider workforce, such as pharmacists and HCAs, and have the ability to demonstrate clear improvement in outcomes.

Dr Ken Aswani, Chair of Waltham Forest CCG

Implementation Support

Sitting alongside these frameworks is support for implementation.

For Primary Care teams within the UCLPartners footprint, we can provide support to improve the quality of proactive care for patients with long-term conditions. This includes:

  • Clinical leadership from our team of GPs and clinical pharmacists
  • Project and implementation support from a team of project managers, implementation experts, commercial and innovation leads and quality improvement experts

Our team can provide the following types of support, all of which can be tailored to the needs of your context:

  • Programme management to adapt and embed the frameworks in Primary Care Networks
  • Support for local clinical engagement and leadership
  • Adaption of the frameworks to reflect local pathways
  • Workforce training and education including:
    • Communications training and support – encompassing motivational interviewing and health coaching principles to support the primary workforce to deliver the protocols.
    • Best practice in virtual consultations – practical training and support to deliver high quality remote consultations.
    • Condition-specific training – we are working with local Training Hubs to provide training on each of the conditions covered by the frameworks.
  • Digital and tech resources to support remote care and self care
  • Evaluation

We are also working closely with North Central London Clinical Commissioning Group and North East London Commissioning Alliance as part of a national pilot funded by NHS England and Improvement’s Proactive Care@Home programme. Read out top tips from implementing the frameworks from our partners in NCL.

If you are based within the UCLPartners geography, please contact us at

If you are not based within UCLPartners’ geography, please remember all the resources are freely available from this microsite. For implementation support, please contact your local AHSN.