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A refreshed approach to long-term condition care in the East Midlands

Lakeside Healthcare Group uses the UCLPartners Proactive Care Frameworks to redesign staffing models and reprioritise workload. Freeing up capacity to deliver additional smear tests and their highest learning disabilities checks to date.

By Miles Langdon, Chief Medical Officer and GP partner, Responsible Officer, Lakeside Healthcare Group

Lakeside Healthcare Group is a large single business super partnership in the East Midlands with almost 180,000 patients covering parts of Lincolnshire, Northants and Cambridgeshire. It has eight sites and sixty GP partners. The group has 240,000 patients in four Primary Care Networks (PCN) and three Clinical Commissioning Groups (CCG).

Getting started

We came across the UCLPartners Proactive Care Frameworks last year in the depths of the pandemic and it was immediately obvious to us that they provided an easy, sensible, risk stratified approach to identify which patients we should be reviewing as a priority and those that could safely be contacted later. We expressed an interest to become an East Midlands trailblazer and work in partnership with the East Midlands Academic Health Science Network to plan and implement the Proactive Care Frameworks. We ran the searches for each site centrally and produced a weekly report for sites to see how many “red” or high-risk patients had been reviewed.

Seeing impact

Just after the New Year we had effectively reviewed all our high-risk patients and were making inroads into our “amber” or medium risk patients. Our in-house dashboard also showed us our site Impact and Investment Fund achievement, as well as cervical smears and Learning Disability (LD) checks. Our largest site in Corby, with 50,000 registered patients had made great progress having enthusiastically taken up the UCLPartners Framework risk stratified approach. Many of the Long Term Condition (LTC) nursing staff and Health Care Assistants had been concerned about the lack of proactive contact with patients during the pandemic. 

However, the dashboard showed that the Corby site numbers for smears and LD checks were lower than other sites. This highlighted the need to refocus their efforts in February and March, so they paused the LTC reviews. With some financial support from their CCG, based on a business case built on the tool, they were able to perform an additional 750 smears at weekends with additional staff, and also achieve their highest LD check achievement.

Redesigning our workforce

The next step was redesigning our workforce around the frameworks and shifting work usually done by Practice Nurses to PCN pharmacists and pharmacy technicians, and to social prescribing link workers and health and wellbeing coaches who were in Additional Roles Reimbursement Scheme (ARRS) funded roles. This enabled a much more holistic and patient centred approach to LTC management, as well as releasing capacity for the nursing team.

Our first step was to determine the experience, competency and confidence of the nursing/Allied Health Professionals. We spent a considerable amount of time asking all our nurses to complete a self-assessment of their abilities, as well as documenting when the relevant course had been undertaken and needed renewal on a web based portal. This allowed us to see at a glance what skills we had, where we needed to focus training, and where we needed to buddy/mentor across our organisation to improve confidence.

We then asked the practice nurse and teams that were doing the LTC reviews to divide up what needed to happen during a high, medium and low risk review and allocate time to each role. This allowed us to look at the future “ideal” workforce and better understand gaps so we could ask our PCN management teams to recruit individuals to help us deliver LTC reviews to our varying populations. Our workforce design can be altered to the local demographics and running the UCLPartners Proactive Care Frameworks at the same time gives all our PCNs a much better understanding of an ideal workforce design to meet population need.

Traditionally, the concept of sharing staff or expertise across sites was not that common and practices haven’t had the resources to really understand their workforce and partners.  This new way of working has shown many positive outcomes with lasting changes that can be sustained in a post COVID-19 world to reduce the burden on primary care

Miles Langdon, Chief Medical Officer and GP partner, Responsible Officer, Lakeside Healthcare Group

For further information about the East Midlands Health Science Network please visit Home (