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Proactive care frameworks transform care for patients with long-term conditions during COVID-19

UCLPartners team developed a series of long-term condition frameworks that have supported primary care teams to transform the way they deliver proactive care for patients.


There are 15 million people in the UK living with one or more long-term conditions. COVID-19 dramatically disrupted pathways of care in the primary care setting for these people, with abrupt withdrawal of face-to-face appointments, cancelled referrals and limited access to diagnostic and monitoring tests. Alongside this, the pandemic created fear for many patients of contracting the virus if they reported symptoms that might require them visit the GP practice and/ or be admitted to hospital.

From previous epidemics, such as Ebola, we know that more people die, not from the pandemic itself, but from associated lapses in care for other conditions. It was important to support primary care teams to help manage the conditions of people with long-term conditions, such as diabetes, hypertension and Atrial Fibrillation, so they could maintain good health and avoid exacerbations. 

This support was essential to ensure patients with long-term conditions still received regular proactive review with assessment, monitoring and optimisation of treatment.

What we did

Our team developed a series of long-term condition frameworks (for type 2 diabetes, hypertension, COPD, asthma, atrial fibrillation and lipids) to support primary care teams to transform the way they delivered proactive care for patients. The frameworks were built on four key principles: virtual first, mobilising the wider workforce, a step change in self-management, and use of digital technologies. The frameworks comprised multiple components, these included:

  • Comprehensive GP search tools to stratify patients into risk cohorts.
  • Pathways for local adaptation that prioritise high risk patients for follow up, support treatment optimisation, maximise remote delivery of care, and identify 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/protocols to guide 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.

The frameworks also included clinical and project management support for local pathway adaptation and implementation.

Impact and next steps

The frameworks were extraordinarily well received, both in the UCLPartners region and nationally. By February 2021, there had been over 20,000 views of the framework web pages and 2,299 downloads of the search/ stratification tools.

Both North East and North Central London have adopted the frameworks for roll out, covering 475 GP practices and 2.8 million people. North Central London have written their use into their long-term conditions strategy and have appointed a clinical lead per borough to help drive forward implementation. In North East London, the Waltham Forest and East London (WEL) group of CCGs and Barking, Havering and Redbridge (BHR) group of CCGs have written incentive plans to help drive uptake.

Through the wider AHSN Network, eight AHSNs are supporting their local systems to implement these frameworks. For example, in the Leicester, Leicestershire and Rutland ICS, all 120 practices have agreed to adopt the frameworks as soon as possible. Clinical and strategic leads in all these geographies across England are expressing confidence that at-scale implementation of the frameworks can be expected to drive significant improvement in care and outcomes for patients.

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/Clinical Director, Hayling Island and Emsworth PCN

This work has been recognised nationally and NHS England and Improvement (NHSEI) is funding the accelerated roll out of the frameworks in four Integrated Care Systems in England between January and March 2021.  These are:

  • Cheshire and Merseyside
  • Leicester, Leicestershire and Rutland
  • North Central London
  • North East London

Each area has received £25,000 to fund project management and clinical leadership to spread the frameworks within a number of Primary Care Networks in each area. 

NHSEI is planning national roll-out of the frameworks from April 2021.

NHSX has also provided funding to support the programme which includes:

  • Deployment of home monitoring tech (e.g. blood pressure machines, urine testing, Atrial fibrillation diagnostic apps).
  • Development of patient facing guides that are translated into different languages/ culturally appropriate to ensure accessibility of the tech.
  • Development of workforce training support to ensure the breadth of primary care workforce are confident in selecting and supporting patients and their carers to use home monitoring and patient self-management tech.

View the frameworks

Impact Report 2020/21

Our impact report 2020/21 shares how we have worked in collaboration with those across our partnership to accelerate research and innovation into practice during the COVID-19 pandemic.

Read the report