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An initiative to optimise care for people with atrial fibrillation by monitoring blood pressure and cholesterol – high risk factors for heart disease, stroke and dementia, has shown considerable benefit to patients in North East London.

Matt Kearney on supporting primary care to do things differently and at scale as we emerge from the pandemic. Discussing the expansion of NHS Proactive Care @home, and how the UCLPartners Proactive Care Frameworks assist to deliver optimised care for long term conditions.

October 2021 is national cholesterol month. High cholesterol causes cardiovascular disease and accounts for a third of all heart attacks. Cholesterol has been a 'cinderella' condition since cholesterol indicators were largely removed from GP contract in 2014. The NHS Long Term Plan has put cholesterol back in the spotlight as one of the high-risk cardiovascular conditions requiring improved detection and management.

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.

The Innovation Agency – the Academic Health Science Network (AHSN) covering the North West Coast of England, is working with GP practices in Knowsley to help improve care of patients with asthma. By using the UCLPartners Proactive Care asthma framework they have been able to reduce high risk patients by almost 50% based on the principles of the programme.

As a GP working over the course of the pandemic across multiple GP sites, but predominantly in Enfield, I have been quite overwhelmed by the rise in the incidence of patients presenting with worsening of chronic conditions such as diabetes, hypertension and asthma and COPD.

Daphne Amevenu is Deputy Programme Director for cardiovascular disease (CVD) prevention and proactive care at UCLPartners. Here, Daphne reflects on the importance of involving patients and the public in healthcare design and explains the approach she has taken to ensure patients are influencing the way the UCLPartners’ proactive care programme develops.

UCLPartners team developed a series of long-term condition frameworks (for type 2 diabetes, hypertension, COPD, asthma, atrial fibrillation and lipids) that have supported primary care teams to transform the way they deliver proactive care for patients.

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.

Our Managing Director Prof Mike Roberts provides an update on how we are supporting the response to COVID-19.