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New long-term condition Proactive Care Frameworks improve workforce capacity and patient care

22 April 2022
An independent evaluation report published today has found initial implementation of UCLPartners’ Proactive Care Frameworks is progressing well with wide support from clinicians who also reported positive feedback from patients who say they feel their care is better streamlined and tailored to their needs.

In 2020, UCLPartners developed a series of Proactive Care Frameworks with the aim of helping people who are living with long term conditions stay well both during COVID-19 and in supporting the system to recover post pandemic. 

The frameworks, which focus on Hypertension, Type 2 Diabetes, Cholesterol, Atrial Fibrillation, Asthma, and Chronic Obstructive Pulmonary Disease are underpinned by risk stratification and prioritisation tools. They seek to optimise workforce capacity and utilise available digital resources, aiding a step change in self-management, remote support, and personalisation of care.

This new report, written by the Centre for Healthcare Innovation Research (CHIR) at City, University of London evaluated the implementation of the Proactive Care Frameworks across six pilot sites across England.

Early insights are encouraging, with primary care workforce colleagues describing the Proactive Care Framework as a useful way to ensure patients received the right care at the right time, and clinicians believing the frameworks will result in improvements to long term condition management.

The report also found that there is a perception that the frameworks will provide an appropriate structure for supporting the introduction and integration of wider workforce roles, helping operationalise the personalised care agenda and transition towards more holistic care.

Kerry Gardner, Group Lead Nurse, Lakeside Healthcare Group said: “We found applying the framework risk stratification tools helped us to assign the appropriate level of care to each of our patients. This expanded our workforce capacity because each member of the team was working to the top of their licence, thus dealing with a workload best suited to their skillset. We managed to get 650 more cervical smears done in one of our sites and our more highly skilled staff were available for more complex or high-risk cases.”

At the time of the evaluation, implementation of the frameworks was at an early phase and many pilot sites are not yet fully engaging with their patient population about them. As such, it was not possible to collect in-depth patient feedback. However, general practice staff reported patients felt particularly positive about an approach that was seen as offering more streamlined, personalised and holistic care. Patients told their care teams they felt more listened to with their needs being taken seriously and a wider variety of services being provided.

The inclusion of wider patient characteristics aside clinical characteristics in the proactive care framework risk stratification searches, has also been hailed as an opportunity for the frameworks to help tackle health inequalities.

Dr Alexandra Ziemann, Senior Research Fellow, CHIR said: “This review summarises qualitative feedback we collected through interviewing 41 staff members involved in the implementation of proactive care frameworks. The interviewees demonstrated a shared belief that these frameworks could be truly transformative for how primary care operates across England. We’re very much looking forward to the next round of evaluation which will look to assess the impact on patient experience and outcomes.”

Dr Matt Kearney, General Practitioner and Programme Director at UCLPartners said: “This report offers early evidence that the UCLPartners Proactive Care Frameworks can be successfully adopted by primary care.  They demonstrate the potential positive impact on patient outcomes and on the capability and capacity of the wider primary care workforce.  As Proactive Care frameworks embed, we must continue to monitor and gather insights from local experience of implementation. It is this knowledge that will ensure the frameworks and resources can be adapted where needed and that their potential to transform care is optimised.”

Read the full evaluation report here

View summary here

Webinar – If you would like to hear more about the report findings including hearing from some of the sites involved and discuss next steps with us, register to attend our event on 10 May:


Proactive care frameworks

Our online support package contains tools and resources to help primary care teams to continue to effectively deliver proactive care for patients with CVD and respiratory conditions.

View the frameworks