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New primary care support package to help manage patients with long-term conditions

8 June 2020
Today UCLPartners has launched a new package of digital resources and practical support to help primary care teams to continue providing proactive care to patients with long-term conditions during and post COVID-19.

The support on offer will help teams to stratify care for patients according to level of risk, using new models of care that are virtual by default, mobilise the wider workforce, draw on digital innovation and support patient self-management.

This support package focusses on the management of asthma and COPD. Resources for the management of type 2 diabetes and cardiovascular disease will soon be added.

Resources available include:

  • Search and risk stratification tools – That can be used with EMIS (and SystmOne to follow), accompanied by user guidance
  • Education and training resources – Including protocols, guidance, videos and virtual training sessions to upskill the breadth of primary care team members to proactively support patients.
  • Clinically appraised digital tools – to support patient activation and self-management in the home setting.

Dr Matt Kearney, GP and UCLPartners Director for Primary Care Innovation said: “In recent weeks, there have been huge efforts across the system to change ways of working in response to COVID-19. In primary care proactive care for patients with long term conditions is essential to maintain good health and prevent exacerbations.

“To help teams in our region continue to provide this proactive care during and after the pandemic, we have created a comprehensive support package, which includes a number of free resources as well as implementation support, to help primary care teams to adapt local pathways – including practical training, health coaching and communities of practice.”

Enfield Primary Care Network (PCN) are one of the first to take advantage of the implementation support.

Dr Sarit Ghosh, Clinical Director Enfield Unity PCN said: “Enfield Unity are looking forward to working with UCLPartners to support the long-term conditions care of our patients. We feel it’s a great opportunity to develop an innovative model that many can benefit from”

View the full support package here

To discuss how we can support your team with implementation, contact us at