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Here you can find frequently asked questions, split into eight categories. If you have a question that is not answered here, please email

Search tools

Q. Can I access the searches if I’m not in UCLPartners’ patch?

A. Yes. To access the searches, please complete the request form here.

Q. What system(s) do I need to be able to run the searches?

A. To run these searches, you will need either EMIS or SystmOne. 

Q. I’ve already run searches, is this support relevant to me?

A. Running the search tools are the first step in our frameworks. There are further resources about how to manage patients identified through the search tools, workforce training and development and use of digital tools in the pathway.

Q. We have Eclipse Live in our practice, how do these searches relate to that?

A. The searches can still be run in your practice.

Q. How does this work with HealtheIntent?

A. We are sharing the search criteria with the HealtheIntent team working in North Central London to support integration and all practices will be able to run the searches on individual GP systems as well.

Q. How have UCLPartners worked with the Clinical Effectiveness Group (CEG) on this?

A. UCLPartners’ clinicians designed the search criteria that defines the risk categories: high, moderate and lower risk. The Clinical Effectiveness Group has developed these into tools to be run on EMIS and SystmOne, which search and stratify patients.

Q. I’m not confident using technology to download search tools, are there any guides out there to support me in this?

A. This training video shows you how to download the searches, import them into EMIS/ SystmOne and run them in your practice.

Q. Do the search tools require someone to have a diagnosis?

A. Yes, the search tools have been developed using read/ snomed codes and require a diagnosis.

Q. Are there likely to be any issues in terms of IT compatibility with primary care systems?

A. These tools have been developed to be run on EMIS and SystmOne, which search and stratify patients. They will not be compatible with other GP systems.

Q. How often should the searches be run?

A. The UCLP Proactive Care searches should be viewed as an adjunct to the GP recall systems. We would recommend running the UCLP Proactive Care searches on a quarterly basis.

Q. Are stratification searches already built into the clinical system?

A. Searches haven’t been built into clinical systems but are available to download from the UCLP website and are easily uploaded into EMIS and SystmOne. Some local systems may have made the search tools accessible via central portals. Speak to members of your CCG/ICS or PCN regarding this.

Programme implementation support

Q. Can we trial this package?

A. The resources published on our website are all free to use. However, we strongly advise that they are used in conjunction with dedicated implementation support. For local partners within the UCLP geography, we are able to provide project management and clinical oversight and engagement to support this. For more information, please email us at

Q. Is this for practices or Primary Care Networks (PCNs)?

A. We strongly encourage working at a PCN level to enable economies of scale and to reduce health inequalities across local health systems. Please contact us at to find out more.

Q. What about patients who do not have Wi-Fi?

A. The pathways include digital tools for patients to access via their computer or mobile phones. Where patients do not have access to Wi-Fi or laptops/ smart phones, we encourage practices to send hard copies of the information contained within the digital tools to patients in the post. It will be important for local networks and practices to develop systems to ensure that patients who are unable or unwilling to consult digitally to continue to have good access to healthcare. UCLPartners is happy to support local systems in developing these pathways.

Q. We have no video capabilities in our practice. What should we do?

A. Please speak to your local CCG/ICS about equipment needs. However, patient contacts could also be made via telephone and text message rather than by video conferencing; all resources can be adapted to meet local contexts and preferences.

Q. Why should I/ my PCN/ practice get involved?

A. This approach ensures that highest risk patients are managed as early as possible with a focus on using the wider workforce to support education, self-management and behaviour change to improve the care offered to patients and reduce demand for clinician time. Post-COVID, much of the care provided for patients in the primary care setting is likely to be conducted virtually. These frameworks provide a range of resources to support this.

Q. Will I be paid to do this/ is there additional funding for my PCN?

A. The frameworks are designed to help GPs routine care for patients with long term conditions. It is not a new demand, but a framework for adapting routine proactive care in post COVID primary care. It can help practices to meet QOF targets in these conditions. Some PCNs may have local incentive schemes linked to implementation of the frameworks. The frameworks are the basis of the NHSE Proactive Care @home programme. Optional funding has been offered to regional personalised care teams to deliver this programme. Please contact your ICS Personalised Care and/or Long-term Conditions lead who can advise whether there is further funding available through this national programme and/or local incentive schemes.

Q. We already undertake a variation of this approach so is this relevant to me?

A. The tools, resources and associated training and implementation offer from UCLPartners has been developed to build capacity in primary care whilst also reducing variation and ensuring sustainability. The frameworks can be adapted for local use to reflect current activity and priorities.

Q. What if we don’t have capacity to implement the frameworks?

 A. We know that primary care is extremely busy. The frameworks are not creating new work but focusing on helping to deliver existing work to support patients with long-term condition management. The frameworks can be implemented at a pace suitable for your system. We advise you to identify the key roles required within your system needed to plan and support implementation. Local partners, such as Academic Health Science Networks (AHSNs) like UCLP, may be able to provide implementation support to increase capacity in the system. Please see the link to the AHSN map (see bottom of website page) showing the geographies and contact details for AHSNs across England. Key roles expected to be involved in early planning discussions will be PCN Clinical Director(s), Practice Manager(s) lead GP(s), lead Nurse(s) and Clinical Pharmacist(s) and other identified roles for your system.

Q. How much time will I need to do this?

A. The amount of time that it takes to implement the frameworks will vary depending on your local setting and the scale at which you would like to implement this. Speak to your local AHSN or UCLP ( if you are within our local geography.

Q. Is the diabetes work aligned with the May 2020 NHS England report, Type 1 and Type 2 diabetes and COVID-19 related mortality in England: a cohort study in people with diabetes?

A. The UCLPartners searches will identify patients with the long-term condition and stratify them according to their risk of deterioration/exacerbation. Guidance for clinical management is in alignment with NICE guidance. This paper focused on risk of death from COVID-19.

Q. What support is available to deliver these frameworks?

A. AHSNs may be able to support delivery of these frameworks.This level of support will vary depending upon the size and scale of ambitions for local implementation. Please see the link to the AHSN map (see bottom of website page) showing the geographies and contact details for AHSNs across England.

For organisations within the UCLPartners geography, we will deliver a bespoke implementation support package that will involve sharing learning, resources and tools, and providing clinical guidance and expertise. For more information please contact

Q. How much does this support cost?

A. The tools and resources are free to access. However, to help build local ownership, support the workforce, and adapt resources for local use, we recommend these tools are used in conjunction with dedicated implementation support.

For organisations within the UCLP geography, we can provide a package of support to enable this. Please contact us at to discuss further.


Q. Is this approach a good use of clinical time?

A. This approach enables the redistribution of work across all primary care staff for long-term condition management. The wider primary care workforce (e.g. pharmacists, healthcare assistants and social prescribers) are involved in patient management for patients across all priority groups. Lower risk patients will only need to be seen by the wider primary care workforce. Using the wider workforce to support education, self-management and behaviour change will improve the care offered to patients and will reduce demand for clinician time.

Q. Can other staff types, rather than Healthcare Assistants, be used to deliver this package?

A. With appropriate training physician associates, nursing associates, social prescribers and other workforce members can help deliver the frameworks. We can support the appropriate training for these roles.

Q. What if our practice team do not think this will work for us as they need to physically see their patients?

A. It is highly likely that post-COVID a much larger proportion of consultations will be virtual in primary and secondary care. This framework uses virtual consultations where appropriate however the consultations should still be tailored to suit the practice and local population needs. We have identified interventions that can be delivered remotely including the use of digital solutions. A list of digital resources for each condition is available here.

Q. How many staff are needed to deliver this. Have you modelled the ratios?

A. The proactive care frameworks have been developed for local systems to adapt depending on local circumstances and preferences. We have not modelled numbers of staff required. The searches will show how many patients are in each high, medium and low risk cohort. PCNs and practices will be able to use these numbers to phase work over time and to model staff numbers. Due to the variation in training requirements and local populations, the number and type of staff members able to implement the framework will vary across regions.

Q. Is there a role for wider partners such as neighbourhood teams e.g. social prescribing?

A. Yes. Involving neighbourhood and community teams as well as local charities, will strengthen the capacity of the workforce across your system, support sustainable pathway transformation and development and improve patient journeys and experiences. For example, an ICS are partnering with Healthwatch who are providing volunteers to deliver blood pressure monitors to patients and guide them on how to use them.

Q. How do you calculate the level of project management time to deliver the programme?

A. The proactive care frameworks have been developed for local systems to adapt depending on local circumstances and preferences. We have not modelled the amount of project management time required, however this will vary depending on the scale of implementation. In time, we will be able to provide an example from an ICS of the amount of project management time that has been sufficient to implement the frameworks.

Q. How do you bring all GP practices on board? What do you do if some don’t want to participate?

A. Engagement and buy in will be critical, particularly at a time when systems are under a great deal of pressure. A phased roll out approach may be more suitable in this situation where you engage willing and more able sites to demonstrate implementation learning from a first phase and apply learning and best practice to a second phase roll out. A central role to coordinate and run searches and risk stratification may also support practices where they have a reduced administration capacity. East Midlands AHSN and UCLPartners can also share learning from early adopter sites and connect sites via communities of practice where appropriate.  For more information contact us at


Q. What are the training requirements for each staff group across each framework?

A. Training requirements will vary depending on the experience of each individual. UCLPartners have listed some recommended competencies prior to implementing the frameworks for each staff group. This is available here.

Q. How many hours commitment is needed for HCAs/ pharmacists/ GPs etc?

A. The level of training required will vary by staff type and experience. A training programme will need to be developed to meet the needs of local staff. We advise an initial training needs assessment to be completed based on the proactive care frameworks. UCLPartners can support local organisations to develop their training approach.

Frameworks content

Q. Why have you not included type 1 diabetes?

A. Our initial focus has been on long-term conditions that are generally managed within primary care. Type 1 diabetes has not been included as these patients are usually under the care of the community team.

Q. What about patients with multimorbidities?

A. The UCLPartners’ resources include a unified multimorbidity protocol. This will support consultations by staff such as healthcare assistants for patients who have more than one cardiovascular condition. Resources have been developed for patients with one or more of a number of cardiovascular risk conditions. If the patient has 3-4 of the risk conditions, you may want to schedule a longer appointment or split the content into two if more convenient for the patient. Slide decks that have a multimorbidity focus are also available to support clinicians in managing these conditions.

Q. What about patients at high risk of COVID-19? How does this fit with them?

A. Many patients who are at high risk of COVID-19 are likely to have one or more long-term condition. Their long-term condition risk can be assessed in the same way using the search tools and stratification framework. Where remote consultations are appropriate, specialist care, support for self-management and lifestyle change can be delivered in the same way as for lower risk patients.

Q. Is this approach safe for patients/ what safety measures are in place?

A. This is a framework to support primary care to do things differently in the management of patients with long-term conditions. This will help to mitigate the risks of not seeing patients face to face during the pandemic. It will be important for local clinicians to be satisfied that pathways are safe and to ensure that staff have the appropriate competencies to deliver care. Our programme offers support for training and professional development.

Patient engagement and involvement

Q. How were patients consulted in the development of the frameworks?

A. In March 2020 UCLPartners held a patient and public involvement event, attended by approximately 30 people including those with high risk cardiovascular conditions and some carers. You can read the feedback from these patients in our report. UCLPartners continues to engage patients in the ongoing development of the frameworks primarily through consulting patients when developing new resources that are patient-facing or that will be used directly with patients.

Q. What are the perceptions of patients seeing other healthcare professionals rather than their GP?

A.  UCLPartners conducted an engagement session with patients who explained that they are happy to see other healthcare professionals other than their GP, as long as the professional has access to their medical records.

Q. Have Equality Impact Assessments (EIA) been completed with sites participating in the project?

A.  An Equality Impact Assessment has been conducted for the national programme Proactive Care @home based on the UCLP frameworks. It is for local sites to decide whether they conduct an EIA for their local work.

Through implementation of the frameworks, we do seek to tackle health inequalities and provide personalised support to patients. The prioritisation approach supports reducing health inequalities by identifying those at greatest clinical risk.

Secondary Care

Q. What is the impact on secondary care through the increased testing for each framework?

A. Increased testing may lead to referrals for patients with more complex cases. Conversely, increased testing and management of patients is expected to reduce the number of avoidable emergency admissions for heart attacks and strokes.

There is an opportunity for secondary care to work in collaboration with primary care through our frameworks. For example, secondary care cardiovascular pharmacy teams could support the upskilling of primary care pharmacists. For further information, please email

Q. Have secondary care been involved in the development of the frameworks?

A.  The UCLP Proactive Care team is made up of multidisciplinary professionals from both primary and secondary care, and all have been involved in the development of the frameworks.

Impact of Proactive Care Frameworks

Q. How will I know they have made an impact?

A.  We are developing an evaluation framework but expect this to encompass overall engagement with the programme, patient outcomes, and reduction in serious events. All of the frameworks are based on NICE guidance and there is a strong evidence base linking optimal treatment with improved outcomes for patients.

Q&A PCN/Practice Level Common Questions