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Proactive Care Frameworks: Background and Context

Developed by primary care clinicians and patients

The COVID-19 pandemic is displacing much routine primary care. There is a risk that disruption of proactive care for people living with long-term conditions, such as Type 2 Diabetes, hypertension, CVD, COPD and asthma, results in exacerbation and complications in these conditions. This could add further waves of demand for unscheduled care in primary care, emergency and hospital admissions. The pandemic has given primary care an opportunity to rethink and reset how care is delivered to patients, and to optimise the management of cardiovascular and other conditions.

To help primary care manage this challenge, UCLPartners has developed a series of Proactive Care Frameworks for the management of long term conditions in this new world of primary care.  The frameworks focus on how to do things differently at scale: they enable practices to prioritise clinical activity by stratifying patients who are at highest risk; they deploy the wider workforce to reduce the workload for GPs; and they improve the personalised care offer for patients.

The frameworks cover four cardiovascular conditions (atrial fibrillation, high blood pressure, high cholesterol and type 2 diabetes) and two respiratory conditions (asthma and COPD).

They are built around four key principles:

  • virtual where appropriate and face to face where needed​
  • mobilisation of the wider primary care workforce
  • a step change in support for self-management and
  • underpinned by digital tools and other resources.

These frameworks are designed to be adapted to local context and preferences and have been created following patient and public consultation. In March 2020 we held a patient and public involvement event, attended by approximately 30 people with high risk CVD conditions, and carers.  The aim of this consultation was to gather insights and information to enable better identification and treatment of people with high blood pressure, atrial fibrillation and high cholesterol in the primary care setting.  Read the feedback from patients in our report

UCLPartners Proactive Care Frameworks and the relationship with the Proactive Care @Home programme

Proactive Care @home is an NHS England and NHS Improvement programme delivered by the NHS @home team with support from UCLP. The national programme is based on the UCLP Proactive Care frameworks and NHS England and NHS Improvement has provided funding for this programme via Regional Personalised Care team budgets.

Blood Pressure Optimisation Programme and UCLPartners Proactive Care Frameworks

The Blood Pressure Optimisation Programme will see AHSNs support Primary Care Networks (PCNs) to implement the UCLPartners Proactive Care Framework for hypertension, to optimise clinical care and self-management of people with hypertension.