UCLPartners proactive care programme

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 over the coming months in primary care, emergency and hospital admissions.

The pandemic has given primary care an opportunity to rethink and reset care is delivered to patients, and to optimise the management of cardiovascular and other conditions.

Proactive care frameworks

We have developed a series of proactive care frameworks to restore routine care by prioritising patients at highest risk of deterioration, with pathways that mobilise the wider workforce and digital/tech, to optimise remote care and self-care, while reducing GP workload.

The frameworks include atrial fibrillation, high blood pressure, high cholesterol, type 2 diabetes, asthma and COPD.

The frameworks are comprehensive and include:

1. Comprehensive search tools to risk stratify patients – built for EMIS and SystmOne.
2. Pathways that prioritise patients for follow up, support remote delivery of care, and identify what elements of long-term condition care can be delivered by staff such as Health Care Assistants and link workers.
3. Scripts and protocols to guide Health Care Assistants and others in their consultations.
4. Training for staff to deliver education, self-management support and brief interventions. Training includes health coaching and motivational interviewing.
5. Digital and other resources that support remote management and self-management.

The frameworks are being implemented by GPs across the country, helping practices to identify who needs priority care, and those whose care can safely be delayed.

These frameworks are designed to be adapted to local context and preferences. 

The CVD LTC and stratification tools are wonderful…super-easy to upload and already in a few days making a difference to patient care and staff resilience in my PCN. Picked up some quick wins and new determination to get things right

Dr Hannah Morgan, GP and Clinical Director for Hayling Island and Emsworth PCN, South East Hampshire

Find out more about our frameworks

Implementation Support

Sitting alongside these frameworks is support for implementation.

For Primary Care teams within the UCLPartners footprint, we can provide support to improve the quality of proactive care for patients with long-term conditions. This includes:

• Clinical leadership from our team of GPs and clinical pharmacists
• Project and implementation support from a team of project managers, implementation experts, commercial and innovation leads and quality improvement experts

Our team can provide the following types of support, all of which can be tailored to the needs of your context:

• Programme management to adapt and embed the frameworks in Primary Care Networks
• Support for local clinical engagement and leadership
• Adaption of the frameworks to reflect local pathways
• Workforce training and education including:
  • Communications training and support – encompassing motivational interviewing and health coaching principles to support the primary workforce to deliver the protocols.
  • Best practice in virtual consultations – practical training and support to deliver high quality remote consultations.
  • Condition-specific training – we are working with local Training Hubs to provide training on each of the conditions covered by the frameworks.

• Digital and tech resources to support remote care and self care
• Evaluation

The UCLPartners Proactive Care Frameworks have now been adopted into a new national programme (NHS Proactive Care @Home) with 12 Integrated Care Systems in phases 1 and 2. The roll out across local PCNs is currently proceeding in North Central London Clinical Commissioning Group and North East London Commissioning Alliance, with both ICSs planning implementation at scale to improve care and outcomes and reduce demand for urgent care. Proactive Care @home is an NHS England and NHS Improvement programme delivered by the NHS @home team with support from UCLPartners.

If you are based within the UCLPartners geography, please contact us at primarycare@uclpartners.com

If you are not based within UCLPartners’ geography, please remember all the resources are freely available from this microsite. For implementation support, please contact your local AHSN.

Primary care webinars 

We run regular webinars for primary care staff which aim to support staff development by: 

• Sharing learning and best practice 
• Collectively problem solving 
• Celebrating success 
• Building peer networks 

For details of upcoming webinars, please see our events page. For more information, please email primarycare@uclpartners.com