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Top Tips for implementing the Proactive Care Frameworks


North London Partners in health and care are one of the pilot ICSs to pilot the UCLPartners Proactive Care Frameworks that have now been adopted nationally as the NHS Proactive Care @Home Programme. The area is made up of 5 London Boroughs: Haringey, Camden, Islington, Enfield and Barnet. 

North London Partners in health and care model for implementation  

North London Partners in health and care opted for a unique model for implementing the pilot, by utilising Clinical Fellows (CF) in each of the boroughs to operationalise the pilot at their respective PCN and Practices. The CFs included GPs, nurses and clinical pharmacists and presented the perfect opportunity for testing out the skills mix in implementing and rolling out the Proactive Care Frameworks. 

Long term condition focus 

North London Partners in health and care were keen to test out the hypertension proactive care framework as part of the BP @Home initiative as it focuses on BP optimisation in the whole hypertensive population.

We asked the Clinical Fellows what went well and their key learnings to date, these were their reflections and top tips for implementation: 

Top 5 tips for implementation 

  1. Research interest level in your network: It’s important to ensure senior level buy in and local clinical leadership/champions at practice/PCN level. Agreeing a point of contact at each practice creates a sense of ownership of the initiative. 
  1. Using email over text to contact and inform patients: We can share more information over email along with educating patients about why measuring blood pressure at home is useful, and the minimum criteria for effective blood pressure monitors in one step.  
  1. Introducing BP @Home with other reviews that are already taking place: With pressure on appointments in primary care it can be difficult to run additional chronic disease clinics.  Introducing patients to the Proactive Care Framework within other reviews saves time with already limited staff resources.  
  1. Develop templates to monitor outcomes: Developing a template that allows you to record when patients have had self-management review, so that the UCLP searches can identify the outstanding patients helps to manage the workload.  
  1. Investing in staff training: It is helpful having nurses who have completed a prescribing course with a focus on hypertension as this gives staff the confidence and self-assurance when contacting at risk patients.  UCLPartners also has several free resources on the website for health care professionals for training purposes. 

The UCLP Proactive Care Frameworks include searches and a suite of resources for clinicians and patients. They are designed to be adapted to suit local needs and preferences, which will vary.  They were created following patient and public consultation and they can be used for individual conditions like several of the boroughs in the area or are by taking a multimorbidity approach. 

“The Proactive Care Frameworks is a very useful tool, as it prioritised patients at highest risk of deterioration.  UCLP searches are accessible on EMIS and very easy to comprehend.”  (Haringey)