During the year we began supporting two local health systems to implement a series of frameworks to proactively manage patients with long-term conditions.
As primary care transforms its models of care in response to the pandemic, UCLPartners AHSN has developed ‘real world’ frameworks to support proactive care in long term conditions. The conditions covered within the frameworks are for respiratory: chronic obstructive pulmonary disorder (COPD) and asthma and cardiovascular disease risk conditions: hypertension, type 2 diabetes, atrial fibrillation and cholesterol and are now being rolled out across the country.
The frameworks help teams to identify, risk stratify and manage those with long term conditions, working with the GP practice’s current IT systems. They include education and training to support the wider primary care workforce (for example health care assistants, clinical pharmacists and physician associates) to proactively manage patients. They promote patient self care where appropriate, using digital monitoring when it is beneficial.
One of our local systems - Leicester, Leicestershire and Rutland (LLR) ICS - has been chosen as one of four national ‘trailblazers’ by NHSX and NHS@Home, which wants to test how the approach can be extended further. The programme in LLR will initially work with approximately eight primary care networks (PCNs), before building up to cover all 25 PCNs in LLR. Our other site, Lakeside Healthcare Group, intends to implement all proactive care frameworks across 4 PCNs and are keen to focus on the impact that the programme will have on their workforce. Significant learning is being generated from both East Midlands sites and actively shared regionally and nationally.
The programme is key to supporting the wider NHS in restoring services following the pandemic. As such, virtual consultations and digital tools form part of the frameworks to help support both patients and workforce. Successful implementation of the frameworks would expect to see patients able to undertake increased self care and have better control of long term conditions leading to less exacerbations and ultimately fewer hospital admissions.
