Patients in the East Midlands with long-term conditions will soon benefit from a new approach to support them.

Proactive care frameworks being developed by UCLPartners (the AHSN for the northeast and north-central London) aim to help GP practices and primary care networks to deliver comprehensive care to patients with long-term conditions, by offering:

• Search and risk stratification tools to identify patients with long term conditions.
• Education and training to mobilise the wider primary care workforce (for example health care assistants, clinical pharmacists, physician associates) to proactively manage low and medium risk patients.
• Digital tools to support both patients and workforce, encouraging better patient self management.

A number of East Midlands clinical commissioning groups and primary care networks expressed an interest to be involved in this innovative programme. Leicester, Leicestershire and Rutland STP has also been chosen as one of four national ‘trailblazers’ by NHSX, which wants to test how the approach can be extended further.

Last year, UCLPartners created frameworks for high blood pressure, type 2 diabetes, asthma and COPD. Now, two new frameworks have been added for the management of atrial fibrillation and high cholesterol.

The frameworks enable practices to risk stratify patients to prioritise clinical activity, deploy the wider workforce to reduce the workload for GPs, and maximise support for remote management and self-management.

For more information about the proactive care frameworks, visit our project page and you can view the frameworks here.

If you would specifically like to know more information about how the frameworks are being trailblazed in the East Midlands, please contact Gemma Summerson at This email address is being protected from spambots. You need JavaScript enabled to view it.. We would also be keen to hear from you if you are considering using the frameworks, particularly the new framework for high cholesterol.