Proactive Care Frameworks

Project summary

The Proactive Care Frameworks programme aims to support primary care teams to implement and deliver Proactive Care Frameworks, created by UCLPartners (the Health Innovation Network for the northeast and north-central London). These are designed to help restore routine long-term conditions care post COVID-19 and do things differently at scale: they enable practices to prioritise clinical activity for patients who are at highest risk, working with the GP practice’s existing IT system; they help reduce the workload for GPs; and they improve personalised care for patients.

We are working with local health and care partners to support their uptake and implementation of these frameworks.

 

The challenge

Around 15 million people in England have a long term condition and (pre COVID-19) approximately 55% of people with long term conditions account for about 50% of all GP appointments, 64% of all outpatient appointments and over 70% inpatient bed days (Department of Health).

In addition, COVID-19 has dramatically disrupted pathways of care with withdrawal of face-to-face appointments, cancelled referrals, limited access to diagnostic and monitoring tests.

The solution

As primary care transforms its models of care in response to the pandemic, UCLPartners has developed ‘real world’ frameworks to support primary care colleagues to deliver high-quality, routine, proactive care for patients with long-term conditions. The conditions covered within the frameworks are for:

  • Hypertension
  • Type 2 diabetes
  • Atrial fibrillation
  • Lipid management
  • Chronic obstructive pulmonary disorder (COPD)
  • Asthma

The resources available within these frameworks include:

  •  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.

Following an introductory webinar, HIEM held last October, two primary care systems in the East Midlands have taken forward expressions of interest to be involved in this innovative programme: Leicester, Leicestershire and Rutland ICS (LLR) and Lakeside Healthcare Group. LLR ICS has also been chosen as one of four national ‘trailblazers’ by NHSX, which wants to test how the approach can be extended further.

Impacts and outcomes

Health Innovation East Midlands has collated some learning and top tips to support any new sites planning to implement the frameworks, based on learning from LLR and Lakeside Healthcare Group and UCLPartners.

The programme is key to supporting the wider NHS in restoring services following the pandemic. Successful implementation of the frameworks would expect to see patients able to undertake increased self-care and have better control of their conditions, leading to fewer exacerbations and ultimately fewer hospital admissions.

29 Primary Care Networks, representing 150 practices, have agreed to be part of the programme during 2021-22.

Contact

For more information about the Proactive Care Frameworks programme or to have a conversation on how we can support, email: This email address is being protected from spambots. You need JavaScript enabled to view it. 

LTC resources 

Case study - A refreshed approach to long term condition care in the East Midlands - Lakeside Healthcare Group

 Proactive Care Framework - top tips for Integrated Care Systems 

Introduction to UCLPartners proactive care frameworks