The document discusses the impact of the COVID-19 pandemic on proactive care in primary care, emphasizing the shift to remote care and the disruption faced in managing long-term conditions. It outlines a framework to restore proactive care, focusing on utilizing a wider primary care workforce, digital technologies, and support for self-management to improve patient outcomes. The document includes specific incentive opportunities for cardiovascular disease prevention and highlights the importance of personalized care and shared decision-making in addressing health inequalities.

1. Supporting Recovery in Primary Care
UCLP Proactive Care Frameworks for
Long Term Conditions
Dr Julia Reynolds PhD
Associate Director for Transformation
Innovation Agency

2. Welcome!
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AGENDA
3 presentations – Case Studies
• Blood Pressure (PCN)
• Respiratory (GP Federation)
• Multimorbidity (GP practice)

3. COVID-19: Impact on Proactive Care in
Long Term Conditions
Urgent challenge
• Pandemic resulted in overnight transformation in primary care: universal shift to remote
care and reduced face to face access
• Disruption of routine, proactive care in long term conditions such as CVD, hypertension,
diabetes, COPD, asthma
• Risk of deterioration/exacerbation in long term conditions driving further waves of demand
for urgent and acute care and worse outcomes for patients
Opportunity
• Restore and transform proactive care for people with long term conditions
• Support a step change in Personalised Care
• Mobilise wider primary care workforce to support remote care and self management
• Optimise clinical care and reduce variation

4. Our challenge
• Large number of excess
deaths due to COVID
• High levels of health
inequalities
• Industrial legacy – poor
health
• High level of deprivation
• High levels of variation
• Variable staff levels and
staffing profiles

6. UCLP
Proactive Care
Frameworks
• Conditions included
• CVD prevention
• Atrial Fibrillation
• Blood pressure
• Cholesterol
• Type 2 Diabetes
• Respiratory
• Asthma
• COPD
6

7. Copyright © UCLPartners 2021
UCLPartners Proactive Care Frameworks Overview
February 2021
Principles:
• Virtual first
• Wider 1o care workforce
• Step change in self management
• Digital technologies
Stratify (clinical, ethnicity, social
factors)
Low priority
Medium priority
High priority
High priority – early review
Prescribing clinician
Medium priority – phased review
Prescribing clinician
Low priority – holistic proactive care
Eg HCA, nursing associate, link worker etc
1. Begin with highest priority
2. Use wider workforce to share
delivery of care
3. Innovation to support remote
care and self care
HCA/other roles
Structuredsupport
for education, self
management and
lifestyle change.
© UCLPartners 2021
Arrange bloods,
collate data to inform
risk assessment
There are frameworks specifically for Hypertension, AF,
High Cholesterol, Asthma, T2D and COPD

8. The frameworks
Systematic
support for
primary care to
restore and
improve
proactive care
• Comprehensive search tools to risk stratify
patients – built for EMIS and SystmOne
• Stratifying the population - Pathways that
prioritise patients for follow up, support remote
delivery of care, and identify what elements of
LTC care can be delivered by staff such as
Health Care Assistants and link workers.
• Scripts and protocols to guide Health Care
Assistants and others in their consultations.
• Using the wider workforce - Training for
staff to deliver education, self-management
support and brief interventions. Training
includes health coaching and motivational
interviewing.
• Using remote monitoring - Digital and
other resources that support remote
management and self-management.

9. Primary Care
Incentive
Opportunities
– CVD
Prevention
22/23
• CVD 01 & CVD 02 – Hypertension patients on the QOF
Hypertension Register
• CVD 03 – Lipids Patients with a QRISK2/3 who are treated
with statins
• CVD 04 – Lipids Patients 29 and under with with total
cholesterol >7.5 referred for assessment for familial
hypercholesterolemia and those over 29 referred if total
cholesterol is more than 9
• CVD 05 – Atrial Fibrillation CHA2DSVASc >2 (female) & >1
(not female) prescribed anti-coagulation
• CVD 06 – Atrial Fibrillation Patients prescribed Edoxaban
• PC01 – Personlised Care Referrals to social prescriber
• SMR02C – Structured medicine reviews
• RESP 01 – Asthma Patients on more than 3 inhalers (ICS) in
last 12 months
• RESP 02 Asthma patients who received more that 6 SABA
prescriptions
• ES01 – Environmental sustainability inhaler prescriptions
• ES02 – Environmental sustainability – inhaler carbon
emissions

10. Personalised care
conversation: Starting
with what matters to
John, knowledge, skills
and confidence,
holistic view of ‘whole
lives’ and outcomes
they want to achieve,
and SDM conversation
re range of options
available?
Measurement of
digital and health
literacy, baselining
level of self-
management?
Digital skills, small
PHBs?
Signposting to digital
tools? PHB to access
digital equipment?
Development of a
PCSP or wellbeing
plan?
Preparing people for
SDM conversation
with clinician ‘
Prepared Patient?
Workforce training and culture shift
Shared Decision
Making
Conversation?
Review of PCSP?
Shared Decision
Making Conversation?
Review / development
of PCSP?
Isolated, not connected to community?
So what? What is the impact/outcomes?