Since 2020, we have developed a series of Frameworks with the aim of helping primary care to weather and emerge from the Covid-19 pandemic stronger, able to restore and transform care for people who are living with long term conditions.


We developed the UCLPartners Proactive Care Frameworks to ensure that all patients with long term conditions received the care they needed despite the pandemic, and are delighted by how well received they have been in communities across the country. A big thank you to all the AHSNs who have tirelessly supported their uptake of the Frameworks locally.


Laura Boyd, Director of Implementation for Cardiovascular Health at UCLPartners

What the project involved

The Covid-19 pandemic caused massive disruption to primary care. Patients with long term conditions such as diabetes and hypertension could have their conditions exacerbated, which could add further waves of demand for unscheduled care in primary care, emergency and hospital admissions. In response, UCLPartners developed a series of Proactive Care Frameworks for the management of long term conditions in this new world, including atrial fibrillation, high blood pressure, high cholesterol, type 2 diabetes, asthma, COPD, and severe mental illness.

The frameworks are made up of five key elements:

  • A comprehensive set of patient search and stratification tools built for EMIS and SystmOne
  • A selection of appropriate pathways that prioritise patients for follow up, support remote delivery of care, and identify what elements of long-term condition care can be delivered by staff such as Health Care Assistants and link workers
  • Straightforward scripts and protocols to guide Health Care Assistants and others in their consultations
  • Training for staff to deliver education, self-management support and brief interventions, including health coaching and motivational interviewing and digital
  • and other resources that support remote management and self-management.

The frameworks particularly emphasise working at scale by:

  • enabling practices to prioritise clinical activity by stratifying patients who are at highest risk
  • deploying the wider workforce to reduce the workload for GPs
  • and improving the personalised care offer for patients.

They are also designed to be adaptable to a variety of different local contexts and preferences to ensure that they are applicable on a national scale.


The frameworks have been adopted by 30 primary care networks across North Central London and North East London, and is being supported nationally by all 15 AHSNs as part of the National Blood Pressure Optimisation Programme, as well as being included in the Royal College of GPs national pandemic recovery guidance.

They have also had an impact on a more local level, such as in Barking, Havering and Redbridge where application of the AF framework led to 80 patients being anticoagulated, which is a 7% improvement, much higher than the London annual improvement average of 2% prior to this initiative. This will prevent seven strokes every 18 months, providing the NHS with a cost saving of roughly £175,000.

Next steps

We hope to continue the rollout of the frameworks in primary care settings on a national scale, improving the management of care of long term conditions across the country, and continuing the work done to improve current levels.

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