Supporting people with long-term conditions
“It’s [the UCLPartners Long Term conditions frameworks] clinically the best thing we can do for patients.”
PCN Clinical Director
Challenge / Problem Identified
Maintaining good health and avoiding exacerbations in long-term conditions such as diabetes, hypertension and COPD needs regular proactive review with assessment, monitoring and optimisation of treatment. COVID-19 has dramatically disrupted pathways of care with abrupt withdrawal of face-to-face appointments, cancelled referrals, limited access to diagnostic and monitoring tests and patient fear of contracting the virus if they report symptoms that might mean they need to visit the GP or be admitted to hospital. In order to ensure patients with long-term conditions still receive the care they need, it is important to support primary care teams to work differently.
Actions Taken
UCLPartners has developed a series of long-term condition frameworks (Type 2 diabetes, hypertension, COPD, asthma, atrial fibrillation and lipid management) to support the restoration and improvement of services post COVID-19 in primary care. The frameworks are built on four key principles: virtual first, mobilising the wider workforce, step change in self-management, and digital technologies. The frameworks include:
- Search tools built for EMIS and SystmOne that risk-stratify patients based on clinical features, co-morbidity and ethnicity.
- Pathways that map interventions and staff roles to level of risk. For example, patients at high risk are prioritised to ‘see’ a clinician soon, and phased over time all patients have virtual consultations with staff such as healthcare assistants (HCAs) or link workers to support education, self-management and lifestyle change.
- Digital and online resources that support remote management and self-management.
- Scripts and protocols to guide HCAs, link workers and others in their consultations.
- Training for staff (including health coaching and motivational interviewing) to deliver self-management support and education for patients.
UCLPartners’ support for implementation includes clinical and project management support for local pathway adaptation.
Impacts / Outcomes
The frameworks are now being rolled out at scale in North Central London and North East London ICSs, with alignment of local incentive schemes, and by a growing number of CCGs across England supported by other AHSNs.
The comprehensive frameworks are proving very popular with GPs across England because they respond to the urgent need to restore proactive care to patients with LTCs in a way that improves the quality of care for patients and reduces workload for front line clinicians by mobilising the wider workforce.
To date there have been 16,900 views of the framework web pages and 1,749 requests for the search / stratification tools.
Lessons Learned
We are working with local systems to ensure the tools fit with local contexts and priorities. This has led to adaptions in the hypertension search and stratification tools for all. For local systems, we are working with local clinicians to provide condition specific training that can then include local preferences / pathways / innovations already in existence. We are also capturing the learnings and insights at this early stage of implementation so that they can be shared with other adopting organisations. One method of sharing these insights has been via a monthly community of practice with representatives from across the AHSN Network.
Future Plans / Next Steps
City University is conducting an evaluation of this work, with results expected early 2021.