COVID-19 has placed unprecedented pressure on our health system. Immediate focus has understandably been on supporting patients with or at risk of the virus. However, there are a large number of people living with long-term conditions (LTCs) who need continuing, proactive management to prevent a wave of exacerbations, increasing healthcare demand in the months ahead.

Over the past 12 years, the number of emergency hospital admissions in England has increased by 42 per cent, from 4.25 million in 2006/07 to 6.02 million in 2017/18. Over 60 per cent of patients admitted to hospital as an emergency have one or more long-term health conditions such as asthma, diabetes or mental illness.

The Innovation Agency is supporting UCL Partners, our fellow Academic Health Science Network (AHSN), who have developed a set of tools to support identification, stratification and management of patients post-COVID-19 in primary care.

UCL Partners, led by Dr Matt Kearney, are working with AHSNs to disseminate and roll out support tools that enable CCGs, practices and services to identify and manage patients with LTCs, using a virtual-first approach. The LTC framework is based on new pathway development, virtual consultations, digital solutions and optimal use of the wider primary care team.

The Innovation Agency is supporting this framework by concentrating initially on COPD and asthma. The framework has been well received to date and, in one of the first group of practices to run the searches, has helped identify more than 250 patients with COPD not previously known to the local community respiratory service.

Further information and details of the support package can be found at

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