Proactive management of Long-Term Conditions (LTCs)

Part of the NHS @Home programmes

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.

UCL Partners , our fellow Academic Health Science Network (AHSN), have developed the Proactive Care @Home framework and are working with all other 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.

This framework, led by Dr Matt Kearney, is based on new pathway development, virtual consultations, digital solutions and optimal use of the wider primary care team.

Despite the challenge of COVID-19 restrictions, staff from the Innovation Agency, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool University Hospitals NHS Foundation Trust and Primary Care Knowsley worked to provide a virtual and face to face service. 

A trial involving five GP surgeries in Knowsley began in October 2020. 

Case study

UCLPartners Proactive Care Frameworks help to improve care for asthma patients in north west England

Read the full case study > 

This trial was short listed for three HSJ Awards.

Proactive Care @Home has now been adopted by NHS E and NHS X and they have provided funding for Cheshire and Merseyside. The Innovation Agency are early adopters of the work (in part, due of the Knowsley Asthma project) and have been chosen as one of 4 national pilot sites. The view is that this approach will roll out further in 2022.





Proactive Care @Home frameworks are available for the following conditions on

  • Hypertension
  • Atrial Fibrillation
  • Cholesterol Primary
  • Cholesterol Secondary
  • Familial Hypercholesterolaemia
  • Diabetes
  • Asthma
  • COPD

Find out more >.

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