Proactive management of Long-Term Conditions (LTCs)

Part of the NHS @Home programmes

COVID-19 placed unprecedented pressure on our health system. The immediate focus was understandably  on supporting patients with or at risk of the virus. However, there are a large number of people living with long-term conditions 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.

UCLPartners, our fellow Health Innovation Network, have developed the Proactive Care @Home framework and are working with all other HINs to disseminate and roll out support tools that enable systems, practices and services to identify and manage patients with long term conditions, 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 Health Innovation North West Coast, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool University Hospitals NHS Foundation Trust and Primary Care Knowsley worked together to provide both a virtual and a face to face service. This trial was short listed for three HSJ Awards.

Case study

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

Read the full case study > 

The Proactive Care @Home framework has been adopted by NHS England and they have provided funding to support its rollout in Cheshire and Merseyside. Health Innovation North West Coast are early adopters of the work and are one of four national pilot sites. 





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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