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using proactive care to support patients with long-term conditions

Why change was needed 

Multiple long-term conditions (MLTC) present a significant challenge to the NHS - with two-thirds of over 65s estimated to have MLTC by 2035. The Proactive Care approach is a model of community-based, multi-disciplinary working which aims to support older people to remain healthy, independent, and at home for longer.

What we did

Through a series of workshops, healthcare professionals are coming together to share the learning of current Proactive Care practices from Primary Care Networks (PCNs) and partners. By providing more proactive support to individuals with these conditions, Proactive Care aims to offer early identifications of people at risk of future deterioration, e.g., those living with multimorbidity, frailty, or complex needs, and to work with them to stay well and independent for longer through structured Proactive Care.


As one of the commitments within the NHS Long Term Plan, Proactive Care provides personalised community-based coordinated care that starts with what matters to the individual, and approaches care based on the individual’s strengths.

The Proactive Care model will also support the delivery of the wider transformation programme currently underway to embed population health management (PHM) approaches. An electronic data system called HealtheIntent has been developed to identify local groups of people who have chronic illness or are at risk of ill-health. Over time, multiple data sources will be brought together to help build a better understanding of a person’s health and care needs and the circumstances they live in.


What’s next?

Further workshops are scheduled to take place in Coventry, with two PCNs – Unity PCN and Navigation 1 PCN leading the development and testing of the proactive care pilot model.