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Clinical Effectiveness Group

CEG’s data searches will support proactive care for a third of adults in England with long-term conditions

CEG’s risk stratification searches form an integral part of the Proactive Care Frameworks developed by UCL Partners. These resources have now been adopted into a national NHS programme ‘Proactive Care @home’, to be used in 12 Integrated Care Systems across England. This covers around one third of the adult population. 

Blue graphic showing heart and lungs

Proactive Care @home is an NHS England and NHS Improvement programme delivered by the NHS. It is built around UCL Partners' Proactive Care frameworks, which help GPs deliver efficient care post-Covid. The CEG-built searches scan patient records for clinical codes and list people with specific conditions - including asthma, type 2 diabetes and hypertension. They stratify the patients into high, medium and low risk. Typically, high-risk groups are then managed by the GP or pharmacist, and the lower-risk groups by healthcare assistants (for example, to support blood pressure monitoring at home).

The adoption of these resources into the Proactive Care @home programme has made CEG’s risk stratification searches widely available, for free, to support prioritisation of care for those most in need and reduce the demand for urgent care. Taking a systematic approach to proactive care also helps to ensure no patient is missed and everyone has equitable access to the right treatment.

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