Proactive care is personalised and co-ordinated multi-professional support and interventions for people living with complex needs.

The specific aims of proactive care are to improve health outcomes and patient experience by:

1. delaying the onset of health deterioration where possible
2. maintaining independent living
3. reducing avoidable exacerbations of ill health, thereby reducing use of unplanned care.

The Proactive care: providing care and support for people living at home with moderate or severe frailty guidance supports a more consistent approach to proactive care across England for people living at home with moderate or severe frailty, in line with the latest evidence and best practice.

Frailty is increasingly common – more than one in 10 people over the age of 65 (British Geriatrics Society, 2023) and up to half the population aged over 85 (Clegg et al, 2013) live with frailty, but frailty is not an inevitable part of ageing. The onset or progression of frailty can be slowed by taking a biopsychosocial approach and putting in place personalised and preventative measures that address a person’s range of needs in a timely way, enabling them to live independently and healthier for longer.

The increasing numbers of people with frailty have significant implications for health and care provision. Where early signs of frailty in people are not recognised and supported in the community, many subsequently present in crisis (British Geriatrics Society, 2023). Around 47% of hospital inpatients aged over 65 are affected by frailty (Doody et al, 2022) and this costs wider UK healthcare systems around £5.8 billion per year (British Geriatrics Society, 2023).

ICBs hold overall responsibility for ensuring implementation of proactive care, as part of an overall local plan to support people living with frailty. Working with relevant partner organisations, primary care networks (PCNs) will be well placed to identify the proactive care population cohort, with multi-professional support and interventions delivered through integrated neighbourhood teams. Those teams will likely include professionals from primary care, community services, mental health, secondary care and the voluntary sector.

The importance of delivering proactive care is set out in NHS England’s Mandate, the 2023/24 Winter Plan, the Major Conditions Strategy, GP Contract, NHS England Delivery plan for Recovering Access to Primary Care and the Fuller Stocktake report.

Further information and resources to deliver Proactive Care can be found on our community health services FutureNHS workspace. (Login required).