Proactive Care Team

Our Proactive Care Team conduct home visits for appropriate patients to complete a comprehensive health and well-being review.

Surrey Heath and Ash Vale GP Practices

  • Bartlett Group Practice (Ash Vale Health Centre and Frimley Green Medical Centre)
  • Camberley Health Centre
  • Lightwater Surgery
  • Park House Surgery
  • Park Road Group Practice (Heatherside, Old Dean and Park Road)
  • Station Road Surgery
  • Upper Gordon Road Surgery

What is a Proactive Assessment?

Our aim is to help patients prepare for their future, to stay well, independent, and supported in their own homes.

A Proactive Assessment is a comprehensive health and well-being review, offered by the GP Practice to eligible individuals. This review is carried out in the patient’s home, lasting up to 90 minutes and provides an opportunity for patients to discuss what matters most to them regarding their health, independence, and overall well-being. All information gathered during the visit is added to the patient’s GP record so their usual practice team can access and act on the findings.

How are patients selected?

– Eligible patients are identified through NHS population health tools, that highlight individuals who may benefit from a Proactive Assessment and review.
– Selection is based on clinical indicators, recent use of health services, and other factors that may suggest someone is at increased risk in the future of declining health or changes in independence
– Eligible individuals are contacted directly by the Proactive Care team.

What does the assessment include?

This holistic approach helps identify potential needs early and is an opportunity to offer advice and guidance. During the assessment, we will discuss a wide range of wellbeing and clinical topics, which may include:

– Physical health and existing medical conditions
– Mental health, memory, and mood
– Lifestyle factors such as nutrition, social support, activity, falls prevention and sleep
– Any personal priorities or concerns the patient would like to discuss in relation to their health and wellbeing

Who will carry out the assessment?

Assessments are completed by our Proactive Care Team who work closely with and on behalf of each of the GP practices in Surrey Heath and Ash Vale. The Proactive Care Practitioners are registered Healthcare Professionals and DBS-checked.

Meet the Proactive Care Team


Andy Dixon – Proactive Care Practitioner

Helen Beckmann – Proactive Care Practitioner

Charlotte Claytor – Patient Services Coordinator and Proactive Care Administrator

What happens after the assessment?

At the end of the visit following suggestions and advice, we will offer a proactive plan. The summary is added to the patient’s GP record.
With consent we may refer the patient onwards if needs are identified, making sure the most appropriate teams are involved in their care. This may be within the NHS or with approved organisations.  

Contact Us

Telephone Number: 0333 332 0017 (Please leave a message and a member of the Proactive Care Team will call you back)
Email: shcp.proactivecare@nhs.net

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