Here at Integrated Health, we’re delighted to share with you the finalists of the Primary Care Impact Awards 2023, celebrating innovation, new ways of working and good practice across primary care in the NHS and beyond.
Through categories exploring teams making a difference in primary care through patient access, digital solutions and more, here you’ll find out more about our finalists and hopefully take inspiration from their work.
Congratulations to each finalist!
Health Care First
Overview: “Paediatrics service in general practice”
Why? The GP workforce crisis hit hard, and children under 16 were being hit the hardest. We needed to increase capacity, ensuring paediatric patients were safely looked after and reducing our impact on A&E.
What happened? We recruited a paediatric practice nurse team, designed governance arrangements, set out a competency framework, and came up with patient pathways using the risk mitigation and escalation approach. The team was responsible for acute management of undiagnosed, undifferentiated presenting conditions on the same day; ongoing management or follow up of more chronic, recurrent problems; health promotion/prevention equivalent to PN role; and supporting and flagging with safeguarding issues. In six months, we had reduced the need for a whole time equivalent GP a day with a 50 percent cost reduction, we had reduced A&E attendances in under 16s, and patient feedback was 99 percent positive.
Looking ahead. The potential for learning to be shared vertically across the system is being assessed, and wider system partnerships are being developed to further support patients.
South Eastern Health & Social Care Trust
Overview: “Primary care multidisciplinary teams in general practice”
Why? To help support traditional GP practices by providing an innovative local wraparound service with the aim of better meeting the social, physical and mental health wellbeing of the population.
What happened? Primary care multidisciplinary teams (PCMDT) in GP surgeries allowed for collaborative working and reducing unnecessary referrals into secondary care services. 89 percent of patients surveyed were “satisfied” or “very satisfied” with the service and CCG data demonstrates a significant decrease in referrals of up to 50 percent into other trust adult mental health services in 20/21 and 21/22. “Beyond the foodbank”, a QI co-production initiative targeting improvements for people experiencing food poverty, evidenced that cooking from scratch increased by 57 percent and 100 percent reported increased nutrition levels.
Looking ahead. The positive impact of PCMDT impact will continue to be felt across areas such as inequality in access to care, service user experience, and a decreased need for referrals into secondary care.
Thistlemoor Medical Centre
Overview: “Amazing results from population health management approaches for our inner city Peterborough population.”
Why? To identify high intensity users of the primary health care and emergency care system using a data driven approach, and reduce demand on primary and secondary care ahead of winter.
What happened? A group of 400 people with low-level medical needs, who visited A&E more than 20 times a year and the GP more than five times, were identified and offered support through a Population Health Management approach. The practice held meetings with stakeholders including the local authority, to discuss options. A practice team made up of GP trainees/social prescribers/health coaches offered 1-1 consultations aimed to prioritise their wellbeing. They identified areas of ongoing concern for individuals. A cohort of 151 patients at Thistlemoor received a supportive consultation from the Thistlemoor team, use of A&E dropped by 70 percent and use of the GP by 30 percent.
Looking ahead. The cohort will be followed for the rest of the year to assess impact on their wellbeing and use of services, and 1-1 support sessions for employment/housing/social care issues will be continued.
Mid Mersey Digital Alliance
Overview: “Improving patient digital access”
Why? To promote digital inclusion for patients and GP practices, delivering support and assistance to promote the use and understanding of digital tools to improve outcomes.
What happened? Our teams delivered support to patients and clinicians on digital technologies, using heat maps to identify patients they could offer support to. They offered 1-1 support, group sessions and even home visits to get patients online. Work at one practice saw an increase in 8 percent of the patient population now using online services (514 patients), and we estimate this piece of work has saved the equivalent of 13 additional appointments per week. The team also gave practice managers access to data on telephone calls which allowed them to see information such as the number of abandoned calls. The practice are now answering more calls per day, and have seen their calls answered increase by 20 percent.
Looking ahead. Both of these pieces of work continue to be deployed across our other GP practices and patient populations, with our teams on hand to offer additional advice and support.
Old Mill Surgery
Overview: “Drive by Flu Vaccination Service”
Why? To help vaccinate and protect the local community.
What happened? We operate a Saturday drive-by Flu vaccination day, supported by the whole practice team and PPG, with support from local community. The council organise road closures, and we have police intermittent drive-by to support the delivery of this service. We initially send out invites, patients book electronically their car slot arrival time, which we preset using Accurx to ensure spread of appointments to avoid traffic. We set up vaccination stations roadside, and have marshalls greeting cars to check paperwork. The clinical team provide the vaccinations at the stations with HCA’s from other practices supporting us. Approximately 2000 people attend, reducing pressure on Nurse appointments.
Looking ahead. We hope that these measures will continue to help us to meet pressures on time and capacity.
The Royal Wolverhampton NHS Trust Primary Care Network
Overview: “Improving access within primary care”
Why? To improve patient care, services and access as a whole in a number of different ways, which is a continuous journey for us as we strive to be the best we can be for our patients.
What happened? A new call hub set up to ease pressure on our front-facing receptionists, answered over 1,000 calls at each GP surgery every week, reducing wait times by over 71 percent overall. iPads were introduced in waiting rooms, so that patients are able to book in for their blood tests. GP-led consultation clinics were held at Solace, which is a homeless facility in Wolverhampton. Asylum seekers living in hotels were offered clinics to receive vaccinations, health checks and more. The Enhanced Health in Care Home (EHCH) service worked with 17 care homes to ensure patients receive high-quality personalised care. We introduced Accurx to allow patients the opportunity to send queries over to GP practices via an online form.
Looking ahead. The project will continue its work to support patients in accessing care services, and will look to share learnings with other PNCs and health organisations across the country.
Southern Health and Social Care Trust
Overview: “Phone First and Urgent Care Service, SHSCT – Providing excellent primary care urgent care to our local community”
Why? The Urgent and Emergency Care Review recognised that the only access to same day urgent care for primary care patients was via emergency departments, leading to unsafe conditions for patients and staff.
What happened? We developed Phone First (PF) and an urgent care centre as a primary care, GP-led, multidisciplinary team collaboration. PF is staffed by GPs, nurses, first contact practitioners and advanced nurse practitioners, who can triage calls, advise, prescribe and book patients directly into appointments either into a local minor injury unit or urgent care centre with access to diagnostics. Calls per month into PF are in excess of 6500 and continue to grow. PF/Urgent Care has transformed how the population access and experience urgent care, whilst reducing the burden to GPs and secondary care colleagues.
Looking ahead. We have secured funding from the Department of Health to open a satellite Urgent Care Centre in October 2023, which will enable access to the full range of Primary Care Urgent Care Services 24/7.
North Cumbria Integrated Care NHS Trust & Northumbria Healthcare NHS Trust in partnership with NENC Primary Care Training Hub
Overview: “Embedded Knowledge and Library Specialist within Primary Care Training Hubs, taking the ‘heavy lifting’ out of getting evidence into practice”
Why? Staff working in NENC primary care had limited access to NHS knowledge and library services and did not have time to undertake in-depth searches of research evidence to inform their decisions.
What happened? The Knowledge Specialist role has helped primary care staff in evidence searches, quality improvement, project support, free access to journals, and sharing knowledge. Educational programmes informed service improvement and innovation by facilitating knowledge sharing and lessons learned workshops, offering health literacy skills training underpinned by digital skills. Staff were connected with digital knowledge resources, and to study and research skills. After the first year, evaluation showed more informed decision-making, improved quality of patient care, better professional development opportunities, improved safety, and improved service quality.
Looking ahead. A full evaluation at the end of this two-year pilot programme is due to report in January 2024 with expectation that this will support its continuation in 2024- 25.
NHS Royal Wolverhampton Trust
Overview: “GP End of Life”
Why? The care for those with complex care needs can be highly fragmented and prior efforts over many years to develop integrated ways of working and establish cohesive care pathways have failed to deliver benefits.
What happened? We adopted the WHO Model of Chronic disease management to put data and informatics at the heart of innovation work for transformative change. We deployed new systems into care at the interfaces, where care breaks down. We built a digital platform that suggests patients who may be end of life. Over the last 18 months, colleagues from our Digital Innovation Unit, with collaboration from six pilot practices, have been working on this system, which has been modified to incorporate feedback from our GP colleagues. It takes the whole practice population, then digitally risk stratifies (about 10 percent) them for clinical assessment, defining those who have unmet needs, who then have a semi structured needs analysis assessment (about two percent).
Looking ahead. It is expected that GPs will see improved benefit through supported triage, outlining the conditions a patient may have, and any interventions that have already been in place.
Northern Lincolnshire and Goole NHS Foundation Trust and Meridian Health Group
Overview: “Connected Health Network – Rheumatology”
Why? To help reduce referrals to hospital, outpatient-based care.
What happened? The rheumatology pilot with Meridian Health Group PCN, has managed 85 percent of referrals within primary care, with high patient satisfaction levels. The Connected Health Network (CHN) model sees GPs working in partnership to manage patient’s care, accessing the Connected Health Network service within their own PCN. The CHN clinics are supported by Dr Tim Gillott, a rheumatology consultant. The 15 percent of patients who need to be referred into secondary care receive a full work up, so the hospital team has information to facilitate their onward pathway. Meridian Health Group PCN’s rate of referral to secondary care by GPs per 1,000 patients is already 60 percent lower than other PCNs in NE Lincolnshire.
Looking ahead. The CHN model is being piloted across other PCNs and specialties in Northern Lincolnshire including cardiology, gastroenterology and diabetes.
Healthwatch Essex
Overview: “Access to Community Pharmacies in West Essex”
Why? Residents of Stansted Mountfitchet were unhappy with existing community pharmacy provision.
What happened? We undertook this project using a survey, case studies and one to one interviews, canvassing the populous of West Essex around their access to pharmacy services. A significant number of respondents to the survey came from residents of Stansted Mountfitchet. They were frustrated that there was only one NHS dispensing pharmacy in the village with no disabled access, long queues (often outside the store), long waiting times for prescriptions to be filled, no adequate space for private one to one consultations with a pharmacist if required etc. We completed a report, which was submitted to Hertfordshire and West Essex ICB, and we also presented it at the Primary Care Board meeting. The Pharmacy Appeals Committee ordered for the application to be granted.
Looking ahead. We are committed to continuing to help improve access to health for residents.
Shifa Surgery
Overview: “Identifying gaps in health needs”
Why? Exploring innovative ways to improve health outcomes, and creating sustainable services to meet the greater needs of the community.
What happened? The team analysed gaps in health needs using various indicators, and then worked collaboratively to find a solution. The introduction of the LumenEye clinic, a GP-led endoscopy service, has helped reduce waiting times for patients with non-sinister lower bowel problems from nine months to two weeks, with a full report being sent to the referring GP within 48 hours. Our in-house audiology service means eligible patients can now access this service within a fortnight. In-house bowel screening, an out of hours clinics and a midwife clinic, have also helped improve care for the local population. We worked with the Local GP Federation to offer extended hours access, which reduced demand at the local A&E department.
Looking ahead. Shifa will continue to collaborate with external services to better the care of their patients and the community, and will continue to integrate these services into the surgery to promote improved access.
Barnsley Healthcare Federation and South West Yorkshire Partnership NHS Foundation Trust
Overview: “Making an Impact in Primary Care – effectively tackling health inequalities”
Why? The life expectancy gap for people with severe mental illness indicates that people with SMI are five-and-a-half times more likely to die prematurely than those without an SMI, due to preventable physical health conditions.
What happened? Our health care teams came together to improve the physical health of people with SMI or a learning disability. We developed a joint plan to reach hard to contact patients, and provide these people with an annual health check. We connected community teams with others from primary care, and enhanced data sharing across organisations so recommendations from results could be followed up by all healthcare providers involved with the patients care. We delivered SMI training to staff to enable more pro-active conversations to take place with patients. We expanded our specialist team by employing a SMI Lead Nurse and Strategic Health Facilitator. By December 2022, over 50 percent of people with an SMI had received a check.
Looking ahead. We are rolling this service out across the whole of Barnsley, and plan to share this good practice across South Yorkshire. Six additional health and wellbeing coaches will be recruited to add capacity.
Burlington Primary Care
Overview: “Improving quality, access and supporting DPI inhaler switches for people living with asthma through group clinics”
Why? The challenge of maintaining the asthma register and the unsustainability of 20-minute telephone reviews.
What happened? We switched to group clinics and combined the asthma QOF review and the switch conversation. To assure choice, equity of access and convenience, we provided both video group clinics that align with working lives – 7.30 am and 12.30 pm – and face to face group clinics with refreshments. All nurses deliver both formats. We invite 20 people aged over 18 to each asthma group clinic. Under 18’s get a face-to-face, one-to-one review. In advance, people complete the asthma control test. The questions and concerns the group raises are discussed in an interactive discussion. Then the clinician has personalised one to one discussion with each person in turn.
Looking ahead. The team hopes to support rheumatoid arthritis patients with pain management through group clinics in the future.
Broxbourne Alliance PCN
Overview: “Improving access to personalised menopause care and support: the Broxbourne Alliance PCN integrated menopause pathway”
Why? Menopause can be crippling – 20 percent leave work as a direct result. Women may attend up to 10 GP appointments before getting diagnosis and treatment, and few GPs are trained in menopause.
What happened? Broxbourne Alliance PCN embedded a refreshed menopause pathway, built around a video group clinic. All practice booking teams and clinical staff were trained to recognise peri-menopause and menopause symptoms. Patients are offered a video group clinic appointment, facilitated by our social prescriber, with a GP joining to answer questions and discuss HRT options. Those requesting HRT attend an assessment with a GP trained in menopause management. Once on HRT, PCN clinical pharmacists conduct annual HRT reviews. Our health and wellbeing coach supports with motivation, weight management, mental health and nutrition. The initiative has increased uptake of NHS health checks by 80 percent, and increased health and wellbeing referrals.
Looking ahead. The team will continue to make improvements to the pathway, based on patient feedback and stakeholder meetings.
Brompton Primary Care Network
Overview: “Community Corner at Violet Melchett Health and Wellbeing Hub”
Why? To develop local solutions for residents and improve access to services.
What happened? The community corner is an open and flexible community engagement space at Violet Melchett Wellbeing Hub. The development of the space has been informed by local evidence relative to demographics and population health data. Community engagement is pivotal to increase the footprint of the space, therefore the community corner offers themed sessions to patients and uses activities as a tool to enhance engagement and generate wider conversations about health and wellbeing. In addition, the community corner promotes volunteering programs to serve as a designated space for information sharing and induction. The space is manned two to three days a week by neighbourhood navigators, patient navigators and community volunteers.
Looking ahead. Brompton PCN will continue to take on board patient and stakeholder feedback on how the space can be developed to further meet the needs of the local community.
Sheffield University Health Service
Overview: “EDOC – Eating Disorders Outreach Clinic at Sheffield University Health Service”
Why? As a Student Health practice, we see a disproportionately high rate of patients with complex eating issues, who do not fulfil the very strict criteria needed to get help in the local tertiary referral clinic.
What happened? The clinic has three part-time staff working six clinical days, and sees patients with a range of eating disorders, many of whom also have comorbidities including ASD, ADHD, personality disorder or gender dysphoria. It provides one-to-one weekly bespoke sessions for each patient. The team lead provides a vital link to the Sheffield Eating Disorder Service where she works two days per week, ensuring patients are seen and followed up. The clinic saw over 150 patients last year (a 50 percent increase on the previous year). Team lead practitioner Gilly has also spent a lot of time developing and expanding the team and training other members of staff and regularly provides in house help, training and advice for colleagues. She has also led the introduction of a real-time recovery app for patients.
Looking ahead. The team hopes to continue its great work in this area.
Leeds GP Confederation
Overview: “Leeds Community Ambulatory Paediatric Service (CAPS) – Improving Access for Children and Young People with Respiratory Infections”
Why? To help manage paediatric presentations of acute respiratory symptoms in children aged 12 weeks to 16 years old, and to reduce unnecessary ED attendances and hospital admissions.
What happened? CAPS is delivered by a skill mixed team of GPs, Advanced Nurse Practitioners and Advanced Clinical Practitioners, through a blend of telephone and face to face consultations. Between 23 January and 10 April 2023, 3411 appointments were offered, which represents 123 percent of the base model. Feedback from GP practices shows reduced pressure in managing the demand of paediatric presentations. Of all 3411 CAPS attendances, only 18 children required onward referral to hospital. This represents an overall onward referral rate of 0.5 percent, meaning most patients that utilise the service have their needs met without the need for onward referral. This is much lower than the national average of 5 percent (admission rate) when compared with other similar urgent primary care services.
Looking ahead. The West Yorkshire ICB has commissioned the service to run year-round, and it is hoped that the service can be replicated regionally and nationally.
Oberoi Consulting
Overview: “Heart Failure Therapeutic Review Service”
Why? To identify and optimise the treatment of those with chronic heart failure (HF) in primary care in the North East.
What happened? The optimal management of heart failure in Darlington was used as the model for this work. Oberoi delivered education in HF to practices, then a stepwise approach from data validation through to patient identification, clinical coding, clinical notes assessment, virtual heart failure clinics, reaudit and robust clinical reporting. The local HF pathway was followed for medicines optimisation reviews. Any patients who were deteriorating significantly and/or any patient with severe heart failure not previously known to the service were referred to the local team. Prevalence increased from 1.03 percent to 1.30 percent (an extra 290 patients HF coded). Within sub-categories, this saw an uplift of £19,601 practice income from QoF.
Looking ahead. The team hopes to continue to develop the service and use it as a model to help other regions manage HF in primary care.
Focused Care
Overview: “Focused Care CIC – Making the invisible visible”
Why? To provide innovative high-quality health and social support to complex patients who are often adversely affected by the social determinants of health.
What happened? Focused Care supports the delivery of improved public health outcomes, such as reducing inappropriate urgent care use, improving financial stability, or preventing homelessness. Focused Care Practitioners (FCPs) are Band 6 skilled healthcare professionals with backgrounds from a range of health and social care settings, allowing us to give our service users targeted care and support. Focused Care has its roots in Hope Citadel Healthcare CIC but is now independently commissioned in over 65 GP practices across Greater Manchester and beyond. In January 2020, the Research Team at Greater Manchester Combined Authority examined the records of 430 random Focused Care records. The analysis suggested a positive impact of Focused Care on socio-economic outcomes.
Looking ahead. Focused Care hopes to continue to offer high-quality care and support to patients adversely affected by the social determinants of health.
Central Basildon PCN
Overview: “A collective effort of Nine GP practices in the Basildon area, united by a common vision to provide comprehensive, high-quality healthcare services to their community”
Why? To enhance the health and wellbeing of the local community.
What happened? Central Basildon PCN prioritises collaboration among healthcare professionals, to ensure patients receive holistic care that addresses their physical, mental, and social needs. Recognising the potential of technology, the PCN has implemented digital health solutions such as EHRs, telephone consultations, and online appointment booking systems. EHRs have streamlined patient data management, making it easier to access crucial information and deliver more personalised care. Patients have benefited from reduced wait times, improved access and enhanced communication with their care providers. Moreover, digital tools have allowed Central Basildon PCN to gather and analyse data more effectively, aiding in population health management and targeted interventions.
Looking ahead. The PCN hopes to continue to innovate and evolve, inspiring others to follow in their footsteps.
Southend Integrated Healthcare for the Homeless (SIHH)
Overview: “Providing Primary Care Health for the Homeless population in Southend on Sea”
Why? There is a large population of homeless in Southend, with no access to primary care. SIHH provides primary care services to enhance quality of life, reduce avoidable use of crisis services, and reduce premature deaths.
What happened? Partners from food banks, soup kitchens, hostels, outreach teams, hospital, mental health and substance misuse providers, have collaborated to build this service, which maximises opportunities to tag on other health initiatives, such as HEP C screening, COPD, blood pressure testing and flu/COVID-19 vaccination. Weekly clinics are held at the local homeless centre and at two local soup kitchens, a rough sleepers mental health team has been developed, and clients are encouraged to register with Southend Medical Centre. Three undiagnosed cases of Hep C have been picked up so far with screening, and services like prescriptions and wound dressings are offered.
Looking ahead. The service is looking to recruit a HCA, and is in discussions with Eastern Deanery to provide placements for GP trainees, as well as Anglia Ruskin University to be added to the health inequalities curriculum.
Wandsworth PCN
Overview: “Primary Care Network Nursing and Home Visiting Service”
Why? The service recognises the importance of extending care beyond traditional medical facilities, particularly for those with limited mobility, chronic illnesses and the management of complex medical conditions.
What happened? The service assists with areas including COVID, flu, shingles or pneumonia vaccinations, diabetes, COPD and asthma reviews. The PCN Nursing and Home Visiting Service has emerged as a beacon of hope and support for housebound individuals who require care. The service is set up for not one but six surgeries working in collaboration. It includes a team of nurses, healthcare assistants, paramedics, administrators and support staff who work with patients facing complex health challenges, coordinating with other healthcare professionals and ensuring that the care they provide aligns with broader treatment plans. The impact of the Primary Care Network Nursing and Home Visiting Service is quantifiable and evident in the improved health outcomes of patients.
Looking ahead. It is hoped that the team’s contributions will continue to inspire others in the field.
Healthcare First
Overview: “Remote heart rhythm assessment using smartphone-based photo plethysmography in primary care to detect undiagnosed atrial Fibrillation in patients with chronic obstructive pulmonary disease”
Why? To use technology to improve early detection and management of atrial fibrillation (AF) in patients with COPD.
What happened? The study evaluated the use of smartphone-based photoplethysmography (PPG) technology, specifically the FibriCheck app. Among 90 COPD patients who participated, the study identified five cases of newly diagnosed AF using the PPG-based monitoring. This remote assessment approach was found to be feasible, enabling early detection and initiation of guideline-based management for AF in COPD patients. The study highlights the potential of smartphone-based PPG technology for efficient AF screening in primary care settings. The initiative successfully identified previously undiagnosed AF in 5.6 percent of the COPD patients who participated in the remote heart rhythm monitoring using the FibriCheck app.
Looking ahead. It is hoped that the value for money and increased efficiency in AF screening and management in COPD will encourage the use of this approach across different healthcare contexts.
The Homeless Health Service
Overview: “Dentistry for homeless people”
Why? To support the homeless population of Bristol in accessing dental support, to prevent their continued marginalisation for their looks or inability to function in the normal world.
What happened? The Homeless Health Service is a GP practice in central Bristol, commissioned to provide healthcare for homeless and vulnerably housed people of Bristol. To date it is very difficult for those with no fixed address to access dental care so we have introduced a dental hygienist who supports and educates clients with dental hygiene, nutrition and mouth health. She is also working with the dental hospital to establish clear pathways that will make access for clients of no fixed abode, easier going forwards. The service has made a significant impact to date, for example a lady, frequent injector of heroin for over 10 years, was fitted with a pair of dentures, and left smiling, laughing and full of hope for her future.
Looking ahead. Since the first lot of funding (six months) ran out, we have continued to self fund, and are now working with opticians to try to establish an equally invaluable service.
Healthtech-1
Overview: “Making new patient registrations a thing of the past and giving NHS staff one less task with Healthtech-1”
Why? The NHS GP practices have long been burdened by administrative tasks that divert valuable staff time away from patient care. Admin staff spend at least 15 minutes processing just one new patient registration.
What happened? Over 200 GP practices have automated their registrations to date, saving time, increasing patient satisfaction and improving data quality. New patient registration is a task that requires meticulous data entry, verification, and coordination. The manual process is not only time-consuming but also prone to errors, which can have downstream effects on patient care and resource allocation. Healthtech-1 have developed a solution to not only register the patient but also complete all the clinical coding too. This means that practices get an uplift in data quality and reduction in staff time since up to 95 percent of registrations can be automated.
Looking ahead. Healthtech-1’s team hopes to continue helping practices across the country to free up time by automating new registrations, and improving quality of data to improve care.
Agilio Software
Overview: “Agilio TeamNet + My Locum Manager: Seamless Workforce Solution to Ease Crisis”
Why? Practices across England are becoming overwhelmed by the increase in patient demand that is outstripping the available supply and placing an unbelievable strain on healthcare services.
What happened? Agilio has taken its operations management software, TeamNet, and, working closely with PCNs and ICBs, introduced My Locum Manager (MLM) – a seamlessly integrable tool to significantly enhance TeamNet’s existing workforce and HR capabilities. Together, TeamNet + MLM provides a staff bank solution which allows access to a wider pool of clinicians, nurses, and ARRS roles. Coupled with TeamNet’s HR and workforce modules including rotas, staff availability, HR cards (including HR checks and key credentials), and mandatory training, practice managers are provided with what they need to source, book, and manage staff compliantly all in one place. At Nottinghamshire ICB, in a six-month period, there were over 1,772 shifts filled.
Looking ahead. Agilio wishes to continue empowering healthcare providers to overcome pressures with innovative tools that enable adaptation, foster excellence, and support sector sustainability.
Inhealthcare
Overview: “Surrey Heartlands scales up remote monitoring service with Inhealthcare to support 125,000 people living with high blood pressure”
Why? To increase levels of patient activation, reducing emergency attendances and GP appointments, maximising resources for those with higher levels of clinical need.
What happened? Blood Pressure@Home enables patients to monitor their blood pressure from the comfort of their own home. The service is led by clinical pharmacists and care coordinators, working alongside GPs and other specialists. Patients most at risk of hospitalisation or stroke are actively monitored, submitting BP readings via a channel of their choice – an app, email, text message, or phone call – to the long-term conditions digital care coordinator, whose post, along with Inhealthcare licenses and blood pressure monitors, has been supported through NHS England funding. 3,161 patients from high-risk cohorts engaged with the BP@Home service between October 2021 and June 2023 and progressed through 4,031 cycles of monitoring.
Looking ahead. The ICS is scaling up the service across a population area of 1.1 million people, which includes an estimated 125,900 people who are living with poorly-controlled diagnosed or undiagnosed hypertension.
Cumbria Health on Call
Overview: “Health@Home”
Why? To facilitate the remote monitoring of patients at home and in care homes thus alleviating pressure on GPs, reducing carbon footprint, increasing patient experience and engagement.
What happened? Health@Home is used to remotely monitor key health metrics in patients’ own homes, including COVID-19, blood pressure, INR levels for Warfarin patients, and heart failure risks. Patients are on-boarded to the appropriate service following a referral from GP or secondary care. The services utilise one patient app (HealthWatch) which delivers all services in an easy-to-use interface with the results displayed in a single dashboard monitored by a non-clinical monitoring team. BP@Home averages 90 referrals per month at Alston practice alone, and the INR@Home project is expected to save over 1000 appointments per year in practices per 100 patients based on recent projections.
Looking ahead. Further developments for the projects include consolidating digital solutions onto one common platform, and integrating the Health@Home service into programs such as virtual wards.
Solve.Care
Overview: “Solve.Care’s Care.Platform, streamlining for efficiency”
Why? The platform seeks to address inefficiencies and complexities within healthcare by streamlining processes while increasing transparency – giving patients more control of their healthcare journeys.
What happened? Care.Platform provides enhanced access and seamless coordination, decentralising healthcare data and storing in the individual’s personal data node. Patients can access their health records and connect with healthcare providers from anywhere, consulting specialists worldwide for second opinions or simply reviewing test results while on vacation. Care.Platform utilises blockchain technology to securely and transparently manage healthcare data, and AI and ML algorithms to provide predictive insights, tailored care plans, and data-driven recommendations. The user-friendly interface makes it straightforward to navigate. Care.Wallet mobile app is the primary access point for users to engage in health networks and services available on Care.Platform.
Looking ahead. Through innovative use of blockchain, AI, and machine learning technologies, Solve.Care hope to continue to change how healthcare is accessed, managed, and experienced.
Dictate.IT
Overview: “Dictate.IT’s speech recognition solutions are unrivalled”
Why? Dictate.IT are tackling existing rules of technology implementation that are restrictive and don’t offer GP practices the best or fastest solutions.
What happened? Our clinical correspondence solution utilises our speech engine, so administrative and secretarial teams no longer receive audio files to type from. Letters from the clinician arrive transcribed via speech recognition, so letter-typing is a thing of the past. Our speech recognition solution is 99 percent accurate from first use; users don’t need to train the speech engine to understand their voice or accent; and anyone can pick it up and use it immediately, with 99 percent accuracy from the start. Plus, it’s made for healthcare, so its knowledge of medical terminology is unrivalled. All of our solutions are web- and cloud-based. Users are provided with a unique login and can then access the solution from anywhere in the world, or on-the-go.
Looking ahead. Dictate.IT will continue to update their solution to keep pace with technological developments, helping support practices even further.
Enhanced Primary Care
Overview: “We have found £1,476,761 of unclaimed practice income in the past two years!”
Why? To help GP practices locate unclaimed income, to prevent loss to the practice and thus patients they look after.
What happened? 334 practices have signed up to the service since 2021. Once theses reconciliations are complete we will have found £5.3 million. This income would otherwise be lost to the practice and thus the patients they look after. We have supported GP practices to locate £1,476,761 of unclaimed income in the past 2 years. We offer practices a remote “done-for-you” reconciliation service. Using bespoke in-house technology the EPC team analyse data from the practices clinical database. This analysis identifies work that has been undertaken but not claimed. Maximising the use of digital technology allows practices to provide all information required to compete the reconciliation in less than 15 minutes.
Looking ahead. We will continue to scale to meet the needs of the remaining 6884 practices in England and Wales, as well as realising of the remaining £3.9 million for those already signed up to the service.
Thistlemoor Medical Centre
Overview: “Understanding and improving the wellbeing of our patients by understanding what’s actually happening with them and supporting them”
Why? To identify high intensity users of primary care, ideally reducing demand ahead of winter.
What happened? A group of 400 people with low-level medical needs, who visited A&E more than 20 times a year and the GP more than five times, were identified and offered support through a Population Health Management (PHM) approach. The practice held meetings with stakeholders including the local authority, to discuss options. A practice team made up of GP trainees/social prescribers/health coaches offered one-to-one consultations aimed to prioritise their wellbeing. They identified areas of ongoing concern for individuals. A cohort of 151 patients at Thistlemoor received a supportive consultation from the Thistlemoor team, use of A&E dropped by 70 percent and use of the GP by 30 percent.
Looking ahead. The cohort will be followed for the rest of the year to assess impact on their wellbeing and use of services, and 1-1 support sessions for employment/housing/social care issues will be continued.
East London NHS Foundation Trust
Overview: “The Greenhouse Practice: A Community Health Hub in Hackney”
Why? To help improve access to care across the community and into vulnerable or hard-to-reach populations.
What happened? We converted refurbished London buses into mobile healthcare units. We work with Public Health in Hackney Council and the City of London homeless team to provide outreach to rough sleepers. A community wellbeing van provided by Hackney council parks in City of London every week with a clinician to provide a space for rough sleepers to easily access healthcare. We provide weekly clinics with interpreters onsite for asylum seekers to access care, and run regular outreach to hostels in Hackney to improve access to health care for those patients who historically do not attend the GP service. Our focus on specialised care pathways has been effective in managing infectious diseases, reducing ER visits, and enhancing patient outcomes.
Looking ahead. Future plans include moving to a larger site to provide more services in-house, and becoming a training practice to train future GPs and nurses in inclusion health.
Shifa Surgery
Overview: “Preserving and maintaining health and reducing inequalities in the community”
Why? Shifa Surgery provides services to a registered population of over 10,500 in a town with a high index of socioeconomic deprivation, and wants to tackle inequalities.
What happened? The Shifa team is made up of a clinical and admin team with different specialities. We use statistics and health economics to identify the needs of the population, aiming to reduce inequality. We established effective teams that include a social prescriber, chronic health disease monitoring, palliative care and a mental health team. An area of service development based on patient feedback was pain management and the lack of secondary care services to deal with this. A gap was found where waiting time for a joint injection at the hospital was over six months. Shifa surgery expanded its team of joint injection administrators with training and support. Waiting time for joint injections at the surgery is around two weeks.
Looking ahead. A sleep clinic is hoped to be up and running within the next two months. The surgery will continue look for new and more efficient ways to deliver and to elevate patient care and improve staff wellbeing.
Barnsley Healthcare Federation
Overview: “Barnsley Healthcare Federation – Practice Delivery Agreement achievements”
Why? Improving outcomes and delivering excellent patient care.
What happened? Barnsley Healthcare Federation holds the contract for four general practices in Barnsley. All our teams’ objectives are patient care focused, and BHF is extremely proud of the achievements of our four practices in 2022/2023, particularly the great work achieved through the Investment and Impact Fund with all four practices hitting the targets demonstrating excellent patient care. All four practices also achieved all targets for the Practice Delivery Agreement contract, which ensures patients receive an excellent quality of care. Our practices were also the first to go live with NHSE Register with a GP surgery, giving patients the opportunity to register with a GP practice online. We received a letter from NHSE for achieving 77 percent of our hypertensive patients treated to target.
Looking ahead. BHF is committed to continuing to deliver outstanding patient care.
Holderness Health
Overview: “New call hub from Holderness Health Practice Team”
Why? To help and empower patients, embrace change and consistently strive for excellence putting our patients and staff at the heart of our approach.
What happened? We created a new ‘call hub’ to reduce call waiting times. This includes a GP on-site to support staff and manage access to appointments. We’ve built a mobile library to help our Proactive Care team visit remote communities, and launched projects including the Holderness Integrated Care Centre – a virtual model of managing frail patients through an multidisciplinary team (MDT) approach with multiple partners; an assistive technology pilot with East Riding Council to identify and support patients with early onset cognitive memory impairment; and an Integrated Neighbourhood Teams pilot using an MDT approach to review patients ‘of high concern’. We conducted an annual staff survey, and 77.6 percent of respondents said they would “recommend Holderness Health as a great place to work”.
Looking ahead. Our team is committed to continuing to support and empower our patients.
Mundesley Medical Centre
Overview: “When most practices would crumble, we have innovated and educated”
Why? To overcome staffing and GP shortages, ensuring patient care remains the focus.
What happened? With one remaining GP, a senior nurse practitioner deals with queries from reception and medication queries. Our physician associates carry out our home visits and will video call the GP if they need support. Our reception team use templates developed by the practice, to guide them to correct treatment pathway for patients. We have encouraged many of our patients to use the NHS App to order medication, and are running regular IT clinics to support patients in using it. In end of life, we have developed the roles of care coordinators to lead on communication with patients and carers. Our ICB commented “there is some great best practice”, and is hoping to publish the case study more widely.
Looking ahead. We have just been approved by NHS England as a learning environment and have our first registrar starting in November 2023.
The Hollies Medical Centre
Overview: “The Hollies Medical Centre: Practice Of The Year”
Why? To provide the best care we can every day for our patients and the community.
What happened? We have a forward thinking, patient-centred team, dedicated to providing the best we can every day for our patients and the community. Every member of the Hollies team has produced incredible results, adapted to continuous change and evolution in the world we work in. We are constantly engaging with our patients and our Patient Participation Group wherever we can. We have increased the feedback from our patients on the NHS Review Website from nine to nearly 400, and achieved a five-star rating. We constantly look at ways to make the best experiences for our patients in getting to the right clinician at the right time, and providing a strong, educated and dedicated administrative team to back them throughout the week’s work.
Looking ahead. The team will continue in their commitment to improving patient experience.
Merepark Medical Centre
Overview: “Always Going the Extra Mile”
Why: To improve patient and staff experience.
What happened? The team have worked 24/7 at the vaccination clinics and in January 2023 we set up an Acute Respiratory Hub (Jan-March 2023), which was open seven days a week. We have set up an MMC Walking Group for our patients of all age groups so they can socialise with others supporting their mental health. Our receptionists are now care navigators under our patient experience Team, and we have introduced a patient experience manager who set up an email address for patients to provide feedback. We were awarded gold plus and top of the national greener practice table. We have also implemented a wellbeing coach in the team to support both staff and patients alike.
Looking ahead. Merepark Medical Centre is dedicated to providing patients and staff the best experience possible.
Havergal Surgery
Overview: “Project Feed Well, committing to a positive culture”
Why? To promote a safe and healthy working environment, and to overcome staff burnout.
What happened? A committee was formed consisting of both clinical and admin staff, and we held discussions with staff members to see what was most important to help them. Project Feed Well uses the common interest of food to break boundaries, as the team has been able to spend time together outside of work. The clinical and admin team have been able to work closely together and this has improved efficiency, but also the teams feel more comfortable approaching each other and even train each other to help patients. The project has been recognised on an ICB level in recognition of our commitment to a culture of wellbeing and health, and practices within the PCN were invited to some of the surgery activities, this would encourage a better working relationship.
Looking ahead. Havergal will endeavour to promote staff wellbeing and morale.
St Lawrence Surgery
Overview: “Clinical Signposting – meeting the demands of the patient in the most effective way”
Why? To reduce the significant burden on the triage system and to improve patient access and satisfaction.
What happened? We wanted ensure that the patients are treated by the most appropriate health care professional in the most appropriate way first time. We focused on improving patient experience and access to the surgery, and triaging red flag symptoms to promote timely action. The number of patients being seen by the surgery increased by 10 percent, which equates to 600 more patients seen per year. Paramedic appointments were utilised to see minor acute illness, and paramedic activity grew by 1600 interactions in 2022. The pharmacist team was utilised more effectively, and e-consult activity rose from 1 percent to 10 percent. This resulted in a 24 percent reduction in GP triage time, an 8 percent increase in pre-booked GP telephone calls, and the number of times patients were seen multiple times reduced.
Looking ahead. We hope to further reduce the burden on the triage system and improve patient access and satisfaction.
The Banks & Bearwood Medical Centre
Overview: “Staff determination supporting reputation”
Why? To help the practice overcome current challenges.
What happened? The surgery has struggled with retirement of partners and salaried GPs leaving due to being ‘burnt out’. However, with a new building scheduled for this year, and thanks to our amazing staff and patients, we are staying afloat. With new management and the determination of our clinical and non-clinical staff, the reputation of our surgery is growing again and we are recruiting new clinical staff. A planned merger has not proceeded, and this surgery will go far without being held to a surgery group merger.
Looking ahead. With recruitment and a new building underway, we look forward to delivering the best possible care to our community.
Avicenna Medical Practice
Overview: “Improvements in patient care, access and team working”
Why? To redesign practice access arrangements and improve patient flow through the system.
What happened? The practice team worked together by meeting, brain storming, and sharing ideas to come up with several solutions to access challenges. These were shared with patients and the changes developed and implemented. Complaints have reduced too, previously we used to get on average one to two complaints a month about access and getting through on the phone. Since the new system has been implemented, we haven’t received any. Our Friends and Family results have shown a marked improvement over the last 12 months from 43 percent of patients would recommend our surgery to 92 percent of patients were likely or extremely likely to recommend our surgery. Our mental health patients and learning disabilities cohort get full annual health checks and a care co-ordinator assigned to help them and their families.
Looking ahead. We want to continue to develop and improve on access, but to also use those improvements to improve quality for our most vulnerable.
Southend Medical Centre
Overview: “Southend Medical Centre is a ‘Beacon in the Community'”
Why? Southend Central is a deprived area with a high number of homeless patients, struggles with drug and alcohol addictions, mental health crisis situations and English is not the first language of many of our patients.
What happened? We welcome patients to the surgery in multiple languages. We are a Dementia Friendly Practice, including a support pack and services available for patients and their families. We have amended registration forms and a safe space for our LGBTQ+ community. We highlight veteran status on patient records should they require to be seen sooner, or a more sensitive approach to their care, including a quieter place to wait. We are the leading surgery for the Homeless Project in our area, and are currently involved with a Pilot for Child Protection Services, for CP-IS (Child Protection Information Sharing) which allows us to view the last 25 involvements with health care in other areas and known to other services.
Looking ahead. We will develop our practice to suit the needs of our community.
The Royal Wolverhampton NHS Trust PCN
Overview: “Improving access within primary care”
Why? To improve patient care, services and access as a whole in a number of different ways, which is a continuous journey for us as we strive to be the best we can be for our patients.
What happened? A new call hub set up to ease pressure on our front-facing receptionists, answered over 1,000 calls at each GP surgery every week, reducing wait times by over 71 percent overall. iPads were introduced in waiting rooms, so that patients are able to book in for their blood tests. GP-led consultation clinics were held at Solace, which is a homeless facility in Wolverhampton. Asylum seekers living in hotels were offered clinics to receive vaccinations, health checks and more. The Enhanced Health in Care Home (EHCH) service worked with 17 care homes to ensure patients receive high-quality personalised care. We introduced Accurx to allow patients the opportunity to send queries over to GP practices via an online form.
Looking ahead. The project will continue its work to support patients in accessing care services, and will look to share learnings with other PNCs and health organisations across the country.
Canvey Island PCN
Overview: “Canvey Island Primary Care Network”
Why? To support our local population through outreach.
What happened? Canvey Island Primary Care Network is made up of six GP practices covering a population of approximately 41,000 patients. Outreach clinics support the Core20PlUS5 areas as part of the health inequalities work by providing drop-in sessions on a weekly basis at locations such as caravan parks and sheltered housing. Support from our patient participation group has given us inside knowledge to tailor the clinics to meet the needs of the community. Since April 2023 the team have seen around 700 patients at the drop-in clinics. To help support with early cancer diagnosis Canvey Island PCN hold centralised dermatology and cervical screening clinics once a week, which have supported member practices with additional appointments as well as early detection.
Looking ahead. We will continue to offer this range of outreach and services to our patients to support access.
Barnsley PCN
Overview: “Community integration achieving positive outcomes for patients to tackle health inequalities”
Why? To offer more services, increase clinical appointments and demonstrate positive outcomes for the patients of Barnsley.
What happened? Our PCN is split into six neighbourhoods, with six clinical directors who are all GPs. Our 31 GP practices work together and support one another when needed. Larger practices take on training roles such as trainee nursing associates or physician associates, and we have around 144 additional roles which have monthly meetings, which gives the opportunity for peer support. Our personalised care team, IMPACT, is made up of social prescribers and health wellbeing coaches, for patients wanting support to achieve their goals. Care co-ordinators are in all practices, being the first point of contact for patient care. We also set up three pilot sites where onward interventions and referrals could be monitored to boost onward care.
Looking ahead. We will work together to ensure the needs of our whole population are met.
NHS Willows Health
Overview: “NHS Willows Health PCN: From Exceptional Patient Care, to Teaching, Research and the Primary Care Clinical Trials Unit”
Why? To reduce health inequalities across the region, to promote outstanding patients care, and to integrate next-generation healthcare innovation to give our patients unique access to care opportunities.
What happened? To bridge the gap in healthy ageing inequality, we employ a dedicated geriatrician to take direct responsibility for our 500 care home residents, and integrate digital health tools to support this. We pioneered remote consulting, giving patients access to a clinician through dedicated terminals. In 2020, we established our bespoke Clinical Trials Unit to deliver the latest clinical research directly to our patients. As part of this, we delivered the First Global Patient In to AstraZeneca’s TACKLE monoclonal antibody clinical trial. Through our Participant Identification Centre sites, we have extended our clinical trials unit catchment to more than 1.5m patients in the region, offering unique opportunities to participate in the development of the next generation of medicines for primary care.
Looking ahead. We will continue to drive innovation and commit to outreach to improve patient access and experience.
Healthier South Wirral PCN
Overview: “A beacon of healthcare excellence and innovation”
Why? To improve population health and the quality of healthcare services in the region.
What happened? Our PCN serves 49,500 patients across five practices in North West England. We recently partnered with Optum to leverage data-driven insights on our population to optimise care delivery. Our collaborations with the pharmaceutical industry have allowed us to leverage cutting-edge technologies and treatments to promote early intervention and improved patient outcomes. The Acute Response Team ensures rapid and effective care delivery, reducing hospital admissions and improving patient satisfaction. The General Practice Clinical Pharmacist team supports with medicines optimisation and safety across the PCN. In collaboration with local VCSEs, we have engaged with over 400 community members, ensuring their voices are heard and needs addressed.
Looking ahead. We plan to carry on our collaborations both within the PCN and beyond, to promote the best outcomes possible for our patients.
Mid Dorset PCN
Overview: “Providing ‘Better Care for Carers'”
Why? To enhance the support given to carers, who were identified as suffering health inequalities, including being twice as likely to suffer with depression and diabetes, and less likely to attend appointments.
What happened? A cross-organisational working group was established to improve the support we offer to our carer population. This included developing an accreditation scheme called Better Care For Carers (BCFC) that encourages GP practices to have a consistent approach of support for their carers. All eight practices have achieved at least the bronze level, with several gaining higher awards. Practice training was developed to support BCFC, aimed at all practice staff to ensure the whole practice approach. This was added to the mandatory training portal for all practices so that compliance could be monitored. We employed a carers’ lead for the PCN, joining up existing provision and filling the gaps by establishing links across the neighbourhood, both with voluntary and statutory organisations.
Looking ahead. We will continue BCFC efforts with practices, opening up the programme to community partners such as the NHS trusts and community pharmacies.
Middleton PCN
Overview: “Middleton Primary Care Network”
Why? Overcoming lack of space and supporting patient access.
What happened? We created a bespoke PCN hub in the local shopping centre, with services including mental health clinics, GP services and medication reviews. We appointed an ARRS workforce and actively engage with the neighbourhood team through monthly meetings. Our large team of social prescribing link workers deal with a wide range of social and mental wellbeing issues. Our Paediatric SPLW deals with patients aged up to 19, to support mental health and address suicidal ideations within this age group. We are raising awareness of the service at local schools, to students and teachers who can refer into the service. We also developed a care home team who carry out weekly ward rounds with all of the local care homes, reviewing all patients’ medications, chronic diseases and acute problems.
Looking ahead. We will continue to focus on improving patient access and developing our services for the local community.
Central Basildon PCN
Overview: “A collective effort of nine GP practices in the Basildon area, united by a common vision to provide comprehensive, high-quality healthcare services to their community”
Why? To enhance the health and wellbeing of the local community.
What happened? Central Basildon PCN prioritises collaboration among healthcare professionals, to ensure patients receive holistic care that addresses their physical, mental, and social needs. Recognising the potential of technology, the PCN has implemented digital health solutions such as EHRs, telephone consultations, and online appointment booking systems. EHRs have streamlined patient data management, making it easier to access crucial information and deliver more personalised care. Patients have benefited from reduced wait times, improved access and enhanced communication with their care providers. Moreover, digital tools have allowed Central Basildon PCN to gather and analyse data more effectively, aiding in population health management and targeted interventions.
Looking ahead. The PCN hopes to continue to innovate and evolve, inspiring others to follow in their footsteps.
Southend West Central PCN
Overview: “Southend West Central Primary Care Network: demonstrating the change and brilliance we all make together!”
Why? To make a difference to the health and wellbeing of all those we are privileged to care for.
What happened? We are a multi-disciplinary team working in unison on behalf of our patients, residents and wider community. We provide weekly ward rounds to our 28 care homes, run vaccination programmes ensuring protection for all, organise Community Health Check pop-up events, and take part in a range of community events networking with partner teams locally. We support emotional health and wellbeing via the social prescriber and health & wellbeing teams, undertake structured medication reviews, and run a wide range of condition review clinics. We have joined a pioneering community support model called Pact – PCN Alligned Community Team, which supports patients on discharge from hospital by assessing and ensuring referrals as required to assist with recovery and to avoid re-admissions.
Looking ahead. Our team will remain committed to working together for the good of our local community.
Kingswood Medical Group
Overview: “Positive staff, overcoming a merger, persevering to overcome health inequalities, covering the most deprived areas of Swindon”
Why? To overcome some of the challenges in the region, including inequality and deprivation.
What happened? Following a merger, we continued working as a team and overcoming significant changes which almost tripled the PCN in size. We proactively engage with all aspects of the system, initiating conversations with patients, Swindon carers, the voluntary sector, attending Sahara Health Fair, engaging with Councillors and the Council, to help facilitate greater efficiency and effectiveness, which will benefit patients. We have been innovating and pioneering the use of PCN-purchased iPads to enable translation and communication with patients. The positive outlook of our staff has helped us in providing health care for over 250 refugees and 28,000 patients.
Looking ahead. Kingswood Medical Group is committed to being a great place to work and to be treated.
Hanley Consulting
Overview: “EDATT – Enabling Digital Access Through Telephony”
Why? To support organisations with capacity and demand issues, poor patient access and experience.
What happened? EDATT is an automated chatbot supporting patients to become more digitally literate and carry out healthcare transactions digitally at point of need. EDATT identifies the correct tool for the job and surfaces it, as well as containing in depth, step by step video’s and guides on how to use the tools. EDATT has built in checks which analyse the patients digital literacy and modify their journey accordingly, ensuring that patients of all levels of digital literacy are provided with improved access. We have used patient feedback to improve the chatbot, adding new options for patients and allowing them to self-serve in more ways. We have increased the use of digital triage by up to 300 percent in practices that we have deployed in.
Looking ahead. We hope to be able to help more practices to overcome challenges with capacity and patient access.
Think Healthcare
Overview: “Taking new Access Triage & Access Inequality improvement models to a new level”
Why? To improve access and help prioritise those most in need.
What happened? Over the past year we have worked closely with Foundry Lewes PCN to develop a triage platform. Total Access Triage established Red, Amber and Green categories to prioritise patients. Our contact centre solution enables intelligent prioritisation of calls. Calls can be directed automatically to the correct team, and patients details are displayed. Care home numbers can be automatically recognised and diverted to the correct team. The PCN can send automatic SMS messages to patients in the phone queue containing links to their online consultation platform. Foundry found that over a three-year period, it was expected to reduce secondary care access for the most vulnerable by up to 13,00 days, equalling a saving of up to £2.5 million.
Looking ahead. We would like to be able to help more practices to improve access and prioritise patients quickly and efficiently.
Old Mill Surgery
Overview: “Drive by Flu Vaccination Service”
Why? To help vaccinate and protect the local community.
What happened? We operate a Saturday drive-by Flu vaccination day, supported by the whole practice team and PPG, with support from local community. The council organises road closures, and we have police intermittent drive-by to support the delivery of this service. We initially send out invites, patients book electronically their car slot arrival time, which we preset using Accurx to ensure spread of appointments to avoid traffic. We set up vaccination stations roadside, and have marshals greeting cars to check paperwork. The clinical team provide the vaccinations at the stations with HCA’s from other practices supporting us. Approximately 2,000 people attend, reducing pressure on nurse appointments.
Looking ahead. We hope that these measures will continue to help us to meet pressures on time and capacity.
Mid Mersey Digital Alliance
Overview: “Improving patient digital access”
Why? To promote digital inclusion for patients and GP practices, delivering support and assistance to promote the use and understanding of digital tools to improve outcomes.
What happened? Our teams delivered support to patients and clinicians on digital technologies, using heat maps to identify patients they could offer support to. They offered one-to-one support, group sessions and even home visits to get patients online. Work at one practice saw an increase in 8 percent of the patient population now using online services (514 patients), and we estimate this piece of work has saved the equivalent of 13 additional appointments per week. The team also gave practice managers access to data on telephone calls which allowed them to see information such as the number of abandoned calls. The practice are now answering more calls per day, and have seen their calls answered increase by 20 percent.
Looking ahead. Both of these pieces of work continue to be deployed across our other GP practices and patient populations, with our teams on hand to offer additional advice and support.
Sunderland GP Alliance
Overview: “Sunderland Patient Information Portal Project”
Why? Improving digital access to primary care services in Sunderland by creating a “Digital Front Door” to reduce GP and administrative workload, promote self-care, and standardise website quality.
What happened? To ensure a seamless transition for the GP practice websites, the project was split into four phases. Practices were moved over to Iatro’s Practice 365 website platform over a period of six months. The project has already provided patients with better quality websites, increased access to digital services, and raised awareness and referrals to other services such as social prescribing and self-care options. A website audit was completed to gauge the accessibility of the practice websites before and after the Practice365 solution was installed. Prior to the new installations, nine different website providers were used across the region, and only 16 percent were compliant with modern accessibility guidelines. After the new websites were implemented, all websites achieved 100 percent accessibility compliance.
Looking ahead. The project team is sharing learnings and insights with other organisations and systems, with a view to scaling up the project and improving access to digital primary care services across the wider region.
East London NHS Foundation Trust (ELFT)
Overview: “Reducing Health Inequalities in Primary Care: A Success Story from Cauldwell Medical Centre, East London NHS Foundation Trust”
Why? East Bedford PCN’s low uptake of cervical screening and difficulties engaging the local diverse ethnic community. The ambition was to improve uptake to at least 80 percent.
What happened? Cauldwell Medical Centre elevated cervical screening uptake in vulnerable groups through a Quality Improvement initiative. The project surpassed its target with 80 percent uptake in the 50–64 age bracket and reached 72 percent for those aged 25–49. A multidisciplinary team followed the ELFT sequence of improvement, first identifying the issue by analysing weekly baseline data on a run chart. They then went on to understand the issue by bringing together patients and staff for a focused discussion around the low uptake, especially in the non-English speaking community. Specific changes included translation for non-English speakers and staff education in cultural awareness and attitudes toward cervical screening.
Looking ahead. The team hopes experiences at Cauldwell can be replicated to meet the needs of other local communities. Aspects like cultural awareness, translation, and inclusivity have now become the norm.
Think Healthcare
Overview: “Taking new Access Triage & Access Inequality improvement models to a new level”
Why? To improve access and help prioritise those most in need.
What happened? Over the past year we have worked closely with Foundry Lewes PCN to develop a triage platform. Total Access Triage established Red, Amber and Green categories to prioritise patients. Our contact centre solution enables intelligent prioritisation of calls. Calls can be directed automatically to the correct team, and patients details are displayed. Care home numbers can be automatically recognised and diverted to the correct team. The PCN can send automatic SMS messages to patients in the phone queue containing links to their online consultation platform. Foundry found that over a three year period, it was expected to reduce secondary care access for the most vulnerable by up to 13,00 days, equalling an estimated saving of up to £2.5 million.
Looking ahead. We would like to be able to help more practices to improve access and prioritise patients quickly and efficiently.
Mid Mersey Digital Alliance
Overview: “Improving patient digital access”
Why? To promote digital inclusion for patients and GP practices, delivering support and assistance to promote the use and understanding of digital tools to improve outcomes.
What happened? Our teams delivered support to patients and clinicians on digital technologies, using heat maps to identify patients they could offer support to. They offered one-to-one support, group sessions and even home visits to get patients online. Work at one practice saw an increase in eight percent of the patient population now using online services (514 patients), and we estimate this piece of work has saved the equivalent of 13 additional appointments per week. The team also gave practice managers access to data on telephone calls which allowed them to see information such as the number of abandoned calls. The practice is now answering more calls per day, and has seen their calls answered increase by 20 percent.
Looking ahead. Both of these pieces of work continue to be deployed across our other GP practices and patient populations, with our teams on hand to offer additional advice and support.
Christchurch PCN
Overview: “Bringing dedication and innovation to primary care”
Why? To ensure a seamless care experience for patients, enhance primary care and improve the facility’s reputation.
What happened? The implementation of a PCN website, enabling patients to be informed in the care that they are receiving from across Christchurch, and helping build relationships with patients. Recognising the ever-evolving nature of IT and digital. The team introduced a continuous education programme, ensuring we stayed updated with the latest in primary care practices. This resulted in shorter, more efficient registrations, and in less than a month we received 100 registrations from patients at one practice, saving many hours for our overstretched admin team.
Looking ahead. The innovations that staff member Julio has brought to the PCN will continue to contribute to patient satisfaction and experience.
Dene Healthcare Ltd
Overview: “Time Saving in general practice”
Why? To save previous resources and time in general practice.
What happened? Staff costs equate to an average of 70 percent of total expenditure for general practice. We work in partnership with practices to establish their unique costs at every step of the procurement process, allowing reallocations of time for what general practice does best – focusing and caring for their patients. So far this year, we have worked with around 80 practices, saving one £2470.80 per year. Similar savings were identified within the ordering process, and an innovative standing order algorithm was set up to mitigate the staff expense, product sourcing was outsourced to the supplier, and with customised stock control and individual product costs, this took total savings to £6,675 per year and over 78 hours of staff time saved.
Looking ahead. We plan to continue to help more practices save themselves time and resources to dedicate back into patient care.
Oberoi Consulting
Overview: “Heart Failure Therapeutic Review Service”
Why? To identify and optimise the treatment of those with chronic heart failure (HF) in primary care in the North East.
What happened? The optimal management of heart failure in Darlington was used as the model for this work. Oberoi delivered education in HF to practices, then a stepwise approach from data validation through to patient identification, clinical coding, clinical notes assessment, virtual heart failure clinics, reaudit and robust clinical reporting. The local HF pathway was followed for medicines optimisation reviews. Any patients who were deteriorating significantly and/or any patient with severe heart failure not previously known to the service were referred to the local team. Prevalence increased from 1.03 percent to 1.30 percent (an extra 290 patients HF coded). Within sub-categories, this saw an uplift of £19,601 practice income from QoF.
Looking ahead. The team hopes to continue to develop the service and use it as a model to help other regions manage HF in primary care.
Northern Lincolnshire and Goole NHS Foundation Trust and Meridian Health Group
Overview: “Connected Health Network – Rheumatology”
Why? To help reduce referrals to hospital, outpatient-based care.
What happened? The rheumatology pilot with Meridian Health Group PCN has managed 85 percent of referrals within primary care, with high patient satisfaction levels. The Connected Health Network (CHN) model sees GPs working in partnership to manage patient’s care, accessing the Connected Health Network service within their own PCN. The CHN clinics are supported by Dr Tim Gillott, a rheumatology consultant. The 15 percent of patients who need to be referred into secondary care receive a full work up, so the hospital team has information to facilitate their onward pathway. Meridian Health Group PCN’s rate of referral to secondary care by GPs per 1,000 patients is already 60 percent lower than other PCNs in NE Lincolnshire.
Looking ahead. The CHN model is being piloted across other PCNs and specialties in Northern Lincolnshire including cardiology, gastroenterology and diabetes.
Primary Care Analytics
Overview: “Primary Care Analytics – Population Health Management Tool”
Why? To help identify inequalities and improve health outcomes for patients, as well as generating a clearer oversight on the population to generate a better picture for practices throughout Herefordshire.
What happened? By providing data-driven insights, we help our Primary Care Networks get the most out of their investments and make meaningful changes in patient care. The tool creates more visibility, highlighting key areas to help improve patient outcomes. The PHM tool allows users to see the cost of GP contacts and hospital admissions for different deciles, age groups, genders, ethnicities and more. It shows the average GP contacts and the average medication courses taken. It will display common themes, for instance which conditions are most prevalent within certain brackets. The PHM tool is ‘tailor-made’ to the specification of the PCN. We diligently work with individuals to understand their specific needs, to simplify the data and make it real for Practices and PCNs with regards workforce prioritisation.
Looking ahead. There are many uses for this tool at PCN level but it because more powerful when looking at Places or ICSs, providing strategic insight and highlighting system priorities.
Enhanced Primary Care
Overview: “We have found £1,476,761 of unclaimed practice income in the past two years!”
Why? To help GP practices locate unclaimed income, to prevent loss to the practice and thus patients they look after.
What happened? 334 practices have signed up to the service since 2021. Once theses reconciliations are complete we will have found £5.3 million. This income would otherwise be lost to the practice and thus the patients they look after. We have supported GP practices to locate £1,476,761 of unclaimed income in the past 2 years. We offer practices a remote “done-for-you” reconciliation service. Using bespoke in-house technology the EPC team analyses data from the practices clinical database. This analysis identifies work that has been undertaken but not claimed. Maximising the use of digital technology allows practices to provide all information required to compete the reconciliation in less than 15 minutes.
Looking ahead. We will continue to scale to meet the needs of the remaining 6884 practices in England and Wales, as well as realising of the remaining £3.9 million for those already signed up to the service.
Thistlemoor Medical Centre
Overview: “Understanding and improving the wellbeing of our patients by understanding what’s actually happening with them and supporting them”
Why? To identify high intensity users of primary care, ideally reducing demand ahead of winter.
What happened? A group of 400 people with low-level medical needs, who visited A&E more than 20 times a year and the GP more than five times, were identified and offered support through a Population Health Management (PHM) approach. The practice held meetings with stakeholders including the local authority, to discuss options. A practice team made up of GP trainees/social prescribers/health coaches offered one-to-one consultations aimed to prioritise their wellbeing. They identified areas of ongoing concern for individuals. A cohort of 151 patients at Thistlemoor received a supportive consultation from the Thistlemoor team, use of A&E dropped by 70 percent and use of the GP by 30 percent.
Looking ahead. The cohort will be followed for the rest of the year to assess impact on their wellbeing and use of services, and 1-1 support sessions for employment/housing/social care issues will be continued.
That’s it from us for now – once again, a huge congratulations to our deserving finalists for all their hard work.
The virtual awards ceremony will be held online here on Integrated Health on 14 December 2023 – so remember to come back and celebrate the winners with us!
