A close collaboration between our population health team and secondary care has resulted in targeted, transformative care for a group of patients:

The development of innovative treatments using biotechnological methods has transformed the management of numerous modern-day conditions. Patients with diabetes, various cancers, and those benefiting from measles or HPV vaccines are all examples of  people whose lives have been improved by a class of drugs known as biologics. Typically administered via injection in a hospital setting, these advanced therapies hold significant promise for patients  with severe asthma.

Dr. Peter Creber, consultant in respiratory medicine at Southmead Hospital in Bristol, frequently supports patients grappling with acute asthma. They often require multiple GP appointments and are at higher risk of A&E visits and unplanned hospital admissions – a situation that negatively impacts their well-being and places a significant financial burden on the healthcare system. While biologics offer the potential for substantial improvement in these patients’ symptoms, prescription is currently limited to secondary care. This raises the crucial question: how can patients within the Bristol, North Somerset and South Gloucestershire (BNSSG) area be identified and offered these potentially life-changing treatments when their primary health records are kept by their GP?

To address this challenge, Dr. Creber contacted  One Care, a collaboration that quickly revealed a pathway to support patients severely affected by their asthma. Currently 37 practices within BNSSG have agreed to participate in this work, and collaboratively suitable patients for biologic treatment have been identified. This process involved reviewing specific key health indicators within the patient record, as these medications are not appropriate for all individuals with asthma.

Dr. Creber said: “Once a patient has been identified as eligible, the administration of the biologic injection is straightforward, and the positive effect on their physical well-being is often dramatic.”

A single injection can provide relief for up to five years, offering patients the opportunity to significantly improve their quality of life. This not only reduces the need for urgent GP appointments, freeing up valuable primary care resources, but also minimizes unplanned hospital admissions.

One Care’s population health analyst, Phil Gladwin, said: ‘I’m delighted to have been involved in a project which has supported patients with severe asthma, and potentially freed up urgent GP appointments for other patients.’

This successful collaboration between secondary care and primary care, facilitated by One Care, exemplifies how integrated working can deliver optimal care for patients with severe asthma, resulting in positive outcomes for both the individuals and the wider healthcare system. Dr. Creber and the team continue to identify and support eligible patients across BNSSG, demonstrating the power of joined-up healthcare in transforming lives.

If you would like to find out more – or would like to discuss how our population health analysts can help target patient groups – please email business.intelligence@onecare.org.uk

The general practice landscape is always changing, and One Care wants to help practices be as prepared as possible to mitigate any potential disruptions which could impact their day-to-day operations. Our general practice support team has produced resources to help practices review their business continuity plans and fill any gaps necessary.

Last year, the team also conducted reviews on behalf of practices, looking closely at their plans and making recommendations where additional information was needed. They have undertaken reviews for 46% of our member practices’ so far.

One practice manager said: ‘Our practice had been meaning to update our business continuity plan to ensure that we had considered all possible scenarios.

‘We were aware of One Care’s business continuity plan toolkit, but it seemed a bit of an overwhelming task for me as there are at least 80 items to go through. One Care offered to go through our business continuity plan and the checklist for me; to tick off the areas we had already covered and to highlight which elements we needed to add or refine. They also suggested wording to include which was really helpful.

‘The best bit about this process is that One Care suggested I update our plan to include the EMIS business continuity module. I have to admit, I’d never tried it before this point, but I was so glad I did as less than three weeks later we had the global IT outage and using the EMIS business continuity module was invaluable on that day!’

If you have any questions about business continuity plans or would like help reviewing yours, please contact practice.support@onecare.org.uk

We’re delighted to announce that following a very successful pilot, One Care’s HR services will be free to our member practices as part of their subscription.

We recently offered the free services as part of a three-month pilot which received really positive feedback: 95% of practices rated the overall quality of the HR services provided as excellent, while 86% of practices said the HR support they had received exceeded their expectations.

When asked about the impact the HR services have had on their practice, the most frequently cited benefit was increased reassurance and confidence in HR decisions. Practices also highlighted time and cost savings, improved compliance, and avoiding escalation.

One participating practice said: ‘We find having HR services really useful. The One Care team is quick to respond and has been helpful with difficult HR issues, and basic queries where we need reassurance on the decisions we are making. Having HR included within our OneCare package is extremely useful.’

Gertruda Grudyte, One Care’s HR business partner, said: “We’ve had fantastic feedback from our pilot of free HR services, so we know what we’re offering is what practices need. We can deliver value across multiple key areas of HR work, and are looking forward to supporting as many practices as possible.”

Our peoples services team offers a wide range of expertise and support, including:

• employee relations – assistance with issues such as staff absences
• performance management
• disciplinary and grievance procedures
• advice related to employment termination
• bespoke policies and letter templates
• advice on contractual queries

There are also plans to trial HR training workshops for practice managers – more details will follow soon.

If you’d like to find out more about the HR support available please contact people.services@onecare.org.uk

The GPCB is continuously strengthening how we represent general practice across BNSSG. As part of this, we’re improving our meeting processes to ensure GPCB meetings are as  impactful as possible.

GPCB meetings are a vital space for strategic discussion and decision-making for general practice in BNSSG. To make the most of this time, we’re strengthening our agenda-setting process to ensure GPCB meetings are more focused and inclusive, and that every item brought to the GPCB is clear, well-prepared, and meaningful.

 What’s changing?

We’re introducing a more structured and consistent approach. Before the meetings, presenters submitting a formal agenda item will be asked to complete a form answering questions about their item, engagement with the subject, and next steps.

Sharing a short summary of all agenda items with attendees and the Chair in advance will also help members prepare and engage within their PCNs effectively before the meeting.

 Why this matters

We believe this approach will lead to clearer decisions, better preparation, and more inclusive representation across the system.

Also:

• members will have the right information in advance, giving them plenty of time to engage on the subjects with their own practices and PCNs
• our meeting materials will be accessible to all audiences — avoiding jargon and acronyms
• decision-making items will be flagged and shared within set timeframes, making them clear for everyone

We’re excited to implement these improvements and continue strengthening the way we work together across general practice and the wider system.

 How to bring an item to the GPCB

If your practice has an issue to raise or an item you’d like to bring to the GPCB, you can:

• speak directly with your PCN representative, who can bring the item forward on your behalf
• alternatively, email the GPCB directly. We can direct your query to the most appropriate person – this could be the medical director, a clinical lead, or another representative already working on the issue. Items can also be brought as any other business (AOB) or as a discussion point — not all agenda items require formal papers

We’re here to ensure your voice is heard and that general practice remains well-represented in system-wide conversations. To find out more please contact gpcollaborativeboard@onecare.org.uk

One Care is working with 51 general practice partnerships across BNSSG to pilot ambient voice technology (AVT) — AI-powered scribe tools used during patient consultations. We’re collaborating with suppliers Heidi and Anima, both of which offer NHS-assured, compliant AVT products. Early feedback from practices has already shown promising results. 

Why try AVT in general practice? 

We want to improve patient experience of consultations, save time for practice staff by reducing the admin burden, and help reduce stress by helping to ease workloads. 

AVT supports these aims. It is a tool which listens during consultations, capturing what’s said and turning it into written notes. AVT reduces the need for typing, helping clinicians to stay focused on their patient. Notes are checked thoroughly before being included in the patient record.  

A practice taking part in the pilot reported: “Recently I did an entire surgery without Heidi (AVT). Looking back at the records this morning, I can see the difference in detail captured and safety netting. There’s no doubt my consultation records are richer through using AVT.” 

Another practice said: ‘Heidi significantly reduces typing time – approximately a 50% reduction.  It helps clinicians organize their thoughts and focus more on the patient during consultations. It is particularly useful for mental health and autism assessments.’ 

We’ve worked with practices taking part in the pilot to help them use AVT safely, and to make sure patients are fully informed about its use. All are given the choice to opt-out of having it used during their appointments. With 51 practices taking part in this pilot, the consultations of over 850,000 patients can potentially be supported by AVT during the project. 

What has been learned so far?  

We are a quarter of the way through the 12-month pilot, and our findings to date include: 

• time saving: most practices in the pilot believe the AI scribe is saving time on clinical documentation – and it’s not just GPs using the technology, but medical secretaries, practice managers and other staff too  

• positive patient response: most patients are very positive about AVT being used in their care. Patient opt-outs have been rare, but rose slightly following the media coverage about non-assured products 

• equalities issues: there are equalities issues which need further exploration – for example, whether the technology performs less well for patients whose first language isn’t English 

• levels of use: in the last three months, GPs across BNSSG have held over 40,000 total sessions, generated over 49,000 sets of clinical notes or documents, and over 470,000 minutes have been transcribed with Heidi 

 What’s next? 

We will evaluate the experiences of staff using AVT to help practices decide if it offers value for money. We’ll share updates throughout the pilot, and the final report will be available in early 2026 

We are also discussing with our partners in hospital and community services how the use of AVT can be integrated across health and care in the region.   

To find out more about the AVT pilot please contact morgan.daly@onecare.org.uk and westley.lane@onecare.org.uk 

A project to improve the identification of homeless patients within a Bristol PCN has resulted in more than double the numbers identified, helping the PCN’s practices plan and allocate their services more efficiently.  

People who are homeless face significantly shorter lifespans, on average dying 30 years earlier than the general population. And modern homelessness is complex, now including various forms of unstable housing. Targeting this vulnerable group with the vital healthcare they need is challenging, particularly in inner city settings.    

Our population health management analysts worked with Bristol Inner City PCN on the project to address this.  

Anne Wray, advanced nurse practitioner, who led the project in the role as Bristol Inner City PCN health inequalities lead, said: ‘We found a lack of coding as well as inconsistent coding of homelessness within our healthcare system meant we didn’t have a clear and accurate picture of the health challenges faced by this patient group. This hindered our ability to effectively allocate resources and tailor healthcare interventions.’  

One Care sourced the specific data across the PCN after organizing data sharing agreements, and created a template in EMIS for clinicians to use. The project resulted in the introduction of specific EMIS codes, reducing the number of codes previously used.    

One Care’s population health analyst, Phil Gladwin, said: ‘Clinicians now receive a pop-up in EMIS prompting them to use the recommended codes in a template. The impact was immediate – in just two months the number of homeless patients identified increased from 186 to 508 within Bristol Inner City PCN.     

‘Our data demonstrates that the homeless population in Bristol Inner City PCN is diverse. This highlights the importance of using data rather than assumptions to provide person-centered care. The improved data resulting from this project is currently being used to tailor the care of patients with diabetes experiencing homelessness.’   

Anne Wray added: ‘We hope this template and pop-up alerts can be adopted across the wider system to improve coding in the whole region. By accurately identifying the homeless population within BNSSG, we will be taking a significant step towards providing them with the tailored healthcare they urgently need.’  

If you would like to find out more – or would like to discuss how our population health analysts can help your PCN or practice target patient groups – please email business.intelligence@onecare.org.uk

Since it began in August 2023, the GPCB workforce programme has introduced a number of initiatives designed to ease your practice’s staffing challenges and pressures.

Here’s a brief overview of the programme’s developments so far – all available to you to help with your staff recruitment and support:

• recruitment pool

To help make staff recruitment easier and quicker for practices by enabling the sharing of potential applicants’ details

• entry level general practice non-clinical qualification

A brand new, fully accredited course designed to encourage people to consider general practice as a career choice. The course can also support new staff induction

• Celebrating our clinical and non-clinical workforce

Our recognition scheme to celebrate members of staff who are really appreciated in their practice

• introductory video for new staff

To support staff induction, by introducing new recruits to how general practice works, and how it fits into the wider BNSSG system

• library of resources

With useful information on training suppliers, approved staff agencies, and coaching and mentoring

Full details are available here. If you would like to discuss any aspect of the GPCB workforce programme please contact bryony.campbell@onecare.org.uk.

Our population health management analysts have been working with local GP Dr Claire Hawcroft on a project to extract data on the incidence and prevalence of pelvic floor conditions in Bristol Inner City PCN’s patients. Very little data is available nationally for this condition, and the project aims to get a clear indication of the burden it is putting on primary care.

Phil Gladwin, One Care’s population health analyst said: ‘This project is a great example of how our team can work with practices and PCNs to extract key data in support of service provision.

‘By identifying data for key conditions and associated demographics, we can help practices identify specific patient groups who would benefit from proactive, targeted care. We can also help practices develop strategies for the health needs of all their patients. More targeted services can lead to financial and administrative savings.’

Dr Hawcroft, a GP at Lawrence Hill Health Centre, was undertaking a 12 month population health fellowship with Bristol City Council focusing of promoting women to be more physically active during and after pregnancy.

Dr Hawcroft said: ‘There is a lack of consistent data nationally and locally on the prevalence of pelvic floor dysfunction. This gave us an opportunity, with One Care’s expertise, to interrogate regional primary care data to capture the numbers and prevalence of patients with these conditions.

‘The data has given us an indication of the burden of these conditions seen in primary care. We have also been able to analyse differences by demographic factors such as deprivation, age and ethnicity.’

Data analysis following the project is continuing and final results will soon be shared.

Our population health management analysts have already completed some vital work looking at:

• health inequalities
• chronic disease management
• condition prevalence
• vaccination uptake

If you would like to discuss how the team can help your practice or PCN please email: business.intelligence@onecare.org.uk

With changes to the GP contract set to take effect this October, this is a good time for practices to reflect on and refine their patient access models. Facing the dual challenges of rising patient demand and the pressures of all-day online access, finding solutions has never been more important.

To support this, our practice support team recently hosted an event bringing together BNSSG practices with colleagues from across Devon and Somerset. The session provided a valuable opportunity to share experiences, explore innovative approaches, and discuss practical strategies for improving access.

Some key themes emerged:

• there’s no one-size-fits-all model – practices can tailor their approach to create a system that works for their unique needs
• data is essential – robust data collection and analysis are critical to understanding patient demand and help effective planning
• managing demand without closing the door – practices are looking for ways to remain accessible while coping with increasing pressure

How One Care can support you

We can help you navigate these changes and improve your patient access. Our practice support and digital teams offer a range of services, including:

• hands-on support with care navigation systems
• demand and capacity audits – to help you plan your workforce
• toolkits to support care navigation and access

If you’d like to review or redesign your access model, we’re here to help. Please contact practice.support@onecare.org.uk to discuss how we can support you.

Would you like to explore the potential of technology enabled care and how it can benefit your patients? Our project lead offers a free, interactive course to BNSSG practices to showcase the different types of care technology available and how it can enhance patient care.

The course will also explore how technology can help to support preventative and proactive measures in areas such as hospital admission avoidance, reablement, frailty, cognitive impairment, and supporting long term healthcare management.

The training is open to anyone working in healthcare settings, particularly clinicians, care coordinators, health and wellbeing coaches and social prescribing link workers. Participants will gain an understanding of the types of technology available for care, how to implement these technologies, and the significance of person-centred decision-making.

To arrange training for your practice, please contact digital@onecare.org.uk