Category Archives: News

Continuity of Care toolkit launch

We are proud to announce that the Continuity of Care resource toolkit we helped develop has now been launched nationally by the RCGP and Health Foundation.

This toolkit combines real-life examples, ready-to-use resources, and improvement methodologies. We developed it together with Morecambe Bay Primary Care Collaborative, through the work we did with our practices as part of the Health Foundation’s improving Continuity in General Practice programme.

Through this toolkit, GP practices across the country will be able to discover the evidence behind continuity and it’s benefits for both patients and clinicians whilst also helping to support colleagues in primary care to take the next practical steps to improve continuity, regardless of their current progress.

The toolkit can be accessed here.

Dr Jon Hayes appointed new Chair of the GP Collaborative Board 

We are pleased to be able to announce the newly appointed Chair of the GP Collaborative Board (GPCB) as Dr Jon Hayes. Many of you will know Jon from his roles as GP Partner at Hanham Health since 1999, and Clinical Chair of Bristol, North Somerset and South Gloucestershire (BNSSG) CCG since its inception as an organisation in 2018. 

The interview process was led by a sub-group of GPCB members, consisting of Dr Nicola McGuinness, Dr Sarah Pepper, Dr Richard Berkley and Dr Lee Salkeld. Ruth Taylor, Chief Executive of One Care, was a non-voting observer and the panel was chaired by an independent member, Jeff Farrar, interim Chair of the Healthier Together Partnership Board and Chair of University Hospitals Bristol and Weston (UHBW). The panel put forward their decision to the Board for ratification in early September. 

On behalf of the recruitment sub-group, Dr Lee Salkeld said: 

“We are really excited about Jon’s appointment to the role of Chair of the GP Collaborative Board. He brings a wealth of experience, knowledge and relationships to the Board at this important time in our development. 

Throughout the recruitment process, Jon demonstrated that his 20+ years of working in grass roots general practice combined with his in-depth understanding of the intricacies of our health system mean that he is perfectly positioned to lead us through the challenges and opportunities ahead. 

The Board is looking forward to working with Jon to really cement the role of the GP Collaborative Board in representing, advocating, and working on behalf of general practice in our Integrated Care System.” 

Jon will remain as Chair of the CCG until March 2022 ahead of the transition to the new Integrated Care Board arrangements from April. He will, however, step down as Chair of the Clinical Executive on 31 November. This will ensure that he is not involved in commissioning decisions about primary care and mitigate the risk of any conflict of interest. He will take up his role as Chair of the GPCB in December. Until then, he will attend GPCB meetings as Chair designate, and Board meetings will be chaired by our Vice-Chair, Dr Katrina Boutin, whose appointment we announced in early August 2021. 

Commenting on the appointment, Dr Jon Hayes said: 

“I am thrilled to be appointed as the Chair of the GP Collaborative Board. 

General Practice has achieved so much over the last 18 months – from fast-tracking digital transformation, to driving the local vaccination roll-out and managing the current surge in service demand. Practices have forged new partnerships with our populations, communities and colleagues across the health and care system – and whilst it’s been tough, we have much to build on.  

The GPCB already plays a critical role in the health and care system, and will continue to do so – particularly as we move towards the statutory Integrated Care System (ICS) landscape. It’s important that we have a strong collective voice as general practice, and as the new Chair, I’m really looking forward to working closely with all practices across BNSSG to make that happen.” 

Dr Simon Bradley held the role of Interim Chair of the GP Collaborative Board since its inception in September 2020. On behalf of the GP Collaborative Board, Dr Katrina Boutin said: 

“We would like to offer heartfelt thanks to Simon for his visionary leadership, tenacity and commitment to the Board during his time in the role. He has been instrumental in taking the GP Collaborative Board from concept into reality.” 

Simon will continue to be a member of the GP Collaborative Board in his role as Chair of One Care. 

Our new Medical Director – Dr Mark O’Connor

We said goodbye to our Medical Director, Dr Jake Lee, earlier this year. We are very excited to announce that following an incredibly strong recruitment process, we have now appointed our new Medical Director, Dr Mark O’Connor.

Mark has been a GP in North Somerset since 1995. He has previously held positions with the LMC, North Somerset PCG, PCT and CCG. Recently returned from Qatar, he worked as an executive clinician within the national ambulance service to establish its first country wide integrated community healthcare service. He has a life-long interest in IT/AI and data analytics and is looking forward to playing an active part in One Care’s vision to ensure our member practices are properly resourced, practically supported and have a strong voice in the new collaborative structures to come.

We hope you will join us in welcoming him to One Care and wishing him every success in his new role.

Continuity of care project closure

The One Care continuity of care programme draws to a close this month. Despite the challenges posed by Covid, 23 practices took part in the project and each embarked on their own continuity of care journey. All hints and tips from the practices have been captured in a resource toolkit which will soon be hosted on the RCGP website shortly. Our data shows practices were able to improve their continuity by up to 15% across their practice list. There were even greater improvements in continuity where the focus was on a particular cohort of patients.

We’ve built a timeline of the project, which can be found here:

One of the primary  outputs of this project is a resource toolkit to help implement continuity of care in the practice. The toolkit provides:

  • Practical suggestions on how to improve continuity.
    A way to measure continuity using the Usual GP Measuring Tool, developed by One Care Digital Team.  There are 4 measures available in this easy-to-use Tool.  The Tool is based on consultation activity and shows how consultation activity is spread across your practice.  For example, you will be able to see if your frequently attending patients are shared evenly across the team.
  • Communication material including leaflets and posters together with an animation which you can show on our website or in the waiting room.
    The Resource Toolkit is currently on One Care Team Net but later this month it will be hosted on the Royal College of GPs (RCGP) website, following the demonstration at this year’s RCGP conference and testing by practices across England and Scotland.
    Our practices approached continuity in different ways from those who had already have personal lists looking to further improve continuity, to those testing microteam approaches, to those focusing on a particular cohort of patients. Our data shows practices able to improve their continuity by up to 15% across their practice list.  Even greater improvements were made where the focus was a particular cohort of patients.

As a project we learned:

  • Through our surveys and conversations that continuity matters to both patients and staff
  • Practices regardless of their list size can achieve good levels of continuity, including those that are multi-site.
  • Where the practice has continuity of care processes in place, GPs on low sessions achieve continuity levels on par with GP working a high number of sessions.
  • Practices in deprived areas of Bristol can achieve good levels of continuity.
  • Focusing on a small cohort of patients, has a ripple effect so overall continuity at the practice improves.

We’d like to thank all the practices who were able to take part, and look forward to seeing the impact continuity plays on patients in BNSSG going forward.

Goodbye Jake!

Today is Jake Lee’s last day as Medical Director of One Care. Jake has been instrumental in One Care’s journey – his was one of the signatures on the initial bid for wave one Prime Minister’s Challenge Fund monies that enabled One Care Consortium to be set up in 2014. He was also one of the members of the One Care Consortium board before joining us as our first ever Medical Director four years ago.  

We hope you will join us in saying a huge thank you to Jake for his hard work, enthusiasm, energy and visionary leadership. Jake will continue in his role as a GP in Bristol, so we look forward to continuing to work together in that capacity. He will be hugely missed at One Care and we wish him every success for the future.  

The recruitment process for our new Medical Director is ongoing and we are currently at second interview stage. We will share details of the appointment in due course. 


Introducing the GPCB

According to The King’s Fund, “Integrated care systems (ICSs) are partnerships that bring together providers and commissioners of NHS services across a geographical area with local authorities and other local partners to collectively plan health and care services to meet the needs of their population. The central aim of ICSs is to integrate care across different organisations and settings, joining up hospital and community-based services, physical and mental health, and health and social care. All parts of England are now covered by one of 42 ICSs.”

The government’s recently published White Paper takes this ambition even further. Increasingly, boundaries need to be broken down between organisations in the healthcare system and new ways of working developed as providers come together to create more efficient and patient orientated pathways. General practice being able to come together as one body to participate in peer-to-peer conversations with other large-scale providers is a key enabler of this.

We are pleased to announce that in response to this need, general practice across Bristol, North Somerset and South Gloucestershire has come together to form the GP Collaborative Board (GPCB).  The GPCB brings together all practices, Primary Care Networks (PCNs) and localities in BNSSG, supported by One Care and Avon LMC.

In 2020, practices asked One Care and Avon LMC to work with them to develop and implement an ethical decision-making process and good governance framework for general practice. In September 2020, we took the decision to stand up a Shadow GP Collaborative Board to shape this framework and make decisions about what the GPCB should look like. In April 2021, the GPCB moved out of shadow form and the members came together as a substantive Board for the first time.

The GPCB has four main functions:

  • Coordinating representation of general practice within system governance structures.
  • Ratification of new pathways and strategy.
  • Informing to ensure accurate, relevant and timely information flows to, from and throughout general practice.
  • Enabling general practice to come together at scale, giving a vehicle for provider-to-provider conversations.

The GPCB has already begun to establish itself as an important partner within the BNSSG Integrated Care System.  Find out more about the GP Collaborative Board.

If you want to know more about the GP Collaborative Board, get in touch with us –

One Care making an impact in 2020/21

As we come to the end of 2021/21, we have developed an impact report to demonstrate the work we have done to support our member practices this year 

It’s been a strange and challenging year for us all. We have focused many of our efforts on supporting practices with the COVID response, which meant some of our other activities were paused for a time, then restarted later in the year.

The report includes details of all these COVID activities, as well as our Practice Support Team work which includes digital and analytics support. It also covers improved access, continuity of care and set up of the GP Collaborative Board.

We hope you find this a useful summary of how we have supported our member practices this year. If you have any questions, get in touch with us on

Celebrating general practice vaccination delivery

Monday 15 February marked an important milestone in the delivery of the vaccination programme as we met national targets by vaccinating the top four priority groups as set out by government. We wanted to take this opportunity to celebrate the incredible work the practices and PCNs in BNSSG are doing, delivering around 70% of the vaccines across Bristol, North Somerset and South Gloucestershire.Please click the link for a full size image

We have therefore created this infographic to show just some of the figures that reflect the achievements of BNSSG between December and February. We hope the infographic helps demonstrate our celebration and gratitude to the doctors, nurses, pharmacists, administrative and support staff, managers, volunteers and everyone else too – it’s been a brilliant effort.

We all know there is still some way to go, but we hope that practices are able to take a moment to reflect and congratulate themselves on what they and their teams have been able to achieve in a short space of time.

Many thanks from all of us.

The beating heart of the vaccination programme

Delivering COVID-19 vaccinations in general practice in Bristol, North Somerset and South Gloucestershire 

Shortly after the approval of the first COVID-19 vaccine in December, delivery of COVID-19 vaccinations began in Bristol, North Somerset and South Gloucestershire. The first sites to open nationally were 50 hospital hubs, including our own at Southmead Hospital. Locally, our intention has always been for general practice to play a key role in vaccinating our people and general practice sites were the next to start vaccinating. 

Practices were asked by NHS England to work together in small groups, known as Primary Care Networks, to vaccinate their patients. There are 18 Primary Care Networks (PCNs) in BNSSG and all 18 of our PCNs have chosen to sign up to provide COVID-19 vaccines. 

The first of our Primary Care Network sites went live on 15 December and you may have seen the coverage on the local news about Muriel from Weston-super-mare, who was the first BNSSG patient to be vaccinated in general practice. There were four PCN sites who started vaccinating in that first wave – two in North Somerset, one in Bristol and one in South Gloucestershire. Before Christmas, a further nine PCN sites were able to start vaccinating their patients. 

The remaining PCNs all begin vaccinating their patients this week and next – meaning that by Friday 15 January, there will be 1established Primary Care Network vaccine centres across our patch (one PCN is delivering from two sites). Most PCN delivery centres in BNSSG are based at one of the member GP practice sites but we also have one running out of a community centre and one in an unused school building. To date, general practice through PCNs have delivered more than 90% of the vaccinations in BNSSG. 

The Joint Committee on Vaccination and Immunisation has stated that the initial priority groups for receiving the vaccine are the over 80s, care home residents and health and care staff. Due to challenges around moving the Pfizer vaccine, PCNs started by vaccinating those who were able to attend appointments at their vaccine centre – mainly the over 80s, as well as a small number of health and social care staff. Delivery to care home residents and staff has now started in many of our PCNs too, with brilliant progress being made. 

PCNs have done an incredible job to date and look forward to continuing to play an essential role in protecting people in BNSSG against COVID-19.  It is important to remember this is a marathon, not a sprint and that the last few weeks is just the beginning.  We are in a brilliant starting position in BNSSG, as each neighbourhood will have their own PCN vaccine centre by the end of next week. The government has shared some ambitious plans for vaccinating 13.9 million people by the end of February and our PCNs are eager to help make that happen. This does however depend on having access to sufficient additional workforce as well as a regular and trusted supply of vaccine and consumables. 

Everything achieved so far has only been possible thanks to a huge effort from all general practice and Primary Care Network staff to mobilise vaccine delivery within very short timescales. This has involved not just GPs, nurses and managers but also administrative teams, volunteers, car park marshals, security, practice pharmacists and support from local authorities. Many teams have delivered vaccine clinics over the weekend and over the course of long days. The response from patients has been incredible, many of whom have told their practices how grateful they are to be receiving their vaccine and finally seeing a route out of the difficulties of the pandemic. There is much more hard work to come but our PCNs in Bristol, North Somerset and South Gloucestershire are ready to do everything they can to help successfully deliver the largest vaccination programme in the history of the NHS.

How we’ve developed our dashboards over the pandemic

In order to support general practice throughout the unprecedented times of the COVID-19 pandemic, we quickly recognized that personal data and analytics could be invaluable for practices to help measure their demand, needs, and how they compare with other practices in Bristol, North Somerset, and South Gloucestershire. Therefore, we have recently launched a number of new features on the One Care General Practice Intelligence Dashboard (GPID).

Firstly, we created a flu monitoring page which enables practices to see what proportion of their total eligible population have been vaccinated to date and monitor update among more specific cohorts using the One Care flu searches taken from the local general practice booking system. 


In addition, we’ve also developed an OPEL status page. Operational Pressure and Escalation Levels (OPEL) are used by other providers in BNSSG to measure the stress, demand and pressure they’re facing. To date, there has been no consistent way to do this in general practice. By integrating primary care into the OPEL system, general practice will have a stronger voice in discussions about pressure in the BNSSG health and social care system, ensuring all partners can work together to manage and reduce its impact.


This information also provides you with a quantifiable measure of how busy you are, which you can use to let staff, patients, other practices, the CCG, LMC, NHSE and hospitals about the pressure you’re under and how long it is likely to last.


Lastly, we also worked to help general practice manage throughout the COVID-19 pandemic, we developed a COVID dashboard which provides info about the number of COVID cases in the practice, as well as other data on wider COVID-19 management. The dashboard is refreshed daily with data pulled from practices EMIS platform.

Our wonderful analytics team is always on hand to support practices and to also answer any questions others may have about what we can do to support healthcare and population health analytics across the country. Please don’t hesitate to get in touch with