Category Archives: News

One Care oversees first shifts booked through BNSSG’s collaborative bank

The collaborative bank project has hit an exciting milestone, with the first shifts filled and completed by a member of the bank.

The collaborative bank uses technology from Ryalto to enable practices to offer shifts to other local practice staff, and be matched with colleagues who have the necessary skills and experience to fill them.

Nine practices across BNSSG are taking part in the initial pilot stage. One Care is also recruiting additional staff to the bank itself, including care navigators and medical secretaries. This will increase the agility of their workforce, offering a way for participating practices to fill gaps in their workforce to meet their patients’ needs flexibly and quickly.

Michéle Powell, PCN Delivery Manager at Phoenix PCN, said “The collaborative bank and the Ryalto app are helping us transform how we deliver care to our patients. The additional capacity it offers will be a fantastic tool to help us tackle winter pressures.”

The Ryalto app is also being used to great success in Network 4 PCN to manage shifts for vaccination clinics, with nearly 2000 shifts booked.

Enhancing proactive care and population health through data analysis

One Care’s population health management (PHM) team uses data to better understand the health needs of the BNSSG patient population.

The team supports general practices to deliver targeted proactive care to specific patient groups, particularly those facing significant health disparities.

Phil Gladwin, population health analyst at One Care, worked closely with a Primary Care Network (PCN) in South Bristol to identify patients who would benefit most from personalised support.

Through analysis of health and social factors data and talking with practice clinicians, Phil identified patients with a combination of mental health issues, obesity, and diabetes who were at high risk of further ill health. Practices then contacted this group of patients to offer targeted evidence-based support.

In Yate and Frampton PCN, PHM Fellow Dr Brynn Bird developed a similar project with One Care’s PHM team.

NHS data shows spending on both diabetes care and antidepressants is significant – and has increased since before the Covid-19 pandemic – suggesting these are areas where greater support may be needed.

To identify the patient cohort with the greatest potential, the PHM team also considered other conditions including obesity and hypertension.

This data-driven approach enabled the PCN’s care coordinators to contact this patient group, inviting them for appointments and interventions designed to foster improved health outcomes.

Dr Bird said “We wanted to engage with people in the neighbourhood who are likely to suffer poor health in the long-term, due to their current mix of physical and mental health conditions and social circumstances. We were particularly interested in those who would not normally see us to help with their health, aiming to change the trajectory of their health and wellbeing.”

Providing this kind of support enables patients to better manage their health and wellbeing. The PHM service assists practices in identifying these patients, informing them about available services, and intervening before further complications develop.

Dr Bird added, “We are working with a variety of supportive people in the community, led by our health and wellbeing coach, to give those at high risk of poor health the support they need to make interventions in their own lives that are suitable for them. This is an ongoing process, and we are aiming to build on this with further presence in Yate where individuals can turn for guidance.”

These initiatives are just a few examples of how data analysis can focus healthcare provision to improve population health. If you are interested in discussing a population health management project, please email

One Care helps shape health and wellbeing support for BNSSG primary care

As part of One Care’s enhanced health and wellbeing programme, One Care programme lead Tailte Breffni and North Bristol Trust staff psychologist Dr Emma Lishman met optometry and general practice staff from BNSSG last month. 

The health and wellbeing programme is a nine-month project that aims to improve understanding of the health and wellbeing needs of staff across dentistry, community pharmacy, optometry, and general practice. It aims to engage with staff to shape effective, fit for purpose support. 

At the meeting, Tailte shared some of the project’s key findings, including results from a health and wellbeing survey completed by more than 500 primary care staff members across BNSSG.  

Dr. Lishman presented ‘Start Well, End Well’, an initiative that aims to facilitate team connections to improve staff health and wellbeing within healthcare settings.  

There were productive discussions about how teams can build positive connections, and how time can be found to do this in the face of pressures such as workload and staff shortages.  

The attendees also looked at ways to culturally shift how health and wellbeing is viewed in their organisations. For example, through practical changes such as regular breaks for patient facing staff and collaborating with leaders and managers to make health and wellbeing a common priority for all.  

Participants in the health and wellbeing project will be supported to use a health and wellbeing bursary to implement ideas into their organisation, and measure the effectiveness of their interventions. The results will be shared across primary care in BNSSG, helping to embed health and wellbeing in the area. 

More ideas to support staff health and wellbeing can be found in the June primary care health and wellbeing newsletter.

Contact if you work in a primary care organisation in BNSSG and would like to learn more about the programme. 

GPCB supports PCNs’ successful bid for additional ARI hub funding

Primary Care Networks (PCNs) in Bristol, North Somerset and South Gloucestershire successfully set up acute respiratory infection (ARI) hubs in January, after GP Collaborative Board (GPCB) support enabled them to bid for national funding. 

It followed an NHS England invitation for funding bids to set up ARI hubs, to address extra demand over the winter from patients with respiratory infections, including invasive Group A Strep in children.  

The hub model was based on the Covid vaccination model of flexible care across PCNs, meaning patients are cared for in the community. This approach allowed additional appointments and clinical resources to be dedicated to patients’ respiratory illnesses, reducing the impact on core practice services over winter.  

The mobilisation of general practice at scale across BNSSG, led by the GPCB, meant that BNSSG practices secured the full funding allocation for the area and established the hubs in a very short timeframe. This enabled 17,000 additional appointments to be offered between January and March.  

Funding was distributed based on PCN size, meaning equitable distribution among all PCNs. In future bids, the GPCB will explore how funding can be used to support practices in areas of deprivation to reduce health inequalities across BNSSG. 

An additional project from the same fund was run by University Hospitals Bristol and Weston (UHBW) children’s emergency department. The GPCB worked collaboratively with UHBW to share best practice; understand differing models of care across primary and secondary care in detail; and coordinate the projects to provide optimal benefit to patients.  

 Jim Hodgson, GPCB programme manager for urgent care, said “With the support of the GPCB, we managed to bring in a significant amount of funding into BNSSG to support practices and patients during the winter months. We overcame the challenges of tight deadlines and difficulties in the model to support practices to provide great care for their patients. We look forward to building on the learning and value of this winter’s model, taking the learning and insights to develop an even more effective response next winter.” 

Introducing population health analysis support from One Care

One Care has launched a population health analyst support service, which aims to help primary care networks (PCNs) in Bristol, North Somerset, and South Gloucestershire (BNSSG) gain better insights into the health needs of their populations and the inequalities experienced by different patient groups.

The team provide intelligent insight to support PCNs to design and deliver appropriate services and interventions to address the identified needs.

The population health analysts at One Care also work with the wider healthcare system in making effective decisions to support general practice and the health and wellbeing of the local population.

The analysts are working on several projects, including:

  • Dashboards to support locality ageing well programmes, showing the distribution, relationships and inequalities of various priority health areas across an area (including COPD, diabetes, heart failure). The dashboards visualise overall prevalence of conditions at each practice in the locality, while also breaking them down by age, deprivation and geography to show the most affected areas
  • Sharing priority patients lists for practices across BNSSG, based on clinical risk and amenability to benefit from targeted sets of appropriate interventions, for example: vaccinations; chronic disease reviews; advanced care plans; and cancer screening.
  • Reports on cardiovascular disease, its relationship with other long-term conditions, prescribing patterns, and patient activity within the practice, with a focus on prevention and identifying gaps in existing care
  • PCN reports and priority lists of patients suffering from a combination of long-term mental and physical health challenges, to support a personalised approach to care and continuity

Rhys Lewis, head of digital at One Care, said: “General practice has a unique role in understanding the underlying causes of ill health and supporting communities to address them and drive improvement. We encourage all PCNs to get in touch with One Care’s team to collaborate on turning data into meaningful intelligence to address population health and begin to tackle inequalities.”

Each PCN in BNSSG has a dedicated One Care analyst, who can be asked to investigate specific topics or areas where clinicians feel targeted work is needed. The team is available to meet with PCNs or practices that would like to know more or make use of the service. It can be contacted via email at

‘Meet Team GP’ launches today

One Care and Bristol, North Somerset and South Gloucestershire Integrated Care Board (BNSSG ICB) have launched a new public information campaign, called ‘Meet Team GP’.

The campaign introduces and explains the various professional healthcare roles working in general practice – what they are, what they do, and how they help get patients the right care at the right time.

It covers roles such as paramedics; first contact physiotherapists; clinical pharmacists; physician associates; care coordinators and more.

The aim is to improve public awareness and understanding of these roles, so patients will understand why they may be offered appointments with one of these healthcare professionals instead of a GP, and accept these appointments.

‘Meet Team GP’ uses photographs, quotes and videos featuring real practice staff from BNSSG explaining their roles. The video case studies explain some of the roles, and how they provide patient care, in more depth.

As well as advertising on social media platforms, the campaign has packs for practices to use, including digital screen images and posters for reception areas.

Learn more about the campaign on BNSSG ICB’s microsite.

One Care leads on wellbeing programme for primary care staff

One Care is leading a programme to support staff health and wellbeing across primary care disciplines in Bristol, North Somerset and South Gloucestershire (BNSSG). It is the first programme of its kind, working with organisations across dentistry, community pharmacy, optometry, and general practice.

Staff in primary care face mounting pressures, including: increasing workload; difficulty recruiting and retaining staff; and treating patients with increasingly complex needs. With the additional challenges of winter pressures, we need to look after ourselves and one another more than ever.

Despite its importance, many people working in healthcare don’t feel they have time to focus on their own health and wellbeing. Continuing on this path is unsustainable for most, and is likely to lead to increased burnout and sickness absence.

The BNSSG health and wellbeing programme aims to ensure all primary care staff have an equal opportunity to access support. Hosted by One Care, BNSSG’s GP federation, it is working with the Integrated Care System and the national NHS health and wellbeing team.

The programme has three schemes:

  • Collating and sharing all freely available health and wellbeing support, training, and resources with primary care colleagues.
  • A network of health and wellbeing ‘champions’, linked to a peer support network across primary care in BNSSG, to support with promoting health and wellbeing offers and initiatives to their colleagues.
  • An enhanced health and wellbeing project, working with primary care organisations to explore what health and wellbeing looks like for them, then working with them to embed meaningful health and wellbeing initiatives. This project offers participating organisations a £2,000 bursary.

So far, the programme has contacted primary care organisations across BNSSG to find out which individuals and organisations are interested in taking part. More than 30 organisations expressed interest, and welcome events were held in mid-December. These will run again in early January 2023.

Tailte Breffni, One Care’s health and wellbeing programme manager said “This is a great opportunity to understand the unique issues primary care organisations are having and what support is required, rather than assuming a ‘one size fits all’ package. We hope to use this information to inform the system and develop future health and wellbeing support for primary care.”

Contact if you are in a primary care organisation in BNSSG and would like to get involved in the programme.

Two years of Covid-19 vaccinations in general practice

It’s two years to the day since the first Covid-19 vaccination was administered by a Primary Care Network (PCN) in Bristol, North Somerset and South Gloucestershire (BNSSG).

In that time, general practice staff and volunteers united across BNSSG to deliver over 1.4 million Covid-19 vaccinations at PCN clinics, which is around 54% of all vaccinations delivered in BNSSG.

Reflecting on the last two years, Dr Geeta Iyer, Clinical Lead for Mass Vaccinations, said: “Since the beginning of the vaccination programme, our practices and PCNs have worked incredibly hard to deliver this huge number of vaccinations alongside core services. This has made a massive difference to people in BNSSG and has undoubtedly reduced pressures on our healthcare system.”

“PCNs and practices should be very proud of the work they have done and continue to do, working with their communities and the wider system to ensure patients can access essential services like vaccinations.”

Over the two years, more than 5,000 staff and volunteers were involved in over 50 GP-run clinics, providing communities with first, second and booster jabs.

PCN vaccination clinics have been praised by the public, with a recent survey showing 95% of patients thought their experience at a PCN clinic was very good or good. When asked about their vaccination experience, one patient said it was: “…perfectly orchestrated. I could not be more impressed”.

Ruth Hughes, programme manager for PCN vaccinations, said “General practice has played a huge part in ensuring the success of the Covid-19 vaccination campaign, delivering over half the Covid-19 vaccinations in BNSSG. This emphasises the capability of general practice to meet their local population’s needs, but also the importance of involving general practice in future vaccination campaigns.

“I would like to thank all the staff and volunteers who worked together to run these GP clinics – without your hard work, this would not have been possible.”

It’s not too late to get vaccinated against Covid-19 – click here to find out more. Moving into the winter period, being vaccinated against flu and Covid-19 is the best way to protect yourself and those around you.

GPCB outpatients group seeks to improve primary and secondary interface

The General Practice Collaborative Board (GPCB) was set up by all practices in BNSSG to represent the voice of general practice in system discussions and decision-making.

To ensure general practice is properly represented within Integrated Care System (ICS) programmes of work, the GPCB created its own infrastructure for general practice transformation programmes.

One of these programmes is outpatients. The GPCB set up a committee, bringing together GPs and practice managers from across BNSSG, to provide general practice input to the ICS outpatients programme. It is led by Dr Nicola McGuinness, clinical lead, and Ruth Hughes, programme manager, and works closely with the Avon LMC and the clinical lead for planned care at the Integrated Care Board.

The GPCB outpatients network is funded by the ICS, which allows general practice to be part of key discussions and decision-making in the same way as the acute trusts and Sirona. This is significant for general practice as it allows us both to influence the existing projects and raise our own at-scale issues at a system level to find solutions together.

This improves the relationships and interface between general practice and secondary care, which supports the new ways of working in an ICS: putting the patient in the centre and building support and services around them.

One of the successes of the group so far has been collecting feedback from staff in general practice about advice and guidance processes to bring into the system review of the service. This means the views of both primary and secondary care are brought into discussions about how to improve the service.

The network has also worked with the trusts and the Integrated Care Board to think about how data can be used to support understanding of waiting times for hospital appointments. Following these discussions, the trusts and the ICB are looking at how to ensure accurate, local data is available for clinicians referring into secondary care, and for patients who are waiting for their appointments. This is important to give patients a realistic expectation of wait times, and what they can do in the meantime to support their health.

Dr Nicola McGuinness, GP in North and West Bristol and clinical lead for this programme, said, “The GPCB outpatients network is key to ensuring general practice is represented in the wider ICS outpatients programme. Our successes so far show that involving general practice in system outpatients work ensures the patient experience at the community end of their care is represented.”

One Care launches new digital forum for BNSSG general practice 

The general practice digital forum for Bristol, North Somerset and South Gloucestershire held its first meeting on 8 November. 

Set up by One Care’s digital team, the forum is a place for practice digital leads to meet, discuss operational issues and challenges, share experiences, and take away lessons to apply to their own practice. 

Thirty-five people have already signed up to the group, and more than 20 attended the first meeting, with a mix of roles represented including practice managers, practice IT leads, GPs, PCN managers, and business managers. 

At the meeting, attendees discussed the various online consultation systems currently being used in BNSSG for patient triage and online messaging, and their pros and cons. BNSSG ICB also attended to provide an update on its current work and future plans in this area. 

Bex Tilling, One Care’s head of digital support, said: “The original suggestion for the forum came from a practice IT manager, and we’re delighted to have been able to help bring it about. The first meeting was a success – feedback has been great, and members are excited about the possibilities for the future. 

“We hope it’s going to be a valuable resource for digital leads in BNSSG, enabling them to pool their knowledge and experience. It will also help One Care to ensure our digital services deliver what practices need.” 

The forum will meet every two months, with a Microsoft Teams channel enabling discussion between meetings. 

If you would like to learn more about the forum, please visit the TeamNet page. If you’re interested in joining the forum, please email