One Care is working in partnership with Connecting Care to provide better integrated services and safer care for vulnerable groups in Bristol, North Somerset and South Gloucestershire (BNSSG).
GP surgeries are required to deliver free health checks once a year to anyone aged 14 or over who is on their doctor’s learning disability register.
To help practices identify eligible patients, keep track of health check completion percentages, and visualise insights, One Care launched a dashboard in January 2022, using data exported from EMIS.
Going forward, practices will be able to use the dashboard and its useful features to keep a record of patient information and invite them for their annual health check when appropriate.
While the dashboard enables practices to calculate how many of their patients are eligible for these checks, and how many have been completed, there are other benefits too. Users can sort the data by a range of criteria, for example: ethnicity, deprivation, age and gender – which can highlight inequalities and where targeted support is most required. The dashboard also enables practices to compare different patient groups using the built-in filters, which will offer a greater overview of the BNSSG population and potentially inform future studies.
Speaking about the new dashboard, One Care’s Head of Business Intelligence Rhys Lewis, said: “People with learning disabilities have poorer physical and mental health than others and this has been particularly highlighted by the Covid-19 pandemic. Annual health checks can improve their outcomes by spotting problems early, enabling appropriate treatment and management, and preventing premature and avoidable death.
“The learning disability dashboard provides clinicians and managers with up to date information on how many of their eligible patients have received a health check and how many are outstanding, ensuring maximum uptake by the end of the financial year.”
Eligible patients do not have to be ill to have their health check – in fact, most are well when they accept it. The annual health check can help patients stay well by talking to a doctor or other healthcare professional about their health and medication, and if any concerns are spotted, treatment can be administered before any condition worsens.
If you would like more information on the learning disability health check dashboard and how to use it, please contact firstname.lastname@example.org. To learn more about these health checks, visit the NHS website.
One Care is giving general practices access to the latest referral forms through Resource Publisher (RP).
One Care is responsible for ensuring standardised referral form templates are available to practices and kept up to date, saving time for individual practices as they don’t need to maintain these templates themselves.
RP is a piece of EMIS software, and as a publishing organisation, One Care uses this package to create, update, and share templates and protocols centrally with practices.
To publish resources to a practice, technical data sharing agreements (DSAs) are needed and in Bristol, North Somerset and South Gloucestershire (BNSSG), One Care have DSAs with 99 per cent of practices. One Care also has agreements that allows sharing to Primary Care Networks (PCNs) and each geographical locality.
Reflecting on this achievement, One Care’s Senior Digital Consultant Colette Buckley said: “We are delighted to have reached the milestone of having 99% of practices signed up to receive resources from One Care via Resource Publisher. This will enable us to share a wider range of EMIS resources to practices and PCNs across BNSSG in an efficient and standardised way.”
EMIS-friendly referral form templates are the most commonly published item. However, One Care also creates and shares data entry resources via RP to assist record codes correctly and efficiently, helping improve data quality in BNSSG.
For more information, visit the TeamNet page for RP.
One Care has been involved in supporting general practice and system partners to develop a new process for taking bloods in community settings.
Prior to the Covid pandemic, there were 18,000 bloods taken across general practice and acute outpatient departments every week via the North Bristol Trust (NBT) and University Hospital Bristol (UHB) labs, with additional bloods being done at Weston General Hospital.
For many years, general practice has taken outpatient bloods on behalf of secondary care (hospitals), taking responsibility for both the phlebotomy but also the interpretation, communication and risk holding associated with these blood results.
This has been a significant workload for practices, but they have not been contracted to do the work. It is beneficial for patients to have their bloods taken in general practice as it means they can access care closer to home.
The community phlebotomy programme – otherwise referred to as secondary care bloods – has sought to address the governance of this work, ensuring blood results are returned to the requester in secondary care and to properly resource general practice to deliver this service. Over the last year primary and secondary care have been working together, supported by the CCG, to establish a standard process for this, putting patient experience and safety at the heart of the programme. This collaborative approach saw general practice and the trusts working as equal partners in the design of this new way of working.
The community phlebotomy service was fully launched on 31 October after a soft launch on 1 July, which saw primary and secondary care all working to the same standard operating procedure. Primary and secondary care will continue to work together with the CCG in this new phase of the programme to ensure a smooth transition into this new way of system working and to scope out further potential for development.
One Care have been well placed to support practices in the programme’s development due to the trusted relationships already established with practices.
As an integral part of the working group, One Care was involved in the first aspects of building up the business case for the programme, including initial data collection to confirm phlebotomy volumes and negotiating an item of service fee so practices were sufficiently remunerated for the work.
Throughout the programme, which has supported the outpatient transformation in a clinically safe, understood, and funded way, One Care has provided support for practices, in the form of regular communications, training for practice staff, trouble-shooting issues practices are having and developing EMIS resources to support the programme.
The next steps will see One Care analyse the data being collected to monitor the numbers of secondary care bloods being done in primary care and develop a dashboard to present this information back to practices. This data will also be used to monitor the success of the programme and will highlight any areas for improvement.
GP Collaborative Board Coordinator Rosie Southwell said: “A huge thanks goes to Nicola McGuinness (GP Collaborative Board lead) and Geeta Iyer (CCG Primary Care Development Clinical lead) for their leadership in the programme.
“It’s been really inspiring to see how general practice can influence positive change in the system when we come together with one voice. This has been one of the first programmes of work driven forward by our newly formed GP Collaborative Board.
“Practices have been really supportive and engaged throughout the programme – the feedback we’ve received has been extremely encouraging.
“We have lots of learning to take forward into the future as partners across our system begin to work even more closely together in an Integrated Care system. This is a great example of what can be achieved when we work collaboratively to find a solution that works for our population.”
We have published our latest quarterly round-up of strategic changes, information about new One Care projects and a one-page infographic showing the direct support we’ve provided to practices.
This year has continued to be extremely challenging and pressured for the NHS, including in general practice. In early August, One Care reinstated a situation reporting process which our practices could use to escalate any workforce and workload issues they were facing. This enabled One Care to contact practices in need of support throughout August and September, leading to several new guides and tools being published, including the development of the practice activity graphics in the General Practice Intelligence Dashboard.
Through One Care’s new staff support service, twenty-one new members of staff have had their induction to Bristol, North Somerset and South Gloucestershire (BNSSG) general practice. This is a brilliant opportunity for those who are new to general practice or to the area to get a feel for the landscape they will be working in and to understand what One Care can offer to their practice or PCN.
This year, we have provided a range of resources to support practices with managing flu season. This included EMIS searches and protocols, which were published earlier than in any previous year. We also launched the improved flu page in the General Practice Intelligence Dashboard. This year’s data will be updated twice a week and reports on additional cohorts aligned to the 21/22 Investment and Impact Fund indicators.
One of One Care’s key priorities for this financial year is to develop a longer-term subscription model for the organisation that is separate from improved access. We will move to this new model from April 2022. As part of this work, we need to identify current and future practice needs and the value that our members put on different elements of our offer. We started this work earlier in the year by looking at data from the last year around usage of our current services. In July, we met with a working group of practice representatives, who provided us with some initial feedback about what they value most now, and what they would like to see us develop moving forward.
More recently, we sent a survey to all practices to understand which of our services practices value most and how we should structure our subscription. The results will be used by the One Care board and executive team to inform our subscription offer for next year onwards.
There have been several changes within the One Care team in recent months. We appointment our new Medical Director Dr Mark O’Connor in August and some of our existing team members’ role titles have changed to better reflect the work that they and their teams are currently doing: Rhys Lewis is Head of Business Intelligence; Bryony Campbell is Assistant Director (Transformation); and Emma Goulden is Head of Marketing and Communications.
One Care has continued to offer support to the GP Collaborative Board. In July, the GPCB appointed their substantive Vice-Chair, Dr Katrina Boutin, who has now taken up this post. At the end of September, the GPCB announced the appointment of Dr Jonathan Hayes to the role of Chair. Jon will take up his post at the beginning of December. One Care has been offering project management and coordination support to the system-wide initiatives, such as community phlebotomy. Over the summer, this has included running training sessions and publishing additional guidance for all members of the practice team. We have also been part of several projects to support staffing in general practice (including for Covid-19 vaccinations). This has included setting up ten different staff sharing agreements to enable safe movement of staff between practices and other NHS organisations.
If you would like to learn more about One Care, how we work and how we can support your practice, please get in touch.