Tag Archives: PCN

Introducing population health analysis support from One Care

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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 business.intelligence@onecare.org.uk.

‘We’re showing war time spirit’ with the Covid Vaccination Programme  

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

In that time, NHS staff and volunteers have united across the country to deliver over 100 million doses of the Covid-19 vaccine, with more than 1.7 million coming from our local vaccination programme in Bristol, North Somerset and South Gloucestershire (BNSSG).  

There have been more than 5000 staff and volunteers involved in 53-GP run clinics, providing our local community with first, second and booster jabs.  

Eighty-one per cent of the BNSSG population, aged 12 and over, have now received their first dose, with a 108-year-old taking the crown for the oldest person to be vaccinated. 

In an interview with BBC Radio Bristol, Kingwood Health Centre’s Dr. Neil Kerfoot reflected on the past year saying: “In December we started to design how we would get vaccinations at pace into our population. There were lots of regular meetings and the staff were amazing – everyone came forward and offered to join us. We had volunteers coming out the woodwork, asking to help, and it was a real team effort.  

“In my Primary Care Network, we’ve done 60,000 vaccines now and it takes one-minute to input the vaccination on to the computer once it’s been administered. That’s 41 days of admin time our team has done in the last year so that we can keep track of who has had their vaccine.   

“To have over 80% of the population in Bristol vaccinated is amazing. There’s been some great work from staff in general practice, local pharmacists, community and outreach teams, along with the mass sites.” 

Kingswood Health Centre’s Practice Manager Robyn Clark added: “We often refer to it as our war effort. This is the closest to that war time spirit we’ve ever felt. We’ve all been working long hours in this combined effort to bring about an end to what has impacted so many lives for so long.” 

Care home residents were one of the first cohorts eligible to access Covid vaccinations and praising the work of the programme is 105-year-old Deerhurst care home resident Edna: “It is absolutely marvellous. All the carers around me are good – I don’t know how they work so hard. I’ve had my two jabs and booster and I was a lucky one. I felt so pleased. I’ve not had vaccinations before – it was different, but it was all soon done.” 

Claudia, who works at Deerhurst, followed up by saying: “The success of the vaccination programme has meant a lot more freedom. The residents were more protected, and we were able to look after residents in the same way, while wearing PPE.  

“We had the doctors come in and everyone was vaccinated. Because everyone was vaccinated at the same time, we could open up a little quicker and families could start to visit again.” 

With increasing numbers of confirmed Omicron cases across the country, vaccination is critical to bolster our defences against this new variant.  

Subsequently, our local NHS is working on plans to quickly scale up our Covid-19 vaccination programme, including through GP surgeries. 

Your GP surgery will be in touch very soon to offer you an appointment. Please do not contact your surgery about making a vaccination appointment before you hear from them. 

 From today (Wednesday 15 December) everyone aged 18 and over can book a booster vaccine appointment online here.  

NHS England and the government have asked general practice to focus on vaccinations in the coming weeks. This may mean you will be waiting longer for non-urgent appointments and as always, practices will be working hard to prioritise those who are most in need. Please be kind and treat staff and volunteers with respect. 

Remember, vaccines are the best way to protect yourself, friends, and family from these dangerous viruses, so everyone aged 12 and over are urged to take up the vaccine.  

One Care support for our practices between July and September 2021

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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.

Click to enlarge infographic

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.