Transforming practices for better patient outcomes

A practice in Brent was rated 'Inadequate' by the CQC but the incumbent GP partners and management team did not want to give up but instead turn the practice around into one which could deliver quality care and outcomes for the patients.

We worked with the Senior Leadership Team to devise objectives and key results (OKRs) which we would work to meet before their next CQC inspection.

We advised the SLT on clinical governance, up skilled and provided training to the clinical team on key areas identified in the CQC report including baby immunisations and cervical smears.

In order to assist with the smooth day to day running of the practice, we also provided training sessions for all practice staff on medical coding, clinical IT searches and the importance of accurate and secure data.

We supported a full prevalence audit across 20 Long Term Conditions to ensure all LTC patient lists were up to date to optimise patient outcomes and QOF.

Long Lane PCN commissioned us to improve outcomes for patients with Type II diabetes and allow clinicians to provide treatment and support in the most effective way. LLPCN have over 3000 patients on the diabetes register and needed a better way to treat, manage and monitor the progress of the patients.

We developed an online portal called the 'Diabetes Dashboard' which extracted patient data from EMIS to show the progress of patients against the KPIs.

We more than doubled our KPI of eligible patients who responded and booked into sessions by reaching 16% of those eligible – 487 of 2838 patients.

The mental health screening exceeded expectations, jumping from 14% of patients having a mental health screening prior to the programme starting, to 50% by the end of March.

For those who attended a session, a huge 78% had a mental health screening.

We ran 48 sessions with an average ten patients booked per session and six attending. On average, this means we halved the time a clinician would have spent with these patients had it been on an individual basis.

HealthBridge Direct, a group of GP practices in Redbridge, commissioned DCS to support their primary care networks by improving their prevalence lists for COPD, diabetes, hypertension and osteoporosis.

We deployed our bespoke algorithms which look for identifiers in electronic health records to identify patients who may have these conditions but have not been diagnosed or coded.

We analysed these clinical conditions across four clinical IT systems belonging to 42 practices within two months of being commissioned.

According to analysis from Asthma + Lung UK, the UK has the worst death rates for lung conditions such as asthma and COPD in comparable countries. In order to provide patients with frequent reviews and monitoring, a patient's record needs to be coded correctly.

As part of a project with The Health Foundation, we devised an algorithm support tool to help identify patients with suspected asthma - or 'missing asthmatics'. Our earlier work with improving recorded asthma prevalence has often meant clinician time is needed. We used machine learning (supervised technique) to mimic human activity.

We identified a way to cut the required GP time in analysing potential missing asthmatics by 4.9 hours per 100 patients. We extrapolated our findings from two practices to the whole of England and calculated that it could identify some additional 512,000 patients, saving 55,000 GP hours and £5.4 million of funding for primary care whilst improving patient outcomes and helping to prevent avoidable deaths.