SDSmyhealthcare is one of the largest GP Federations in England and has been recognised for its development and delivery of new, integrated care models to create more efficient use of resource, improve clinical outcomes and enhanced patient and staff experience. As with many Primary Care organisations, SDSmyhealthcare faced increasing demand on its services across its 68 practices supporting a population of over 440,000, resulting in long waiting times, inappropriate use of healthcare resources and declining public health.

A stretched workforce, increasing cost of care and demand on services

SDSmyhealthcare recognised that the available resources were not being optimised and wanted to maximise the opportunity in designing transformational services building on the ‘Hub and Spoke’ model that evolved recently into Primary Care Network (PCN) structures. The aim, to enable GP practices to better work together to deal with pressures across primary care and to extend the range of local services by creating genuinely integrated teams across GPs, community health and specialist services. 

Delivering a more efficient service

SDSmyhealthcare worked closely with its GP practices to create a new ‘hub and spoke’ model to provide extended access and specialist ‘virtual’ services from 8 hub locations supporting 10 PCN’s, 67 practices and over 430,000 patients. Key services delivered, included:

  • Extended and enhanced GP access for patients
  • New services for multi-disciplinary teams to manage patients with diabetes, chronic kidney disease and frailty
  • New centralised pharmacy service
  • Enhanced support for care homes

SDSmyhealthcare recognised that digital technology needed to play a key role if they were to create a fully integrated and interoperable system to support their objectives and optimise resources. They realised digital technology would be key to supporting patient’s ability to access services, as well as more efficiently use the healthcare professionals across the service.

“We wanted to optimise ease of access to the right care, at the right time through an open digital platform that supports effective localisation and integration across NHS and care services.”

Finding the right digital partner

SDSmyhealthcare wanted to find a digital partner with a patient facing digital solution that was highly configurable and flexible to support effective service transformation and enable patient’s easy access to healthcare services. They also wanted to work with a company that would work collaboratively to localise their solution to enable access via an NHS branded ‘front door’ and be capable of evolving the platform to support future service developments. Specific requirements included:

  • Easy access, navigation and signposting of patients to the most appropriate services across all available resources in their locality.
  • Simplify care pathways with the use of digital technology and data
  • Enhance ease and speed of access to appointments, repeat prescriptions, test results and a patient’s personal health record.
  • Empower patients to better manage their health for themselves
  • Enable extended access and reduced inequality of care across all available services

Existing suppliers could not meet SDSmyhealthcare requirements, so specialist digital partner Substrakt Health were selected and in collaboration a new patient facing solution, PatientPack® was  created to best support the service transformation objectives set.

Improved clinical outcomes, better patient and staff experience

“Substrakt Health don’t bamboozle us with technical jargon and work with us as true partners. They take time to understand our organisation; our goals, challenges and values and work with us at the right pace to help us realise long lasting improvements in service improvement and transformation.”

Mani Dhesi, Transformation Director, SDSmyhealthcare

Extended and enhanced GP Access

The hub model supported by the PatientPack® App has delivered seven-day access for the population in the region, with full access to the patients notes and updates via their shared record, along with appropriate appointment booking, with over 70,000 patients now registered for the app.

Services for Diabetes, Chronic Kidney Disease (CKD), Frailty, and Pharmacy

The new services have delivered improved clinical outcomes, along with better utilisation of specialist resources, reducing waste and improving patient and staff experience.

  • Diabetes: the virtual clinic supported the up-skilling of Primary Care Clinicians through faster feedback and transfer of learning between Consultants and GPs within Clinical system. The service supports proactive care led by GPs, as the weekly available clinic allows GPs to feel that the support is always there when required. GPs receive advice in real time without any paperwork or delay involved. Over an 18-month period 92% of patients were seen ‘virtually’ with a 73% improvement in HbA1C measurement.
  • Chronic Kidney Disease: The ‘Advice & Guidance’ support provided by the virtual clinics has reduced unnecessary outpatient appointments in secondary care, demonstrating huge potential for this service to redesign the traditional outpatient model for CKD and reduce F2F referrals.
  • MSK First Contact Practitioner and Hub Based Physiotherapy service: A new Hub based ‘Physio First’ service was developed in partnership with the Community Provider, working in a ‘Hub and Spoke’ model and supported by digital signposting and  appointment booking has delivered a resilient and efficient service, from a 12 week to a 1 week wait for an appointment. Referrals to secondary care have reduced and patients value the quicker access to local care in a more convenient location. Physiotherapist’s feedback is also positive with easier, reduced administration with patient records being linked to GP notes. This was built on by the development of an MSK First contact practitioner service run at a Hub level for the benefit of spoke practices.
  • Pharmacy service: SDS identified that over 35% of their practice’s workload was medication related. The Prescription Ordering Department was supported by a centralised call centre and the PatientPack App to create a vital link between the patient and the surgery for their prescriptions; maintaining direct contact with the patient between GP visits helping to highlight over/under use of medications and identify when patient’s need a medication review booked. The service supports online and telephone access to a clinician/prescribing pharmacist for consultations and repeat medication ordering, up to 5.30pm on weekdays. The service achieved over £500,000 medication cost reduction in practices covered by the service. It increased patient satisfaction to 96% based on quick responses and request resolution; and increased staff satisfaction by reducing workload.

New services for Care Homes – Virtual Urgent Service and Enhanced Care Home Service

In response to Covid-19 and its continuing impact to care homes in the region, SDS set up to two new services for those most at risk, supported by the Substrakt Health CareHome app.  65 Care Homes are currently using the services and benefiting from improved access to primary care for residents, whether that be via specialist GPs, advanced nurse practitioners or clinical pharmacists via telephone and video consultation.

Along with providing care homes with skilled primary care support and the advice they need for patients with acute conditions; this virtual approach also offers care homes the ability to manage urgent prescriptions and helps reduce the risks of coronavirus infection for NHS key workers.

The enhanced care service offers virtual ward rounds allowing residents to receive proactive, regular care for ongoing treatments, general sickness or medications, drug monitoring, reviews and repeat prescriptions as well as help communicating with relatives.

What next?

SDS wants to continue looking at ways they can improve access to healthcare further for patients in its region and are looking to develop app further with support for managing long term conditions and care plans.

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