Case Study: How to deliver service transformation for care homes using digital

South Doc Services (SDS) are a GP collaborative that have been running since 1996 delivering Primary Care at scale. SDSmyhealthcare is a subsidiary organisation of SDS and is one of the largest GP Federations in England supporting a population of over 440,000. They have been recognised for their 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, GP practices in the region were facing increased demand from residents in homes, particularly since the onset of Covid-19 resulting in delays for residents receiving care, increased hospital admissions, inefficient use of healthcare resources and pressures on an already stretched workforce.

SDS had already began work to develop a systemised support mechanism for care homes with their new enhanced care home service in line with the NHS Long Term Plan. This reflects an ambition by the NHS to strengthen its support for the people who live and work in and around care homes by using technology to help reduce the pressures on GP practices and improve care.

Two new services for Care Homes:

SDS launched two new services for Care Homes in their regions, delivered via the Substrakt Health CareHome app to improve access to primary care for residents, whether that be via specialist GPs, advanced nurse practitioners or clinical pharmacists.

Enhanced Care Home Service

The service includes virtual ward rounds, allowing residents to receive proactive care for issues such as general sickness, medication reviews, drug monitoring, regular care for ongoing treatments, developing Advanced Care Plans (ACP) or therapy optimisation. These services were the foundations to the virtual support services which have since been developed in response to Covid-19 and its continuing impact to care homes in the region.

Virtual Urgent Care Home Support Service

SDS’s Virtual Support Service for Care Homes was commissioned by Birmingham and Solihull Clinical Commissioning Group. This is a 7 day a week (8am to 8pm) virtual service for all care homes in Birmingham. This has given every care home facility the ability to get advice as to the best cause of treatment for residents in their care, along with support to manage urgent prescriptions via telephone and video consultations. Along with providing residents with skilled primary care support and advice they need; this virtual approach helps reduce the risks of coronavirus infection for NHS key workers delivering this service.

“We understand this is a very difficult time for care homes up and down the country. Due to the coronavirus emergency, many local GPs have been unable to provide their usual support to care home residents, such as ward rounds. “We’ve been very happy to work with our partners to quickly find effective virtual solutions, by embracing new technology.”

Nirmal Vora, CEO, SDSmyhealthcare



The two services are currently being used by 65 Care Homes in the region who are benefiting from: 

  • Fewer callouts of NHS staff to care homes, reducing the risk of the spread of coronavirus
  • Improved medication management
  • Positive feedback from care home staff
  • Streamlined processes with GPs for example, completion of medical certificates
  • Reduced hospital admissions and use of ambulances

Key benefits

An online platform

SDS wanted to use digital health technology to improve access to primary care for residents in their care homes to reduce the need for urgent care. SDS have found they are having reduced hospital admissions with a reduced need for ambulances. The online medication management service is also supporting improved efficiencies across the region.

Better use of clinical time

The app allows residents to be appropriately triaged to the right health care professional and makes it easy for them to identify and receive the right care or treatment – whether that be with a clinician, pharmacist or advanced care/nurse practitioner, by easily booking an appointment, by telephone, video or face to face (if required).

Proactive care

Regular virtual ward rounds mean that residents receive ongoing care before conditions worsen, medication queries can be answered and records reviewed, advice on supplements and diet can be given, conversations can take place about Advanced Care Planning (ACP), outpatient referrals can be made, other support services can be managed such as death certificates or wheelchair information can be discussed.

Secure patient record access

It is crucial that all patient data remains secure, the App uses two-step security authentication and fully integrates with the primary care system to enable full read and write back capability to the patient record.

Clinical engagement and patient activation

Substrakt Health worked collaboratively with key stakeholders within SDS ensure strong engagement and project management processes were adopted to effectively implement the Health app. 

What next?

SDS Plan to roll out the CareHome app further in the region widening the reach across its care homes.

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