Access and Prevention at Scale

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Access and Prevention at Scale

How The Ridings Medical Group used smart SystmOne reporting and automation to improve safety, increase efficiency and transform long term condition management

The Ridings Medical Group set out to support proactive management of multiple long-term conditions across a large practice population.

Using advanced reporting, protocols, templates and automation tools already available within SystmOne, the practice has built a series of intelligent workflows designed to improve consistency, strengthen patient safety and release clinical capacity – without needing bolt-ons or supplier-built tools.

The work supports a wide range of high-burden long term conditions including cardiovascular disease, diabetes, CKD, respiratory disease, osteoporosis, thyroid disease, neurological conditions, mental health and medication-related risk.

“This is really about using SystmOne not just to record care but actively drive it, making it easy to do the right thing for the right patients. We are using SystmOne to deliver care that aims for quality, safety and efficiency”           

– Dr Richard Holmes

The challenge

Following a practice merger, The Ridings Medical Group identified growing pressure across long term condition management, including high volumes of outstanding medication reviews, increasing clinical demand and fragmented manual processes.

Many workflows depended on repeated manual searches, opportunistic identification during consultations and inconsistent follow-up processes. The practice also recognised the challenge of managing hundreds of individual searches and safety interventions across a population of around 49,000 patients.

At the same time, the team wanted to improve prevention, standardisation and patient safety while reducing unnecessary appointments and administrative workload.

The solution

Using SystmOne’s inbuilt reporting, protocol and workflow functionality, the practice redesigned a number of long term condition pathways to create more connected, proactive and scalable models of care.

Rather than needing to rely on supplier intervention or external systems, the practice developed its own intelligent workflows internally using tools already available within SystmOne. The approach focused on building processes that were efficient, consistent and safe, while making it easier for clinicians to do the right thing at the right time.

Key SystmOne functionality used included:

  • Clinical Reporting to identify at-risk cohorts, abnormal results and patients requiring recalls or intervention
  • Protocols to provide real-time clinical prompts and safety alerts during consultations
  • Auto-Review Rules Engine to automate pathology filing and patient messaging
  • Task Templates to standardise follow-up actions and monitoring
  • Templates to improve documentation quality and coding consistency
  • Batch Messaging and Batch Reporting to communicate with patient cohorts at scale
  • Alerts and Pop-Ups to support safer prescribing and reduce clinical risk
  • Waiting Lists and Recall Lists to ensure ongoing monitoring and follow-up

The practice also developed a single integrated “All in One Casefinder” workflow, combining reporting, protocols, templates and task generation into one clinician-facing process designed to identify unmet need across multiple long term conditions.

Using this model, clinicians can proactively identify patients requiring intervention in under a minute per patient, embedding preventive care directly into routine activity.

The impact

The redesigned workflows have delivered measurable improvements across prevention, safety, efficiency and long term condition management.

Key outcomes include:

  • Reduction in outstanding medication reviews by over 50%
  • Around 50% of pathology results now auto reviewed without clinician time
  • Over 1,400 healthcare assistant appointments released annually through B12 optimisation work
  • 459 osteoporosis risk assessments completed by a single clinician.
  • 106 DEXA referrals triggered by these assessments adhering to principles of National Osteoporosis Guideline Group.
  • 49 missing hypothyroidism diagnoses identified by single clinician use of “All in One Casefinder”.
  • 17 missing gout diagnoses identified by single clinician use of “All in One Casefinder”
  • 50 patients flagged for asthma inhaler review by single clinician use of “All in One Casefinder”
  • Prostate cancer diagnoses increased from 28 in 2021 to 74 in 2025
  • 1,845 SSRI reviews completed through systematic messaging and patient response
  • Significant increase in diagnosis of asthma and COPD and identification of those with high salbutamol use and therefore highest risk

The work demonstrates the power and flexibility of SystmOne, enabling the practice to design, build and adapt sophisticated safety-driven workflows themselves, without needing to rely on supplier-built solutions or additional products.

Please see below a list of protocols published on the resource library by the practice.

  • New diabetes
  • Urate >0.3,
  • TFTs in pregnancy prompt
  • PSA trigger
  • No BP last 6m but meds need it
  • New Pre-diabetes
  • New CKD3
  • Hypothyroid code prompt
  • Coded pregnancy in someone hypothyroid
  • Coded hypothyroid if someone pregnant
  • BP casefinder
  • Asthma Only, lots of Saba