Delivering Population Health at Scale:
How BYTES PCN used smart SystmOne reporting and automation to improve access, reduce workload and generate sustainable value.
“What once relied on appointments or manual admin now happens automatically in the background and patients are achieving life-changing results because of it.”
Daniel Hallsworth, Digital and Transformation Lead, BYTES PCN
BYTES PCN has transformed how patients across Stockton-on-Tees access the NHS Digital Weight Management Programme, replacing a traditional appointment-led referral process with an end-to-end digital model delivered across four GP practices serving a large local population.
Because all member practices use SystmOne, the network was able to design and implement a consistent digital pathway across multiple sites using tools already in place.
The new approach has improved patient access, reduced administrative workload and generated nearly £12,000 in additional income — without any bolt-ons, external systems or additional staffing.
The challenge
Weight management referrals had historically relied on GP or nurse appointments. This meant eligible patients could only be identified and referred during consultations, creating delays for patients while adding pressure to already stretched clinical capacity.
The process also depended on manual eligibility checks, questionnaires and referral administration. As a result, opportunities were often missed when patients had no appointments booked, and valuable staff time was being used on tasks that did not require clinical input.
The solution
BYTES PCN redesigned the pathway using tools already available within SystmOne, creating an end-to-end digital process that automates the route from patient identification through to referral submission.
Automated reports are used to proactively identify eligible patients across the PCN, removing reliance on opportunistic identification during appointments and supporting a more population-focused approach to outreach.
Patients are invited through birth-month cohorts, allowing the programme to run routinely each month with minimal input and continue during periods of reduced staffing.
The pathway also makes use of SystmOne’s inbuilt flexibility to create an autonomous process configured internally, without the need for supplier intervention or additional products. Key elements include:
- Dynamic Questionnaires to capture referral-ready information directly from patients
- Communications Annexe to send personalised coded invitations in bulk
- Tasking and Workflow Automation to auto generate, track and complete referrals
- Integrated Templates to standardise data capture and improve consistency
- Automatic coding for payment to ensure completed referrals are recorded correctly
- Monthly batch reporting to continue invitations with minimal staff input
Across four GP practices, the monthly PCN-wide process can be completed in around 10 minutes using one bulk invitation. Patients can now access support without needing a GP or nurse appointment.
The impact
- Nearly £12,000 additional income generated
- Almost 1,000 referrals completed
- Around 10 minutes per month to run across four GP practices
- No appointments required to access the service
- Patients achieving weight loss of over 4 stone
- Delivered consistently across four GP practices
Benefits
“The results have shown what can be achieved when existing systems are used more effectively. We have improved access for patients, reduced pressure on staff and delivered a scalable model that continues to generate value across the PCN”
Daniel Hallsworth, Digital and Transformation Lead, BYTES PCN
The new model has improved access for patients, enabling referrals to a nationally recognised weight management programme without the need for appointments or contact with the practice. It has also helped reach patients less likely to engage through traditional routes, supporting earlier intervention and meaningful health improvements.
For staff, automation has released clinical and administrative capacity, allowing more time to be focused on patient care rather than manual referral tasks. Referrals are now standardised and consistent across multiple sites, reducing repetitive workload and improving reliability across the PCN.
For the organisation, the process has reduced workload, created additional income and supported improved population health outcomes, while demonstrating the flexibility of SystmOne when its reporting, communications and workflow tools are used together effectively.
A model that can be replicated
BYTES PCN has shown how existing SystmOne functionality can be used in smarter, more connected ways to redesign services at scale. By combining reporting, communications and workflow tools, the approach improves access, releases capacity and creates sustainable value without additional systems or resource.
The model provides a practical blueprint for other practices and PCNs looking to deliver proactive population health programmes.