Prevention at Scale: Digital Health Checks for Long-Term Condition Management
By Stephen Murdock, Digital Transformation Lead, Nottingham West PCN
The pressures facing General Practice today are immense. One of the major pressures is the need to deliver high-quality preventative care and manage complex chronic conditions – all whilst working seamlessly across Primary Care Networks. At Nottingham West PCN, we’ve successfully tackled this challenge by unlocking the immense power within our clinical system: TPP SystmOne.
We set out to simplify, scale-up, and accelerate the NHS Health Check process across the PCN, making it better for both our staff and our patients. We’ve shown how SystmOne provides all the key functionality to underpin an entire innovative population health programme.
Configurability: Shaping digital health to our needs
Our innovation is built on the ability to control and customise core digital tools – in short, the configurability and flexibility of SystmOne. This has let us develop and roll-out a complete integrated end-to-end pathway for chronic condition recall management, with extremely effective workflows. We manage the entire process end-to-end, using SystmOne’s integrated tools.
“A key success factor was configurability. We are not constrained in any way. Far from it. We can shape the system to perfectly align with our chronic condition management needs.”
We’ve configured reporting and analytics functionality to precisely identify eligible patient cohorts, even splitting them by social deprivation for targeted outreach.
We’ve moved patient engagement to digital – for those patients who prefer digital communication routes. The SystmOne Comms Annexe lets us send custom, pre-visit digital questionnaires to patients. We gather key health data before they attend the surgery.
This information is then summarised for the clinician, using our custom-designed SystmOne protocols and a bespoke data view. This has significantly streamlined physical appointments, letting clinicians focus purely on discussions with patients about tests and interventions.
Advanced tools for value-based care
The depth of functionality in SystmOne means we have access to all these configurable, cutting-edge tools, without the cost of purchasing any external software or any “bolt-ons”. To manage complex clinical workflows at scale, you need advanced tools that integrate seamlessly. We have these at our fingertips.
For example, the visualisation dashboards are a game changer – they sit right within SystmOne and allow our admin teams to see the data they need, know the exact next steps for a patient, and manage their journey end-to-end. Without these powerful, deeply integrated functionalities, this simply wouldn’t work.
“As a PCN, we’ve increased our revenue whilst delivering vital preventative care for the NHS. We’re doing more checks for the same amount of clinical and administrative time. We’ve even identified previous missed revenue opportunities. It’s made this a hugely valuable investment of time, not capital.”
As we have built our new pathways on SystmOne’s analytics, communication, and patient outreach tools, we don’t need to pay for any additional software. At the same time, it’s led to integrated processes and improved appointment efficiency. It’s simpler, quicker, more effective, and better value for everyone involved. In an NHS struggling with budget constraints, the fact that we built this entire workflow on SystmOne – whilst delivering preventative care for long-term conditions – is critical.
Seamless PCN Working
Modern general practice relies on integrated working with PCNs and neighbourhood teams. SystmOne is essentially our digital connector across providers. Our overall administrative processes are run by a small, well-trained PCN team – using our SystmOne dashboards. The processes are run centrally, across all our constituent practices.
The integration capability allows us to manage the process end-to-end, across the PCN. It simplifies administrative burden. It ensures our approach is standardised, robust, and reliable. Looking ahead, we know we can change to run clinics directly from the PCN hub. This demonstrates how SystmOne facilitates true integrated working across neighbourhood teams, with the flexibility to work immediately with evolving delivery models.
Measurable care improvement
Ultimately, our goal is better patient care. We’ve delivered this – and can measure it. The volume of invites has increased. Invites are actioned more quickly. Patient satisfaction with the new process is exceptionally high and we’ve had fantastic feedback.
“This is absolutely amazing. So quickly received & so informative. It’s certainly put my mind at rest over a few concerns I had! Thank you!!!”.
Real patient feedback
Crucially, the speed and quality of post health check results for patients – generated automatically in SystmOne – has driven immediate preventative action. We’ve seen tangible outcomes, with patients acting immediately on their results. For instance, one individual signed up for a weight loss programme straight away, highlighting how an end-to-end digital health programme can lead directly to improved patient choices and preventative interventions. This is what it’s all about.
Furthermore, the scale of the benefit is huge. The benefits go far beyond practice efficiency. By ensuring the effective delivery of digitised health checks, we are supporting the early identification and management of serious chronic conditions. This commitment to long-term condition management, delivered at scale, means we are actively achieving reduced pressure on urgent and acute services across the NHS. It’s an exemplar for the aspirations of the NHS 10 year-plan and neighbourhood care; moving from reactive to preventative, delivering care in the community, built on a move from analogue to digital.
My advice to colleagues is simple: Do it! There are huge opportunities to leverage SystmOne’s integrated clinical platform and the deep functionality. The system is unique. It’s highly configurable and supports complete digital pathways – from very simple to extremely complex. There’s no additional cost – it’s all available to you now, out-of-the-box. It will deliver true digital transformation across your PCN and ICB. Innovative, integrated, digitally led, preventative care, delivered seamlessly. This is the future of modern primary care in the UK.
