Vertis Health, Commissioned by NHS Herefordshire & Worcestershire and Worcestershire County Council
Overview: Commissioned by NHS Herefordshire & Worcestershire and Worcestershire County Council, and delivered by Vertis Health, Your Health provides vital health services through collaboration with PCNs, secondary care, public health, and VCSE partners, improving access, early diagnosis, and prevention.
Why? To reduce health inequalities, signpost local services, and provide advice to patients from across Worcestershire.
What happened? Our two vans deliver services up to six days per week, including NHS Health Checks, support with GP registrations, CVD/lipid and HbA1C testing, and signposting to a wide range of local services. With funding provided from Macmillan Cancer Support, the team also provide advice on cancer screening, and signposting guidance for patients and their loved ones dealing with cancer. As a GP federation, we have naturally built upon our strong foundations, working with each of our ten Worcestershire PCNs to use their insights and networks to build out a hyper-local strategy that is led first and foremost by the community we serve. This has led to the development of local programmes and pathways including remote cervical screening clinics in Worcester City PCN, a bespoke Homelessness Pathway in the Wyre Forest area, and a direct bloods pathway in Redditch, ensuring patients with abnormal POC results are streamed directly into care without a GP appointment. This has been supported immensely from close partnership working with our colleagues across our local system, with insights and data provided by Public Health informing our strategic approach. From 5th April to 31st December 2024, our team delivered 1756 patient engagements, and 606 NHS Health Checks to patients through our roving outreach model. Outside of NHS Health Checks, the team also delivered 510 Blood Pressure Checks, 322 Lipid Prevention Tests, and 52 HbA1C tests. In June 2024, we transitioned all data on to a live BI dashboard, which provided our commissioners and local stakeholders with live access to information on the Your Health activity and performance against metrics.
Looking ahead. This service has delivered tangible benefits to our patients, with the team becoming a recognisable presence in areas most impacted by health inequalities—and we believe them to be a credit to our local health and care sector.
Sanius Health
Overview: Sanius Health, in collaboration with Modality Partnership, shifts from traditional methods to a data-driven approach that harnesses real-world data and AI to optimise primary care. This integration empowers healthcare providers with actionable insights, drives research, and informs the development of innovative care models.
Why? A lack of data-driven approaches in primary care can limit its ability to deliver personalised and timely care. Current care models are often shaped without fully leveraging real-world patient data, limiting the opportunities for continuous improvements in primary care delivery, research, and service optimisation.
What happened? Key challenges that hinder this data-driven transformation in primary care include incomplete documentation or inconsistent coding practices across sites. The lack of integration between disparate real-world patient data and non-standardised medical records makes it even more challenging to identify gaps in the current care model and key unmet needs. In partnership with Modality Partnership, a leading primary care healthcare provider, Sanius Health is working to integrate the organisation’s wealth of primary care data with patient-reported outcomes and wearables data from our ecosystem. To unlock the full potential of this dataset, we leverage Artificial Intelligence (AI) and Machine Learning (ML) approaches, including Large Language Models (LLMs), to standardise and structure medical record entries for greater consistency and analytical depth. By consolidating data from multiple sources through this partnership, we were able to uncover valuable insights that would have otherwise remained hidden, transforming the use of primary care data to improve patient outcomes. Our recent analysis of a cohort of patients with specific diagnoses in women’s health focused on trends in prevalence, prescribing patterns, and care coordination within primary care settings. This analysis identified critical areas where primary care could take a more proactive approach to address specific patient needs and has been submitted for abstract publication as a first step towards translating these data and insights into learnings for the scientific and clinical community.
Looking ahead. Looking ahead, we plan to expand our exploration of additional variables and focused disease areas to gain a more comprehensive understanding of the primary care landscape.
Health Innovation Manchester, Greater Manchester Integrated Care Partnership and NHS Greater Manchester
Overview: The Digital First Primary Care programme’s commitment to collaboration, innovation, and patient-centred care has created a strong, successful primary care partnership. Through its unified vision, tailored support, and impactful initiatives, DFPC has transformed patient access to primary care across Greater Manchester.
Why? Strategic aims include building digital capacity, improving patient access, reducing non-patient-facing workloads, and ensuring digital inclusion.
What happened? Key focus areas include promoting the NHS App, enhancing digital inclusion, and reducing administrative workloads. A network of 17 digital facilitators delivers hands-on coaching, training, and guidance to practices and PCNs to help improve patient access and streamline care delivery. The programme’s phased approach began with a comprehensive assessment of the digital landscape, identifying best practices and gaps in patient experience. From there, DFPC reimagined optimal digital tool usage, creating a roadmap for improvement. This co-designed implementation strategy aligns with the national GP improvement programme introduced in June 2023, ensuring integration with broader healthcare goals. In a region comprising of 10 localities, 407 general practices, and 65 Primary Care Networks (PCNs), DFPC’s unified vision of “One Programme, One Team” replaced fragmented ways of working with a shared strategy. This strategic alignment enabled standardised outcomes and system-wide collaboration. Key projects include practice website enhancements, NHS App adoption, virtual consultations, digital triage, and cloud-based telephony. Key achievements over the last 12 months include NHS App Engagement, with 227 events supported from January to September 2024, driving app adoption; and practice websites, with 484 website reviews leading to quality improvements, and 79 percent of practices advancing towards national standards.
Looking ahead. Looking forward, DFPC aims to sustain and scale its impact. Learnings around establishing collaborative frameworks and creating a suite of adaptable tools and resources provide a blueprint for replication in other regions, supporting equitable access to digital tools in other integrated care systems.
