South Camden PCN (Primary Care Network) is based in North Central London and functions across three practices; The Holborn Medical Centre, The Museum Practice and St Phillips Medical Centre.
The aims and objectives of the NCL Digital Champions programme are as follows:
South Camden PCN was facing a challenge that is common across primary care; “how do you communicate efficiently and effectively with your patients to get them to take up the preventative care offered?” All practices have a duty of care to their patient populations so it is essential that practices engage with patient health outreach.
In addition to this, when delivering care at a PCN level it can be difficult to achieve consistency in messaging and services across multiple practices.
Various technological innovations can facilitate patient communication: social media, email and SMS (short message service) are all effective ways of reaching people directly. When managed correctly, these technologies can also be used to publish a single message out to large groups of patients.
As part of the ongoing digital improvement work in NCL, Redmoor has delivered a number of useful training and guidance sessions for the PCN to support good patient communication:
From the training and workstreams conducted between Redmoor and Sanjay, SouthCamden PCN decided to mobilise its capability to deliver an SMS health screening initiative, for a number of health conditions.
South Camden PCN texted patients and asked them to complete an iPLATO patient questionnaire and to include a blood pressure reading. This blood pressure reading was auto-saved into EMIS with the correct SNOMED code. The PCN’s Pharmacist then reviewed any highlighted abnormal readings and arranged further investigation.
A similar approach was taken for heart failure in one of Camden Health Partners Federation practices, where iPLATO patient questionnaires were sent out and responses were reviewed by practice staff who arranged for blood tests to be carried out.
SMS is an easy way of reaching a large population with a targeted message. A large percentage of patients have mobile telephone numbers, including the older population who can be typically harder to reach and have higher morbidity. These telephone numbers are usually recorded in the patient’s GP records, so enable the practices to reach a large number of patients directly.
After the health outreach undertaken by Sanjay and South Camden PCN, 351 patients were contacted about abnormal blood pressure, 95 (27%) returned their blood pressure readings and out of those who responded, five patients had a confirmed diagnosis of high blood pressure and thirteen patients had a suspected diagnosis of high blood pressure. The patients with a suspected diagnosis are undergoing further investigations.
In addition to this blood screening, Digital Champion, Sanjay, set up a heart failure screening using a similar approach in one of Camden Health Partners Federation practices.
For the heart failure screening, 229 patients were contacted. The survey had a higher response rate of 147 (65%). Out of these responses, 89 (39%) patients had one or more positive symptoms and were invited for a blood test, six patients have been identified as having abnormal results. Clinicians have reviewed these patients and referred them to cardiologists. Two were confirmed to have heart failure diagnosis with the other four patients waiting for further investigation.
This case study shows how simple messaging can be used to communicate effectively with patients to achieve better health outcomes. A small amount of training enabled South Camden PCN to develop their SMS health outreach.
South Camden PCN used two sets of standardised messaging to reach hundreds of patients and used two small surveys to capture all the data needed to identify health risks. This shows how a small amount of effort upfront can yield very efficient results.
It is clear that the results of this stream of work could not have been achieved without South Camden PCN’s Digital Champion, they were the driving force for converting the learning provided by Redmoor into actual practice.
Sanjay Dave Clinical Services Manager for Holburn Medical Practice and Digital Champion for South Camden PCN worked with Redmoor to compile this case study and is the chief architect of this health outreach project.
”We're extremely excited about our work with North Central London, their adoption of the Digital Champions' Programme and the partnership between the ICB, Redmoor and the training academies have really put the region as a leader in digital maturity.
We've enjoyed working with Sanjay and the South Camden team, who have used the learning from the Digital Champion Programme to deliver some fantastic health outcomes for their patients.
Clare TempleDigital Programme Manager at Redmoor Health
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