2024: Collaboration, Innovation and Delivering True Integrated Care

·         Preventative health: Enhancing blood pressure monitoring, lipid lowering, and vaccination uptake for flu and pregnancy.

·         Condition-specific support: Identifying and managing atrial fibrillation, chronic kidney disease, epilepsy in pregnancy, and COPD.

·         Home-based care: Facilitating care at home with tools like pulse oximetry, reducing the reliance on hospital-based services.

·         Mental health initiatives: Supporting suicide prevention and serious mental illness management.

·         Thames Valley and Surrey Shared Care Record: A new collaboration between Frimley Health, BOB ICS, Surrey Heartlands, and Graphnet to create a single regional consolidated record, which will bring together clinical, social, and care data for over 3.8 million people. This initiative will enable seamless data sharing and coordinated care across ICS boundaries, with Connected Care’s integration into this platform expected by year-end.

·         Greater Manchester Shared Care Record. The GM Care Record continues to expand, with new digital care plans for dementia and heart failure. These plans have been designed to allow GPs, hospitals, and social care teams across Greater Manchester to work from a single, unified record. This integration has proven vital in enhancing continuity of care across the region, which serves over 2.8 million residents.

·         The One Health and Care shared care record. The OHC SCR has been instrumental in improving safeguarding processes within the Black Country ICS. With this system, multi-agency safeguarding teams have immediate access to vital information, allowing for quicker, more effective interventions when dealing with vulnerable individuals. This has reduced delays in decision-making, which has been crucial for at-risk patients

·         Frimley Health ICS: Leveraging CIPHA, Frimley reduced A&E attendances by 30.4%, hospital admissions by 40.2%, and 999 calls by 36.1% among 6,000 high-risk patients. An independent report revealed that the direct savings from the measures concerning hospital attendance will be in the region of £5m-£8m annually.

·         Greater Manchester ICS: In collaboration with Graphnet’s platform, Greater Manchester has successfully identified 20,000 at-risk patients eligible for novel therapies aimed at reducing cholesterol. This proactive approach has been vital in preventing heart attacks and strokes, contributing to the region's focus on prevention.

·         One Wirral CIC: Diabetes prehabilitation services powered by Graphnet have achieved:

• HbA1c reduction from 73.4mmol/mol to 63.25mmol/mol in 12 weeks.
• Average BMI decrease from 34.2 to 32.99.
• Weight drop from 98.41kg to 95.45kg.

·         Cheshire & Merseyside ICS: Graphnet's population health tools have been instrumental in tackling fuel poverty, identifying over 1,300 individuals at risk. These patients, including those with severe respiratory issues, received early community-based support, preventing unnecessary hospital admissions

·         Cheshire & Merseyside: In Cheshire and Merseyside, the use of Graphnet’s Docobo remote monitoring technology is being combined with population health insights to monitor patients with chronic conditions, such as heart failure, diabetes, and COPD. By integrating this data into the shared care record, clinicians are monitoring patient health remotely, reducing the burden on primary care and hospital services by preventing avoidable admissions and improving patient outcomes.

·         Virtual Wards in North Midlands: Royal Stoke and County Hospitals, along with Midlands Partnership University NHS Trust, implemented consultant-led virtual wards. These provide 228 virtual beds, enabling acute care at home while reducing hospital stays and promoting quicker recovery.

·         DOC@HOME in Vienna: Cancer patients at the Medical University of Vienna have started using this Graphnet remote monitoring solution to track symptoms, significantly enhancing their quality of life and treatment outcomes.

·         Birmingham Care Homes: Birmingham Community Healthcare Foundation Trust expanded remote monitoring to 16 care homes, reducing unnecessary hospital admissions and improving resident care.

·         My GM Care App and Care Plans: In Greater Manchester, the GM Care Record added digital care plans for dementia and heart failure, benefiting 2.8 million residents. Complementing these developments, the ‘My GM Care’ app has been introduced, empowering patients to manage their health by contributing to care plans, self-recording data, and sharing insights with clinicians.

·         Digital ReSPECT Forms in Staffordshire and Stoke-on-Trent: The launch of Digital ReSPECT forms, accredited by Resuscitation Council UK and accessible via One Health and Care, are ensuring patients receive personalised recommendations during emergencies.

·         Forbes: Featured Cheshire and Merseyside’s fuel poverty initiative.

·         GPonline: Reported on Frimley’s success with surgical prehabilitation.

·         ITV: Showcased Dudley’s virtual ward, powered by Graphnet, which allowed neonatal care to be delivered safely at home.

·         Frimley Health and Care: Silver at the HSJ Partnership Awards.

·         Greater Manchester ICS: Best Use of Digital for ICSs at the HTN Health Tech Awards.

·         Cheshire and Merseyside ICS: Gold at the NHS Prescribing Awards for their fuel poverty project.