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Improving health outcomes for people with long term conditions

Once your PCN is up and running, we can support you to develop further understanding of your local patient population, improve services and work with other service providers.

Our offering includes:

  • Service Improvement in Primary Care Networks

This one day workshop is designed specifically for Practice Managers and professional support services staff within PCNs who wish to support change and improve care. The workshop will focus on the fundamentals of service improvement in general practice and community services…

  • Understanding BAME workshop

This workshop begins by providing PCNs with insight into their local communities, including demographic profiles, migration patterns, health behaviours and attitudes to disease and medical treatment. Participants will then be guided to take the first steps to more actively engage BAME patients to secure improved health outcomes.

  • Diabetes profile tool

Developed jointly with Diabetes UK, this tool will allow a PCN to view and interpret data for their local diabetes population. This ensures that PCNs can review the current situation for their patients, plan service focuses accordingly, before reviewing again to ensure sufficient impact is being made. This can be offered for individual Practices or on a wider scale for a PCN as a whole.

This tool plugs into a general medical practice’s clinical system and gives the practice live data about the profile of their diabetes population. A range of reports can be generated, and can be repeated at later dates. This live information will be an essential part of any review of services for people with diabetes. The tool has been developed in partnership with Diabetes UK.

The tool covers: Practice population data; age and gender demographics; diabetes related care processes; diabetes complications; diabetes modifiable risk factors and profiles of at risk populations.

  • CVD profile tool

Similar to the above tool but with a focus on CVD, this tool covers: Records of AF, blood pressure, cholesterol; age, gender and ethnicity demographics; attendance at previous health check data.

  • Asthma profile tool
  • Obesity profile tool
  • COPD and Heart Failure profile tools are due to be launched later this year.

Ready to find out more?

Contact our Primary Care Networks lead Stephen Ryan on or fill in the form below, selecting Innovations as the Type of Enquiry.

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