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Greenwich CCG identify 4,000 patients with long term conditions

Greenwich CCG identify 4,000 patients with long term conditions

We have been working closely with Greenwich CCG and they have achieved some great results which we wanted to share with you.

In 2014, Greenwich had the highest rate of years of life lost due to avoidable death in South East London. The CCG was aware, that compared to the national average, recorded prevalence rates for four key long term conditions were low across the area, meaning that there was a sizable group of local residents that were potentially undiagnosed and untreated.

It was vital that the CCG identified these patients, not only to ensure that these patients received the most appropriate care as early as possible to avoid hospital admissions and any further complications resulting from their condition, but also to secure the much-needed funds resulting from maximising available QOF points.

We have published a population health case study that explains the challenges the CCG faced in more detail and how we worked together to identify an additional 4,000 patients with long-term conditions. You can download a copy of the case study at the bottom of this article. But in summary, here's what was achieved:

  • Used data from 39 practices using Vision and EMIS systems.
  • Identified a 6-18% increased prevalence of the main long-term conditions - diabetes, COPD, hypertension and heart failure across the entire CCG.
  • Categorised and facilitated the management of over 3,000 diabetes patients.

You can see the increase in patients identified with long-term conditions in the following chart: 


The CCG is delighted by the results and the measures that were set-up to ensure new patients are easily identified across the CCG. Here is what Jan Matthews, Director of Commissioning for the CCG said.

“I was really impressed with how up-to-date data from all of our 39 practices across the borough was available for me to review in one central dashboard enabling me to track progress on the identification and review of patients with long term conditions and ensuring accurate service payments were made."

You can download a copy of the full case study in pdf format below. Let us know what you think of the results and if you are experiencing similar challenges.

Click to download Greenwich CCG case study



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