Our Services

Berkshire Primary Care are commissioned to deliver services at scale across Bracknell, Binfield, Ascot and Sandhurst in collaboration with and on behalf of local primary care.

Many services are delivered virtually and remotely allowing us to support practices and primary care networks beyond our local area. The services outlined below show the work we are currently doing, but as we grow this too is an evolving and growing list.

Patient Support Services

The services in this category are well established patient facing services. They increase the capacity of practices and primary care networks to care for ‘at-risk’ patients, using clinicians and innovative solutions to keep them safe, well and at home.

SMI and Learning Disabilities Health Checks

Our dedicated team of clinicians collaborate with practices to provide annual Serious Mental Illness (SMI) and Learning Disability (LD) health checks, ensuring accessibility and convenience for patients. These comprehensive assessments aim to address specific health needs and promote overall well-being within the local community.

BP@home

Our BP@Home service supports hypertension diagnosis by providing loaned Blood Pressure Monitoring devices and remotely monitoring readings over 7 days. This streamlined process enhances efficiency and saves time for patients, ensuring accurate diagnosis and timely intervention for better health outcomes.

Proactive Case Management

Using validated risk assessment tools patients are identified for proactive care, aiming to maintain wellness, prevent hospital admissions, and reduce the burden on their GP Practice team. Eligible patients are offered a home visit for a holistic review and assessment of their needs, often resulting in signposting to local services and advice on self-management.

The data from this service has shown the following positive results:

  • Reduced admissions by 33%
  • Reduced A&E attendance by 31%
  • Reduced GP contacts by 21%
  • Reduced volume of medications prescribed by 17%
  • Reduced outpatient appointments by 54%
  • Reduced 111 calls by 31%
  • Reduced 999 calls by 26%

Remote INR

We offer remote monitoring for warfarin patients, enabling self-testing and medication adjustment without clinic visits. This service benefits working individuals, like teachers and firefighters, who struggle with primary care hours. Patients ‘self-test’ their blood and submit readings for nurse review, ensuring convenient care and continuity for optimal treatment management.

Pharmacist service

Berkshire Primary Care’s Clinical Pharmacy Hub offers proactive support for practices and PCNs to meet quality improvement targets such as QOF, PCN DES, and PMOS. Centralising pharmacy expertise enhances patient reviews, optimising medicines management, improving treatment efficacy, compliance, and reducing polypharmacy, thus improving patient outcomes and quality care delivery in primary care settings.

Home Visiting Service

Centralising home visits within the Hub reduces the impact on GP time caused by traditional requests, maximising patient access and enabling the practice team to focus on delivering services. Utilising experienced Paramedics and Nurses, supported by digital tools such as Teams and AccuRx video function, enhances home-based care delivery, combining clinical expertise with efficient communication for improved outcomes.

Practice and PCN Support Services

These services support the modernisation of General Practice and primary care resilience by tackling administrative burdens and offering business expertise and resources. Support services include HR, finance, training, and data sharing, to mitigate duplication and financial risks, while enhancing efficiencies, and releasing practices to focus on service delivery.

Workflow

Our team of Workflow Administrators process and code all clinical documentation that comes into the Practice electronically. Actions required, such as medication changes are passed to the appropriate team members e.g. Pharmacy Hub for timely action to ensure the patient’s medical records are maintained as correct and current.

Long Term Condition/QOF Recall and Booking Team

Our dedicated team co-ordinate the recall and booking process for Long-Term Conditions (LTC) and Quality and Outcomes Framework (QOF), ensuring thorough claims processing and accurate coding for optimal patient care and practice efficiency.

Digital First and Digital Triage Telephony and Online Consultation Hub

Providing a digital and telephone first front door for practices, the hub provides vital support to the practice’s own administration teams. This service ensures consistency of information given and the processes followed, and produces reduced call waiting, increased use of Pharmacy First and Community Pharmacy Consultation Services, effective use of total triage, improved signposting and utilisation of services, and greater patient satisfaction.

Health checks

We deliver NHS Health Checks at scale to enable primary care locally to target bigger populations and provide this important screening and early intervention service to groups with different needs while reducing pressure on practices. This supports practices to deliver NHS Health Checks and offer equity of access across place.

Back-office support for practices and PCNs

Practices and PCNs do not always have the business support and human resource capacity of larger organisations. We offer services to reduce administrative pressures on staff, that includes HR, finance, training, communication and data sharing support. Through operating at a larger scale, we are able to offer business expertise, reduce duplication and mitigate financial risks.

HR support

We provide comprehensive employment support to practices and PCNs, including job specification development, recruitment tools, interview process support, through to managing the onboarding and HR requirements of employing staff. By addressing common issues across multiple PCNs and practices, we ensure the efficient use of resource and offer impartial guidance for workforce improvement.

Social prescribing link worker service

Our Social Prescribers are embedded within PCNs to empower patients to manage their health and well-being by building shared personalised care and support plans through trusted relationships. By understanding patients' backgrounds and connecting them with local resources, this fosters long- term engagement and empowerment, addressing immediate health needs while enhancing community connections.

BPC Care Home Team

This service offers a multidisciplinary team for clinical and administrative care coordination, including ward rounds, triage, and prioritisation for GP input or visits. It provides medicine management and remote monitoring. Recognizing the unique healthcare needs of care home residents, it addresses complex conditions, malnutrition, flu immunization, and end-of-life care effectively.

Evaluation of our care home monitoring service has shown the outcomes:

  • Reduced admissions by 70%
  • Reduced A&E attendances by 61%
  • Reduced GP contacts by 63%
  • Reduced volume of medications prescribed by 116%
  • Reduced outpatient appointments by 79%
  • Reduced 111 calls by 48%
  • Reduced 999 calls by 76%

Improving Access

Berkshire Primary Care offers additional out-of-hours capacity in the locality enabling general practice to offer access through evenings and weekends and beyond the traditional core hours. Providing extended access above neighbourhood-level has been shown to improve equity of access across a place and reduce pressure on practices.

Improving access for vulnerable Communities

Berkshire Primary Care provides a tailored access scheme at scale to help target vulnerable communities and support practices to develop services specific to local need and work with system partners to provide an approach that ensures every contact counts, Numerous services, healthcare checks and support options are available at a single point of contact within this service.

Homeless outreach

We are proud of our Homeless Outreach service that we deliver in close partnership with Pilgrim Hearts Trust and the Bracknell Forest Council. This is an invaluable service that delivers true primary care outreach to a particularly vulnerable population. Patients are able to see a GP and a nurse at a safe and secure location to receive care for their physical and mental health needs, which might include long-term condition management, wound care, flu vaccinations, basic health screening, and on the day prescriptions.

This service is a drop-in Centre, Tuesday 12:30pm to 2:30pm at St Andrews Church, Priestwood, Bracknell.

Digital Healthcare

Our Digital Healthcare services are innovative solutions that utilise technology to deliver and manage health services ranging from telemedicine consultations and remote monitoring to electronic health records and health apps. These services allow us to provide greater access and efficiency while increasing patient engagement and improving their health outcomes.

Remote monitoring

Through remote monitoring our dedicated Digital Healthcare Team are supporting high-risk patients in various settings, including care homes and emergency care. Patients being remotely monitored are set up in their own home or care home with a tablet device and App and monitoring equipment. Our highly trained nurses support the patient when alerts are received, escalating to an appropriate other clinician when required.

Remote monitoring has shown to have multiple benefits including enhancing self-management, reducing hospitalisations, rapid assessment of vulnerable patients and better utilisation of clinicians.

Vaccination Programmes

BPC has played a vital role in the COVID-19 vaccination programme, leading the programme on behalf of their local area, setting up vaccination centres at short notice and offering workforce support and solutions. This involvement has enabled our local system to benefit from at-scale service delivery and reduce pressures and risk on other primary care providers. Berkshire Primary Care continues to be one of the largest vaccination providers in the Frimley system delivering COVID-19, influenza and RSV vaccinations on behalf of practices.

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