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North Lincolnshire reduce clinic DNAs with the help of GP Connect

Find out how GP Connect has helped North Lincolnshire Clinical Commissioning Group improve attendance in primary care.


North Lincolnshire Clinical Commissioning Group (CCG) were keen to improve the patient international normalized ratio (INR) monitoring service delivered by a regional acute hospital. Approximately 1,500 patients in the area used the service, which offered daily clinics.

The INR is a calculation, based on a test called the prothrombin time (PT), used to monitor patients receiving the anticoagulant drug Warfarin. Warfarin may be prescribed to patients with a higher risk of developing blood clots. The INR calculation is used to ensure the patient receives a sufficient dose to prevent clotting without causing excessive bleeding.

Did Not Attend (DNA) figures for the service were 12.6%. The Primary Care INR Service (PCIS) talked to patients to understand why they failed to attend appointments and discovered that restricted opening hours and travel from rural areas were significant factors. 

A plan to deliver clinics via local hubs in the East and West Primary Care Networks representing 12 GP practices was proposed but technology issues prevented successful implementation. The practices used two different clinical practice systems to manage appointments with no interoperability between them.

The cost of providing different clinical systems in the hubs was prohibitive. At this point the PCIS discussed the implementation of GP Connect: Access Record HTML and Appointment Management via NHS Digital. GP Connect allows different GP practice clinical systems to share patient records and appointment books. It removed the technology barrier for the proposed solution to deliver a better patient experience for users of the service.

Actions taken by North Lincolnshire CCG

An extensive communications programme was set up to understand why the service had such a high DNA rate. Letters were sent out to all patients identified as being on Warfarin at all 12 surgeries, with contact details for the PCIS and asking for any feedback or concerns. A soft launch of the new service was also implemented for a one-week period and asked patients to complete a patient satisfaction survey to highlight where improvements could be made.

The PCIS INR technicians ran reports to identify regular non-attenders to the acute hospital model. They then completed telephone consultations to identify the reasons these patients were not attending and to explain the new model and ease of service.

The programme discovered that the restricted opening hours for the clinic and the need for patients to travel from rural areas were significant contributory factors for the high DNA rate.

Based on patient feedback, community-based local hubs were introduced for INR monitoring. This was designed to provide a choice of clinics for service users closer to home and with extended opening hours. This would reduce the need to travel or use often scarce public transport resources to attend appointments.

These hubs were opened on 1 February 2021 following a promotional campaign to advise all users of the changes, how to access the new hubs and where to go for further information. The new service relied on effective appointment sharing and access to patient records across the two different clinical systems which was delivered by GP Connect Access Record: HTML and Appointment Management. 

A bi-weekly evaluation of the new service measured the impact of the new service. The following factors were identified as key measures:

  1. Number of attendees for the clinics held at the new hubs
  2. Number of DNA for the new service
  3. Patient feedback measuring

What were the results

Reduction in clinic DNAs from 12.6% to 1.2%

over the period 25 January 2021 to 30 April 2021

The headline impact of the new service saw a reduction in the DNA for the clinics from 12.6% to 1.2% over the period 25 January 2021 to 30 April 2021. 

Patient feedback on the new service was very positive with patient’s surveys identifying that the choice of locations, ease to book appointments and communication direct with their GP about their on-going health care were popular benefits. 

From a clinical perspective, GP Connect; Access Record: HTML meant there was an effective flow of patient information between hubs and practices. Clinicians felt more ownership of the end to end patient journey.  

There were lessons learned in the configuration of the GP Connect technology where appointment sharing was well thought through and delivered but the patient record sharing aspect had not had the same focus. 

The issue was highlighted when one site (using EMIS) could not see another patient's records (within TPP). This was discussed with the GP Connect Team who highlighted that practices had not set up their systems to share records with each other.

This was quickly resolved with help from the PCIS IT support and GP Connect teams, and checked with each practice. Visibility was available within 24 hours of the patient being seen - as long as data sharing was enabled for patients on the clinical system.

This project has delivered value for money because GP Connect technology made it possible to deliver this service using a single administrator, whereas there would have been 12 people without this solution. Patient bookings and letters could be processed much more effectively and efficiently.

The PCIS employs 2 INR Technicians who incorporate the administrative work into their daily clinical hours. Due to the ease of GP Connect this has allowed a minimal 5 hours per week, per technician for their administrative duties at a cost of £100 per week. If GP connect had not been an option, the cost implication would have been up to £1000, dependent on practice protocol for assigning clinics over the 12 practices and monitoring of each of the hubs patient data. 

This model of delivering INR into primary care was one of two models deployed. The other model deployed as a comparator used traditional delivery via a secondary care setting. The PCIS model has had the best results according to patient feedback, community nursing feedback and reduction in DNA’s rates.  

Patient communications was a vital element in this project. Before implementation there was a lot of time spent on finding out what the patient wanted from the service and ongoing communications to gauge patient experience and whether the new service was meeting expectations set during the consultation process.

All patients identified as being on Warfarin and requiring INR monitoring were sent letters at 3 important milestones of the project:

  1. 12 weeks prior to launch advising patients of proposed changes to the new service and asking for feedback or concerns 
  2. 6 weeks prior to launch advising patients of proposed hub model and appointment booking system and launch date
  3. First appointment with service – patients provided with patient satisfaction questionnaire to highlight any changes which were required to make the service more accessible to patients and improve their experience.

Last edited: 12 October 2021 2:37 pm