Public and Preventative Health Service Redesign Initiative

Uncovering the hidden burden of disease in Redbridge : Redbridge Primary Care Networks, Healthbridge Direct GP Federation, Redbridge CCG

The aim of the project was to build a more accurate picture of how four chronic diseases affect people in Redbridge. Doing this would make hidden individual patient needs visible and able to be met and treated properly; and enable our Primary Care Networks (PCNs) to create better maps of health conditions to better deploy resources. Using collaborative working across all PCNs and GP Practices, we used innovative digital data capture systems and improved data logging training and successfully closed this ‘prevalence gap’. Over 1400 previously unidentified patients were placed on treatment pathways.