2012 GP and Primary Care
Winner and Finalists

The winner in the GP and Primary Care category supported by UDL Patent Agents was Dr. Ollie Hart, a GP Principle and Clinical commissioning lead for musculoskeletal conditions based in Sheffield who has developed the Sheffield Aches and Pains web resource.


A suite of websites based around a central portal has been constructed to facilitate self-management of common musculoskeletal (MSK) conditions.  After diagnosis, patients refer to the websites for information and support in health care and pain relief, allowing self-management and reducing the need for onward referral to physiotherapy or specialists. The sites are strictly NHS owned, and non-commercial.

There are sub-sites for specific MSK conditions containing resources and educational materials for patients, professionals and other interested parties, such as employers. The sites are multimedia and involve a wide stakeholder, co-production approach between clinicians, managers and patients. Workshops introduced the packages to GPs – attended by  75% of the city’s GPs – and the websites were promoted on radio and TV.

Since going live on September 13, 2011, the portal has attracted:

  • Visits: 40,070
  • Unique visitors: 26,691
  • Page views: 170,396
  • % New visits: 66.48%
  • Views of video clips: 12,133
  • Multiple visits from interested parties

Over the last year, orthopaedic outpatient referrals for MSK conditions have fallen by 17%, a cost saving of £230,000 on first appointments alone. The website can be viewed at www.sheffieldachesandpains.com.

The other finalists in the GP and Primary Care category were Carolyn Garland from Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Claire Seymour from NHS Airedale, Bradford and Leeds, Dr. Arif Khwaja from Sheffield Teaching Hospitals NHS Foundation Trust and Professor Nigel Brunskill from University Hospitals of Leicester NHS Trust.

Carolyn Garland is the Maternal Obesity Lead Coordinator at Doncaster and Bassetlaw Hospitals NHS Foundation Trust and has led the development of the Maternal Obesity Service at Doncaster.


This midwifery-led service aims to educate obese, pregnant women on how to minimise associated risks, encouraging them to make positive and sustainable healthy lifestyle changes.  The service is based upon a face-to-face consultation with women to gain rapport and trust. Additionally, a ‘Healthy Lifestyle Midwife’ assesses risk for mothers and babies and plans individual care with an immediate dietetic consultation.

Working closely with obstetric and anaesthetic colleagues, a care-planning tool has been developed to ensure that all obesity-related issues have been clearly identified, resolved and documented. Training has been developed for health professionals on dietary and exercise advice in pregnancy and they have presented their learning both in the UK and overseas.

The impact of the service is:

  • It is easier for professionals to have frank and informative discussions with women about healthy weight management during pregnancy.
  • The service is continually streamlined based on feedback from users.
  • Our care planning and communication tools ensure seamless care, with CNST criteria met and clearly documented.
  • A 6% reduction in caesarean sections after our intervention equates to a cost saving of approximately £558,000 per annum at the Doncaster site.

Claire Seymour is the Assistant Director for Research and Innovation at NHS Airedale, Bradford and Leeds and has led a team developing Standardised procedures for DNACPR decisions.


In 2010, 53% of deaths in England occurred in hospital, although a survey has found that 63% of people would prefer to die at home.  A National Audit Office study found that 40% of the patients who died in hospital had no medical need to be there. If these patients were discharged, £4.5m per annum per PCT would have been released to invest in community based, end of life services.

In 2009, NHS Bradford and Airedale, on behalf of all Primary Care Trusts across the region, established a common DNACPR form and protocol, transferrable across all care settings. It aims to improve the management of individual end of life cases and reduce the number of inappropriate attempts to resuscitate patients. 

The impact of the standardised procedures are:

  • Introducing the form will, on average, make a saving of between £448 and £1,875 per case
  • 94% of patients’ notes that were audited were using the new form.
  • The education and training package increased staff competence with the form and confidence around DNACPR.
  • Staff found the form easy to use, resulting in better cross-service communication and clearer decision-making.

Dr Arif Khwaja is a Consultant Nephrologist at Sheffield Teaching Hospitals NHS Foundation Trust who has developed a service for remote monitoring and management of patients with chronic kidney disease (CKD-DMP).


Key features are that

  • Identifying suitable patients based on age, clinical history, stability of kidney function and requirement for interventions that can be delivered in the community.
  • An individualised CKD-DMP with monitoring of variables and thresholds for re-referral to secondary care, identifying those requiring intervention.
  • A CKD nurse-specialist based in secondary care (supported by a consultant nephrologist) to liaise with primary care, plus regular telephone consultations to replace outpatient visits.
  • Educating patients in monitoring of blood pressure and allowing online results viewing.
  • Providing resources and training to support CKD knowledge and education in primary care.

The CKD-DMP is currently being piloted with 75 patients in collaboration with the Sheffield Central Consortium of GP practices.

The impacts of the CKD-DMP service are:

  • Development of an integrated pathway of care.
  • Improved patient experience and increased involvement in disease management.
  • Closer collaboration with primary care.
  • 58% reduction in cost to commissioners (excluding transport costs) by reducing outpatient attendance.
  • Reduced NHS transport costs and carbon footprint.
  • Increasing outpatient capacity.
  • Likely roll-out across the region.

Professor Nigel Brunskill is a Professor of Renal Medicine at University Hospitals of Leicester NHS Trust and has been developed and implemented the IMPAKT CKD tool for monitoring patients with chronic kidney disease. The IMPAKT CKD tool is a Miquest web-based data extraction and audit innovation which can be run on any GP clinical system.


The tool:

  • Produces a general practice audit around CKD parameters, including blood pressure management and relevant drug usage.
  • Identifies patients who should be on the practice CKD register and those at a high risk of progressing to end stage renal disease.
  • Allows comparison of individual practice performance.
  • Provides alert, intervention and referral advice for individual patients.

The development of the tool has been a collaborative process, involving NHS and academic colleagues.

The impact of the tool has been:

  • The tool allows practices to easily identify patients with CKD and targets the most effective treatment, reducing referral to secondary care.
  • From pilot work, the tool is identifying significant numbers of un-coded CKD patients - on average a further 2.5-5% not currently on disease registers.
  • Early identification and effective management of just one new high-risk CKD patient could delay renal replacement therapy by five years, equating to £150k per patient.
  • The IMPAKT CKD tool may be used by the National Audit, demonstrating a national impact.