Supported by the Information Centre for Health and Social Care


  • Richard Aldritt, chief executive, Statistics Commission
  • Candy Morris, chief executive, NHS South East Coast
  • Denise Lievesley, chief executive, Information Centre for health and social care

Winner Croydon PCT

Croydon primary care trust used a predictive algorithm to identify patients at risk of unplanned hospital admission. Those at most risk are admitted to a virtual ward, where they are cared for by a dedicated team

The King's Fund (working with Health Dialog UK) has written a predictive algorithm linking hospital data with GP practice data to predict future risks of unplanned hospital admission.

Croydon PCT initially targeted people predicted to be at extremely high risk of future hospitalisation. Patients at the highest risk are admitted to a virtual ward, where they receive multidisciplinary case management, with results communicated to all professionals involved in their care.

Groups of 15 GPs commission a virtual ward, which mimics the working patterns of a hospital ward but cares for patients in their own homes. Each virtual ward has 100 'beds'. When a bed becomes vacant, the predictive algorithm is used to identify which of the GPs' patients is at highest risk of unplanned hospital admission; then the patient is 'admitted'.

Day-to-day clinical work of the ward is led by a community matron, supported by a social worker, health visitor, pharmacist, community nurses and other allied health professionals.

Of the 100 patients on each ward, five are discussed daily, 35 are discussed weekly, and 60 are discussed monthly.

Every night a list of each virtual ward's patients is e-mailed automatically to local hospitals, NHS Direct and GP out-of-hours co-operatives. If a virtual ward patient presents to their services, the staff working there will be alerted automatically to the patient's status. They can then contact the virtual ward administrator to obtain up-to-date details of the patient's care, and arrange early discharge back to the virtual ward team.

When a patient has been assessed by all relevant virtual ward staff, and has been cared for uneventfully for several months in the 'monthly review' section of the ward, the patient can be discharged back to the GP practice. For the first two years, the practice conducts quarterly, rather than annual, reviews.

The judges said the project was 'highly ambitious' and 'breaks new ground', while providing 'huge potential to make better use of existing resources'. They added: 'The rest of the NHS could replicate the approach to virtual wards with potential substantial improvements to patient care and efficiency gains.'

Predictive risk forecasting and virtual wards, contact

Finalist Bolton Hospitals Trust

Unacceptable delays in pathology test results were a spur for a mapping project and consultation exercise at Royal Bolton Hospital that has produced a new improved blood sciences lab

The work began in summer of 2005 in response to staff frustration, inefficient working practices and unacceptable delays for test results. Supported by Simpler Consultancy, a team of pathology services managers, staff and service users produced a new laboratory layout, based on the Toyota production system. The final design, revised after consulting with staff, had a hub-and-spoke layout, moveable benches and analysers, and wider access to service points.

The new lean laboratory was completed in May 2006. Benefits include: a reduction in sample volume required for testing; reduced bottlenecks in processing; a less stressful working day; changes in job roles; and the chance to develop new services such as near-patient testing.

Blood sciences lean laboratory, contact

Finalist Darlington PCT and Scriptswitch Ltd

Cost-effective and evidence-based prescribing have been implemented across Darlington PCT using support software from ScriptSwitch

The software provides locally authored advice and information to GPs at the point and time of prescribing. Clinical and financial information provided by the system includes cost-effective switches, National Institute for Health and Clinical Excellence guidance and drug formulations that represent the best value for money.

The project was piloted in four practices and has since been rolled out to all 11 practices in the PCT. Prescribing data is available immediately at PCT and practice level. The PCT can monitor the extent to which locally adapted prescribing guidance is taken up at practice level. This has reduced variation in prescribing across practices and led to greater equity of patient care.

Getting the message across utilising ScriptSwitch, contact

Finalist Bradford and Airedale PCT

A system was developed to promote the safe, efficient and effective transfer of care of patients moving from hospital to community settings who required continuing nursing care

Each month the community-based teams report problematic discharges to Bradford South and West PCT's professional and practice development team. This information is collated and analysed and a report passed to the manager of the discharge team at Bradford Teaching Hospitals foundation trust.

A cross-organisational problematic discharge liaison group then meets to discuss the initial community reports along with ward feedback, in order to identify common themes. Finally, the community teams that generated the reports receive the ward feedback.

The monitoring of individual ward or department performance on transfer of care has helped senior managers target areas where changes are needed to improve discharge systems.

Improving transfer of care from hospital to home and community, contact

Finalist South Hams and West Devon PCT

South Hams and West Devon PCT has issued budgets to GP practices for several years, but there was little activity information available to help monitor performance

The aim of the project was to provide regular information to practices that could be used straight away, without needing to manipulate it. Managers and clinicians agreed on what activity data they wanted, which included being able to see tariffs against each episode of care.

Being able to cost activity data increased GP engagement and practices now use the data to identify areas of service redesign in which they would like to progress.

The practice-based commissioning reports have helped practices and the PCT learn more about PBC, and have empowered practices to investigate their own data. The project has been developed in-house at no extra cost other than existing wage costs.

Practice-based commissioning expenditure report, contact