Improving Locally Commissioned Services with Ardens Manager

Hertfordshire & West Essex Integrated Care Board (HWE ICB) introduced Ardens Manager as a tool to drive improvements in primary care services for a population of 1.6 million.

By providing near-live data and comprehensive analytics, Ardens Manager enables 125 GP practices across the area to deliver consistent, high-quality care, reduce inequalities, and improve patient outcomes.

The challenge:

1. Aligning place-based commissioning: Practices previously operated with varied place-based local schemes, with different reporting and payment models. This resulted in inconsistent care, variation in data accuracy and coding of information, and limited insights.

2. Data gaps: The lack of robust data systems hindered the identification of undiagnosed conditions and the tracking of improvements.

3. Administrative burden: Manual processes diverted clinical staff from patient care, and complex reporting requirements resulted in long reconciliation processes.

The solution:

Working with Ardens, HWE ICB has addressed a number of key priorities:

• Data-driven decision making: Practices access near-live dashboards, offering visibility into local performance, benchmarking, and progress against care process indicators.

• Streamlined processes: Automated uploads and clinical templates reduce administrative workloads, improving consistency and enabling staff to focus on delivering care.

• Collaboration and integration: Practices, PCNs, and the wider system use data insights to align care delivery, reduce variation, and support population health initiatives.

• Continuous improvement: Insights from Ardens Manager are used to inform improvements to local enhanced schemes, ensuring that care is targeted to patients most likely to benefit, responding to the health needs of the population.

The impact:

• Targeted identification and management:

  • Disease prevalence data highlighted underdiagnosed conditions, enabling timely interventions and improving long-term health outcomes for thousands of patients.

  • Improved coding of disease staging supported the identification of people in need of palliative care support, resulting in an improved end-of-life register and the number of people with Advance Care Plans.

  • Practices used case finders within Ardens Manager to identify patients with undiagnosed chronic conditions. For example, practices that actively used case-finder reports increased their Chronic Kidney Disease register by 0.44%, compared to a 0.17% increase in others. Overall, across the ICB, the CKD registers increased by 4,500 patients.  

    
    

• Improved quality of care and outcomes:

  • The percentage of COPD patients receiving care plans increased from 49.8% to 76.9% within two years. These care plans adhered to international standards, ensuring patients received appropriate staging and referrals to specialist services like pulmonary rehabilitation.

  • Proactive care and medication reviews for frail patients supported a 62% drop in emergency admissions for this group.

  • In diabetes management, increased completion of all 8 care processes for high-risk patients contributed to reduced emergency admissions and improved outcomes.

  • As a result of the GP ECF, practices reduced their prescribing of items not to be routinely prescribed in primary care in 24/25.

    
    

• Reduced variation and inequalities:

  • Ardens Manager standardised care delivery by enabling practices to align with shared clinical standards. Across all disease areas, the ECF has increased the proportion of people receiving evidence-based care and reduced variation, ensuring more equitable access to high-quality care across the region.

    
    

• Integration and continuity of care:

  • Data from Ardens Manager supported the development of integrated care pathways, such as falls prevention and lipid management programmes, by identifying high-risk patients and targeting resources effectively.

  • Improved coding and record-keeping, including a 37% increase in updated CKD staging, enhanced the accuracy of patient data, ensuring better care decisions and reducing risks like acute kidney injury.

    
    

• Operational efficiency:

  • Automation of reporting and data collation saved significant administrative time, with nearly 100,000 interactions recorded by 540 users across practices.

  • Practices reported smoother workflows and faster decision-making due to timely, actionable data.

  • Practices attained 93.6% of ECF points, equivalent to £7.06m in additional funding for care delivery.

    
    

• Equity and integration:

  • Standardisation of care delivery reduced variation, with narrower interquartile ranges across clinical indicators.

  • Insights supported integrated care pathways, such as lipid management and falls prevention, benefiting wider system partners.

    
    

• Data quality:

  • Improved data quality supports direct care including clinical decision-making at the point of care, continuity of care, and avoiding duplication of care.

  • The platform enables data-driven decision-making for service planning, through understanding health needs, highlighting inequalities and showing service utilisation and gaps. HWE ICB has used this insight to develop new models of care for frailty, heart failure, and hypertension.

Conclusion

HWE ICB reported positive feedback for Ardens Manager due to its user-friendly interface, transparency, and ability to empower data-informed decisions. The platform’s success within HWE ICB highlights its scalability and offers a blueprint for other ICBs. It demonstrates how to enable efficient primary care delivery, streamline contract management, advance population health strategies, tackle health inequalities, and drive value-based care.

Ardens Manager has proven instrumental in transforming primary care delivery by enabling data-driven insights, improving patient outcomes, and streamlining operational efficiency. HWE ICB's success highlights how leveraging robust data platforms can lead to sustainable and equitable healthcare improvements.

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