Data from August 2024 to August 2025.
The challenge
Conisbrough Group Practice was managing a high volume of patient recall activity, with monitoring processes that could be time-consuming, variable between staff, and vulnerable to disruption when roles changed. Searches and recall lists could differ depending on who ran them, and some tasks relied on personal knowledge built up over time.
The practice also wanted to match appointment capacity to need, so that long-term condition reviews were delivered steadily across the year, rather than escalating during peak periods.
The solution
Abtrace's Proactive Monitoring Tool provided a shared, up-to-date view of patients who needed monitoring, using clear statuses to show who was due, overdue, or missing key requirements. This made it easier to coordinate work across the team, standardise recall, and reduce the risk of patients being missed.
The practice also used Abtrace to support consistent coding and register maintenance, so that patient cohorts were reliable, and follow-up activity was targeted.
The practice also used Abtrace to redesign its monitoring pathway around a two-step model:
- HCA gateway appointment. Patients attend an HCA appointment to complete measurements and tests across all relevant long-term conditions, including blood pressure, blood tests, and condition questionnaires.
- Clinician follow-up, only where needed. A GP, pharmacist, or nurse then reviews the results, and patients are booked into follow-up appointments when there is clinical need, rather than by default.
This approach helped the practice separate data collection from clinical decision-making, focusing clinician time where it added the most value, and keeping monitoring on track and at scale.
What changed
A shared view of who needs what, and when
Abtrace made it easier to see which patients were due monitoring requirements, reducing reliance on manual searches and personal know-how.
Clinics shaped around demand
By making priorities and care gaps visible, Abtrace helped match clinic capacity with long-term condition needs across the year.
Stronger register quality and follow-up
Abtrace supported consistent coding and register maintenance, ensuring all patients who needed follow-up were identified.
Next steps
The practice is planning to continue using Abtrace's Proactive Monitoring Tool to bring reviews forward earlier in the year and expand proactive monitoring across additional patient groups.
"Abtrace has given us a clear, data-driven understanding of the appointment capacity required to deliver all long-term condition reviews and ongoing monitoring. It has automated and future-proofed our recall processes for the wide range of follow-ups and medication monitoring we manage, while providing a vital safety net against knowledge loss from staff turnover. As a result, our practice is more resilient, and our patients are safer and better cared for."
Bex Cottey · Business Manager, Conisbrough Group Practice