"We're not being reactive. We're being proactive with that tool now. Whereas before it was like pulling the lists off, then having to issue the list to different members of staff, and then they might not get to do that that day because it's extremely busy… Whereas with Abtrace it's constantly up to date."
In late 2023, Moor Green Medical Centre — a 7,000-patient practice in a leafy part of Birmingham, just down the road from Edgbaston cricket ground — was looking for a better way to manage the growing demands of QOF, high-risk drug monitoring, and proactive patient care. Like many practices, they were familiar with the December panic: pulling lists, issuing them out to staff, re-running them when they were already out of date, and racing to get blood pressures and blood tests booked before year end. We sat down with Dr Asfia Aftab, Sonia, and Nicola at the practice to hear how Abtrace has reshaped their ways of working over the past year.
Dr Asfia Aftab, a GP Partner at the practice and the practice's diabetic lead, reflected on how Abtrace's Optimisation feature has helped them identify patients who would otherwise have slipped through the cracks — particularly those at risk of developing chronic conditions.
"Our prediabetes register was always about 300, which is quite normal for this area. Pretty much overnight — well, probably over a couple of months — it went from 300 to 800. That makes a really big difference to the patient. It can make a difference to their outcomes, because you know that they are at risk of diabetes, and then you can monitor them."
Our Optimisation feature uses intelligent searches to identify commonly missed codes and patients eligible for a register, helping practices improve the accuracy of their disease registers without the headache of running and reviewing manual searches. Once a patient is on the right register, they're automatically picked up by all relevant Abtrace functions — meaning they'll be recalled for the appropriate monitoring, every year, in line with current guidelines.
The impact extends well beyond registers. Dr Aftab also shared the difference Abtrace has made to clinical care for her diabetic patients:
"Diabetic foot checks are part of the key points of care for diabetes. We were always running at about 65%. We were a bit dismayed — it was quite a regular thing for years. With Abtrace, it's just shy of 90%. And nothing else much has changed, so we're going to have to give the credit to Abtrace."
For Dr Aftab, one of the most significant shifts has been in high-risk drug monitoring — particularly methotrexate, where unmonitored prescriptions can pose serious safety risks.
"I didn't realise that a lot of patients were not receiving their treatment as per guidelines — they hadn't had the monitoring before they got their prescription. Methotrexate monitoring was running at about 38%, got to 48% — definitely not the standard we were looking for. It is now consistently 88% and above. Last check was 94%. Clearly this has helped to have some kind of a standard set, and it just actually helps the morale of the whole practice to know we're making such a difference to patient care and safety."
Abtrace's Proactive Monitoring tool flags drug-specific monitoring requirements and automatically tracks which patients are due, overdue, or up to date with their bloods, blood pressure checks, and other safety reviews. Practices can be confident that nothing slips through — and clinicians can prescribe safely, knowing the right monitoring is in place.
Sonia, an admin assistant at the practice, described how Abtrace's Patient View has made it easier for non-clinical staff to support patients with everything they need — even when they're calling about something else entirely.
"I had no medical background — I worked in retail. Abtrace has been a very good tool for me: I can see on my screen very clearly each patient's needs. If I'm calling for asthma reviews, I can see they need the flu jab as well. It's like an added benefit. Abtrace really does show me what else they can have."
Our Patient View gives every team member — clinical or not — a clear summary of a patient's outstanding monitoring needs, with an intuitive red, amber, green colour-coded system. Users can action tasks instantly, message patients directly, and ensure every interaction counts. It's how Moor Green has shifted from chasing patients in December to addressing needs the moment a patient picks up the phone or walks through the door.
Nicola, the Practice Manager, summed up the broader operational shift Abtrace has enabled across the whole practice:
"Every time a patient rings in, every time a patient comes to the desk, every time they have to speak to a patient for other things — they'll target it there and then. We're not being reactive, we're being proactive with that tool now. Whereas before it was like pulling the lists off, then having to issue the list to different members of staff, and then they might not get to that day because it's extremely busy… whereas with Abtrace it's constantly up to date."
With Automated Recall running in the background, patients are continuously monitored and contacted when their reviews are due — freeing up Nicola's team to focus on the patients who need a more personal touch. The whole practice operates from a single, always-current view, rather than chasing snapshots that go stale within a day.
Moor Green Medical Centre has already automated many of their recall processes with customised rules — covering everything from QOF reviews to high-risk drug monitoring and locally agreed targets like latent TB screening. Their team continues to work closely with Abtrace to add new features and tailored automations as the practice's needs evolve. We also offer ongoing support for all practices, to ensure users get the most out of both our existing features and new releases.
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"It actually helps the morale of the whole practice to know that we're making such a difference to patients' care and safety." — Dr Asfia Aftab, GP Partner
