Cambridgeshire & Peterborough ICS implement Joy to improve personalised care

17 Primary Care Networks roll out Joy to streamline social prescribing, leading to a 35% reduction in GP appointments.

Profile on Cambridgeshire and Peterborough

An ICS with a Vision

With almost 1 million patients across 22 PCNs in their Integrated Care Systems (ICS), Cambridgeshire and Peterborough may be responsible for supporting a very diverse community but their vision is simple - “we are committed to working together to improve the health and wellbeing of our local people throughout their lives”. Responsible for the planning and delivery of local health and care services, Cambridgeshire & Peterborough ICS brings together NHS organisations, local authorities, and Voluntary, Community and Social Enterprise (VCSE) to promote, support and improve the health and wellbeing of their community. ​

But, they were faced with a problem: how do you facilitate data-driven, personalised care efficiently and effectively to 1 million people?

The problem: data gaps, manual effort, and decentralisation of services

Doctors are measured on the number of referrals into social prescribing, personalised care support plans, and personal health budgets – social prescribing being one of the only personalised care roles that has Key Performance Indicators (KPIs) against it. But for many individual GP surgeries, Primary Care Networks (PCN), and ICS, it is hard to track progress:​

  • Systems are fragmented, so data is fragmented ​
  • Patient outcome data is primarily qualitative ​
  • Referral process and coding is manual, not transparent and inconsistent

Looking at social prescribing specifically, Cambridgeshire and Peterborough historically managed this process manually. And while they could pull reports on coded services from their clinical systems, they did not capture the whole referral pathway. They couldn’t easily see where the referrals were going.

“It's not capturing the whole pathway all in one place. And that we were keen to see, because what you don't see from just capturing number of referrals is where all those referrals are going. What services your local population really need support with?”

But data like this helps to inform what services the local population really need support with, where the gaps are in current services and where they need to put more funding to build out needed services locally.

The Solution: Clinical system integration, streamlined processes, and marketplace of services

Cambridgeshire & Peterborough recognised they needed a solution that could help them make better resourcing decisions, demonstrate the value of social prescribing and ultimately serve their community better.  But for it to be successful, it had to integrate into existing systems, streamline processes and be easy to use. ​

It also had to have a marketplace of services - an up-to-date database of services available locally. Previously this was managed in a very ad hoc way, with multiple different lists. Consolidating resources would streamline referrals and helps make sure people get access to the best services for them.

Integrate into existing systems

One of the most important factors in the decision to buy was integration into existing clinical systems. Joy’s two-way integration with Cambridgeshire and Peterborough’s clinical systems (both EMIS and SystmOne) allows for unlimited adding of notes, referrals and SNOWMED codes.  

"The main priority was the fact that Joy fed back to the clinical systems. We didn't want to have to duplicate work and needed to be able to build the evidence base for the value that Social Prescribing brings to primary care. Whatever you input into Joy then goes straight back into the clinical systems."

This means that everything in the case management system can be added into EMIS with best practice templates and nudges built in to drive proactive social prescribing and improve service quality.  

Ease of use

Adopting new technologies can be difficult. Especially if your team is dispersed and without IT resources available at every location. It was imperative that the solution be easy to use as this would help drive adoption across all the PCNs and individual practices. Joy has worked closely with each PCN to roll out a solution that works for them.

"...the bid that Joy submitted was so easy to walk through and understand. Everybody on the panel liked that there was training to walk you through the different parts of the platform. So, if you weren't a technical person or you hadn't used this type of software before, it was really clear."
Streamline social prescribing

The existing social prescribing process was very manual – from referral to patient management to managing a directory of services. The Cambridgeshire and Peterborough team was looking for a solution that made collaboration between personalised care organisations easy and centralised patient and service information. So, after a through procurement process, Cambridgeshire & Peterborough chose Joy.

Impact: insight-driven personalised care with Joy

Before implementing Joy, Cambridgeshire & Peterborough had little insight into the performance of social prescribing activity across the system, no visibility of the services patients were accessing, nor the ROI being delivered from social prescribing.

Cambridgeshire and Peterborough's reduction in GP appointments since implementing Joy.

Joy is enabling the ICS to start tracking the performance of social prescribing and ARRs roles. Most importantly, Joy Insights is helping them track the reduction in GP appointments. The most important stat to watch and the purpose behind these additional roles in primary care (ARRS).

In addition to tracking ROI, having all the social prescribing information for the region in one place allows the Primary Care Network Practice Manager (PCNPM) and others to build data-driven business cases for growing this work force. And more specifically, the exact services needed by the community.

Hopes for the future

For Cambridgeshire & Peterborough, they may be just getting started but they already have a few goals in mind.

By the end of 2023, they plan to have 20 out of 22 PCNs onboarded. And over the next few years, they want Joy to become the go-to app for patients. They hope to see patient engagement, support and quality of life improve with increased access to needed service via the Joy marketplace.  ​

Stay tuned for updates on how it's going!

After years of lived and professional experience in the health and social care sector, we knew there had to be a better way.
Here it is.

Elevate Your Care Offering with Joy.

Get in touch with us now.

If you are a local service hoping to find out more information about Joy please contact

Connect with our Expert Team for a personalised consultation:

Thank you! We will be in touch shortly.
Oops! Something went wrong. Please try again.