PROACTIVE CARE. SHARED MORE EQUALLY.
Care Planner helps primary care leaders turn unequal care completion into a plan their teams can actually deliver.
Independent proposal built on Abtrace’s existing monitoring, analytics and recall capabilities.
A population average tells a leader how the system is doing. It can conceal who is still waiting. The decision is where to focus a finite care team next.
Accountable for proactive care across practices, with limited capacity and uneven completion.
“I need to explain which group we will help, which appointments we will use, and whether it worked.”Proposed job to be done · to validate in discovery
Turns a priority into staff time, contact attempts and appointments. Needs an executable plan with clear ownership.
May need a phone call, combined visit or reasonable adjustment. Non-response alone does not explain the barrier.
A strong practice average can coexist with lower completion in an underserved cohort.
A leader needs to compare outreach choices with staff time and available appointments.
Messages sent are useful operational data. Success here means eligible people complete the care due.
GP appointments reported in the year to July 2025.[1] System context
NHS England prioritises reducing inequalities, including hypertension management.[2] Policy context
The size of the planning burden and completion gap requires customer discovery. National data does not establish Abtrace’s baseline.
Abtrace already finds care needs, estimates appointment demand and automates recall. The opportunity is to help a leader decide which response will close a gap within capacity.
Population filters, clinical task status, achievement analytics and practice comparisons.
Product documentation [3]Equity comparison + capacity scenarios + an approved plan + a scheduled outcome review.
Care PlannerAutomated recall, self-booking and recall analytics, including unsuccessful contacts.
Product documentation [5]Gap hypothesis: the public documentation reviewed does not describe this integrated workflow. A customer interview and an Abtrace product demo could disprove the gap.
Use a fixed 1,000-person hypertension cohort over 12 weeks. People are eligible for monitoring at baseline; those already complete remain in the denominator.
With the same 160 clinical slots, Care Planner will increase completion by at least 5 percentage points and narrow the priority-group gap by at least 8 points versus usual care.
400 priority-group patients: 200 complete.
600 comparison patients: 450 complete.
20 priority + 80 comparison slots booked. Assumed attendance: 50% / 84%.
77 completions · 60 slots unfilled88 priority + 72 comparison slots booked. Assumed attendance: 80% / 85%.
131 completions · 160 slots usedUsual care adds round(20 × 0.50) + round(80 × 0.84) = 10 + 67 = 77 completions. Planner adds round(88 × 0.80) + round(72 × 0.85) = 70 + 61 = 131. Each slot represents one unique person completing one defined monitoring requirement.
Gap = comparison-group completion rate minus priority-group completion rate. Usual care: 517/600 − 210/400 = 33.7 pp. Planner: 511/600 − 270/400 = 17.7 pp. The comparison group is 1.0 pp below usual care, inside the proposed 2 pp guardrail.
Booking demand and attendance improvements are hypotheses, not Abtrace findings. The estimate assumes assisted outreach fills unused capacity and raises attendance. At 60% priority-group attendance, the same plan yields 114 completions, only +3.7 pp over usual care: the completion target would fail. The prototype exposes this sensitivity.
Same clinical capacity does not mean the same total cost: the model adds 8.8 hours of outreach. Pilot value is additional completed care per incremental staff hour; this model makes no claim about hospital admissions, cash savings or clinical outcomes.
Three care situations. One decision loop. Choose a scenario, inspect the gap, plan within capacity, launch a simulated programme and review the result.
Validate the product and the assumptions together. A before-and-after chart cannot tell us how much improvement Care Planner caused.
Recruit 8–12 practices across two PCNs for a feasibility pilot. Match or randomise at practice level where possible, account for baseline mix and seasonality, and report confidence intervals. Determine powered sample size after observing baseline variance.
Freeze eligibility and group definitions at baseline. Report deaths, moves, exclusions and unknown attributes separately. A recall marked “success” is not automatically proof of completed monitoring.
Recall status distinction [5]Do not scale if uplift depends on extra clinical capacity, if another group falls behind, or if outreach cost outweighs the benefit. If attendance assumptions fail, change the intervention and retest.
The Senior PM’s job is to connect clinical value, reliable data, usable decisions and a proposition a population-level buyer will fund.
Observe three population-planning meetings and five recall sessions. Confirm a repeated decision, buyer, baseline gap and current workaround.
Gate: users cannot already solve this well.Start with hypertension. Agree event definitions with data engineering, import verified capacity, show assumptions and require owner approval.
Gate: trustworthy data and a feasible plan.Run the agreed comparison. Add other pathways only after the workflow earns repeat use and the impact thresholds hold.
Gate: measurable care value within cost.Test a paid population-planning module with existing Abtrace customers. The purchasing case is more completed care per constrained resource, supported by an auditable programme report.
Data access is permitted; the buyer has budget and authority; staff can act on the plan; measured value exceeds implementation, outreach and support costs. Pricing and willingness to pay remain discovery questions.
Patient-task eligibility → practice and approved cohort → outreach & booking events → completed care → capacity & staff effort. Show refresh timestamps and missingness. Restrict record-level access, suppress small group counts, and preserve an “unknown” category.
Public sources establish the product baseline and NHS context. The impact model, user needs and pilot thresholds are proposals to validate with customers.