Chronic Care Clinical Audit Service

Our service supports clinicians to review the management of their patients, combining extracted coded data from de-identified patient electronic medical records and questionnaire data and align it to best clinical practice guidelines.  

Benefits to Your Practice
  • Epidemiological summary report tailored for your practice as well as patient-level reports
  • Easily identify non-adherent patients (questionnaire)
  • Create specific plans to reduce unscheduled care and de-escalate treatment.

Benefits to GPs
  • High-risk patients are identified that could otherwise remain hidden to the GP
  • Education directly reflecting your own patient
  • Opportunity to participate in research


Benefits for Patients
  • Earlier intervention for potentially undiagnosed patients leading to improved care
  • Patient self-management plans to support better control and treat the disease and help monitor symptoms
  • Health benefits through discontinuation of inappropriate treatments


Our practice participated in the CONQUEST pilot, as part of the PREVAIL trial. Participating in the CONQUEST pilot was a simple and smooth process, and was beneficial to our practice and our patients. The OPC team were extremely helpful, and communicated exceptionally well with our staff and patients.

Bradford Respiratory Lead GP

I have worked with OPC on several projects, most recently to deliver a CCG wide initiative to improve respiratory care in a CCG comprising of 19 practices. 16 practices took part and the resulting work and clinical improvement which took place after the initial review has resulted in a reduction in admissions in most of the participating practices.

Norfolk Respiratory Lead GP

All contact was great and the report was very easy to read and your team have been easy to contact and helpful.

Gloucester, Practice Manager

Sample Practice Report

As part of our audit, each practice is provided with a suite of totally interactive HTML reports.
Feel free to navigate through the report and test all the features, download the sample report using the button below. 

Patient Level Report

We recognise that change can only happen at a patient level. As such, we provide practices with individual patient reports for chronic and rare diseases. These reports are accessible on practice computers via our bespoke Optimum Patient Care Tools software. Practices receive a user-guide on how to use Optimum Patient Care Tools, and our service team provide tailored support on accessing patient level reports and using OPC tools.

Individual patient reports support clinicians with face-to-face patient consultations. They help identify high-risk patients and other specific patient groups for review and intervention to optimise their care. 

Patient Report Aspects

  • Individual patient summary
  • Summary of patient questionnaire response
  • Identification of high risk patients
  • Patients associated with recommendations in practice reports
  • Personalised feedback for patients (self-management plan)
  • Disease symptoms and control status
  • Co-morbidities and smoking status
  • Therapy status and overview
  • Tools for referral to respiratory specialist