Cambridgeshire and Peterborough
Personalised Care Programme

In partnership with Cambridgeshire & Peterborough ICB and
ECLIPSE (Equality of Care Led Insights for Patient Safety & Engagement)

Practice Pro-Forma

1. Programme Overview (What this is, and benefits) 

This programme, part of the wider “Your Healthier Future” initiative, supports better health for your patients and practice. We are inviting practices to help us ensure health records are up-to-date—for example, by recording patients’ weight and other health and lifestyle information in a sensitive and respectful way. 

Why participate? 

  • Helps identify patients who could benefit from further health support 

  • Information is used to support patients, not to judge 

  • Contributes to better cardiovascular and metabolic health outcomes 

  • Practice receives additional financial support (see below) 

 

2. What’s Expected – Engaging with Patients 

You choose how your practice participates: 

Practice-Led Engagement: 

  • Your practice team contacts patients directly, reviews health info, and follows up as appropriate. 

  • Full local control; payment of £1,000 if targets are met. 

    Centralised (Eclipse) Engagement: 

  • A central team contacts your patients on your behalf—mostly via SMS or phone. 

  • Your practice reviews patient info received. 

  • Less practice admin; payment of £400. 

    No participation: 

  • No action required; no additional payment. 

Note: All patient communications are confidential, require explicit patient consent, and use sensitive, non-stigmatising language. Patients can always decline or opt out of further contact. 

 

3. About the Personalised Care Programme 

Purpose: Improve health equity by updating health records (weight*, ethnicity, language preference, smoking, alcohol) and supporting people at increased risk of cardiovascular disease or other conditions. 

  • The programme does not label, judge, or pressure people about their weight or health status.  

  • It aims to improve health records in areas like language, ethnicity, and key health factors. It’s about supporting each person’s overall wellbeing, not focusing on any single issue. Any conversations about weight or health are handled with care, respect, and patient choice. The goal is to empower individuals and reduce health inequalities. 

4. Patient Engagement – How It Works 

Practice-Led:  Practice decides which patients to engage and how (e.g., through invites, phone calls, reviews). 

Centralised: 

  • Eclipse platform securely identifies eligible patients using agreed criteria. 

  • Central hub invites patients (via SMS or phone) to confidentially update their health information, explains the programme, and gains consent. 

  • Information is coded back into your clinical system only with permission. 

  • A summary report helps practices consider next steps for patient care. 

All engagement is confidential, consent-based, and worded to avoid stigma or discomfort. Patients are offered supportive resources if appropriate. 

 

5. Confidentiality, Consent and Sensitivity 

  • All information is kept secure and confidential. 

  • Patients are informed, give consent before participating, and can opt out at any time. 

  • All messaging (from practices or central team) will be sensitive and avoid blame or negative language, especially around weight and lifestyle. 

 

6. Evaluation   

As well as quantitative data, which will be collected via Eclipse, patient reported outcomes and perceptions of the new pathway will be collected through patient questionnaires. 

The programme uses Eclipse to identify eligible patients, support clinical decision-making, and enable centralised reporting. To support broader system learning and clinical audit, anonymised data will be evaluated to understand health inequalities, intervention impact, and service effectiveness.  

All evaluation is GDPR-compliant and includes only aggregated, anonymised data. No identifiable information will be shared in reports.  

7. Data Protection and Information Governance  

This programme evaluation is compliant with UK GDPR and the Data Protection Act 2018.  

  • Lawful basis for processing:  
     - Article 6(1)(e) – public task  
     - Article 9(2)(h) – provision of health or social care  

  • Only aggregated, anonymised data will be included in evaluation outputs.  

  • A full Data Protection Impact Assessment (DPIA) and Data Sharing Agreement (DSA) are available upon request.  

  • Prescribing Services Ltd is fully accredited under the Data Security and Protection Toolkit.  

  • Cambridgeshire & Peterborough ICB remains the data controller for evaluation activities. Eclipse (Prescribing Services Ltd) acts as a data processor under contract and data sharing agreement.  

 

8. What Next? (Practice Actions) 

  1. Select which approach you wish to use: 

    • Practice-led engagement 

    • Centralised (Eclipse) engagement 

    • No participation 

  2. Complete the form below with key contacts and permissions. 

  • You’ll receive all the necessary guides and support.