Optimising SMI and CCMI Management in Hillingdon PCNs

Introduction

In Hillingdon, managing Serious Mental Illness (SMI) and Complex Chronic Mental Illness (CCMI) has long posed a challenge for primary care. The complexity of the annual reviews — requiring the delivery and documentation of multiple core and optional elements — made it difficult for practices to consistently meet performance targets. Primary Care IT was engaged to support a group of PCNs with the digital tools and insights needed to improve performance and unlock untapped funding.

Background/Challenge

The LES contract for SMI and CCMI required practices not only to complete structured annual reviews, but also to track performance at a PCN level — meaning that every practice in the network needed to achieve consistently.
Barriers included:

  • Incomplete or inconsistent documentation.
  • Difficulty tracking who had and hadn’t completed required elements.
  • Limited visibility of how each practice was performing against target.


The project set out to:

  • Streamline the review process for mental health patients.
  • Support consistent performance across all practices in each PCN.
  • Maximise income by ensuring every eligible patient review was counted and coded correctly.

Solution

Primary Care IT implemented a coordinated digital response that included:

  • SMI and CCMI Review Templates
    Fully aligned to the LES contract, the templates guided users through required elements at the point of care, ensuring complete reviews and accurate coding.
  • OneAnalytics Dashboards
    Real-time visualisation of review performance at both practice and PCN levels, helping practices to quickly see where to focus effort.
  • Automated Alerts and Protocols
    Smart prompts highlighted missing elements, identified eligible patients, and reminded clinicians when action was needed — reducing the need for manual tracking.
  • Monthly Performance Narratives
    Shared across the PCNs, these summaries called out progress, areas for concern, and quick wins — driving collective focus and improvement.

Outcome

The results were once again outstanding:

  • 100% of available LES funding achieved for both SMI and CCMI across all participating PCNs.
  • £7,485.82 additional income generated from SMI reviews.
  • £48,282.69 additional income from CCMI reviews.
  • Practices were empowered to deliver structured, compliant reviews with reduced workload.
  • Variability between practices was minimised, ensuring network-wide success.

Conclusion

For the second year running, Primary Care IT enabled Hillingdon PCNs to meet every performance target for SMI and CCMI — not just improving income, but ensuring that patients with complex mental health needs received structured, comprehensive care.
This is a repeatable, scalable solution that proves the power of targeted digital innovation in improving both health outcomes and contract delivery.

Similar Posts