Transforming healthcare systems
Building a scalable model for complex care at home
People with complex health needs, often including multiple long-term conditions, can need frequent input from several different teams. This can leave patients navigating fragmented care and increase the risk of avoidable hospital admissions.
We helped design a new model of proactive care for this patient group and brokered key relationships to put it into practice. Working with Royal Free London NHS Foundation Trust, North Central London Integrated Care Board and Doccla, we helped bring specialist care, remote monitoring and patient support together through a virtual-ward platform.
Through this model, high-risk patients receive more coordinated support from a long-term condition team, including education, care planning, online consultations and home monitoring.
The project has gone live in Barnet, with 2,000 patients onboarded so far. Early signs are promising, with reported reductions in hospital admissions and length of inpatient stay, alongside good equity of access across different age groups and long-term conditions.
If these early indications continue, the model could offer a scalable way to improve care for people with complex long-term conditions while reducing pressure on hospital services.
2,000
patients onboarded
into the virtual-ward platform so far
“We are already seeing promising results and patients are keen to enrol in the service.”
Tara Sood, Consultant Emergency Medicine and Group Clinical Director Neighbourhood Health and Virtual Hospital, Royal Free London
“True innovation requires disruptive ways of working, and we are deeply grateful for UCLPartners’ intellectual leadership and agility in preparing the ground for this transition.”
Tom Breeze, Chief Health System Architect & Commercial Officer, Doccla