Transforming healthcare systems
From fragmented appointments to joined-up care
Across England, 26 million adults live with a long-term condition and 10 million have two or more. 70% of the NHS budget is spent on managing patients with long-term conditions but care is often fragmented, with patients having to navigate multiple appointments across different specialist teams.
UCLPartners and West and North London Integrated Care Board (ICB) tested a new approach. Primary and secondary care data was used to identify patients who had the most complex mix of conditions and the highest number of outpatient appointments. Hospital-based consultants then worked collaboratively across specialties and with GPs to provide care without the need for outpatient appointments.
Of 922 patients reviewed:
- 85% were not receiving optimal treatment. As a result, over half had their medication changed and over 60% were offered weight management or quit smoking support
- Over 50% needed to have appointments changed or cancelled
- Over half of patients in the most disadvantaged areas needed more support to prioritise their health, navigate services and bring together fragmented care.
We are now helping embed this way of working within Haringey and developing it for Camden as part of their neighbourhood approach. We’re also linking up with West and North London ICB so that learning from the project shapes how integrated neighbourhood teams are developed.
£678k
projected to be saved
through optimising patients’ treatment
£193k
projected overall savings
for every 1,000 patients
200
hours saved for patients and staff
as result of holding 98 multi-disciplinary team meetings
“This model provides a blueprint for how we can shift time and resources away from reactive outpatient care towards proactive, coordinated support at a neighbourhood level that better helps patients get the care and support they need.”
Dr Mel Heightman, Respiratory Consultant and Strategic Clinical Director at UCLH