New care model improves patient experience while saving NHS time and money

Across England, 26 million adults live with a long-term condition (LTC) and 10 million have two or more. 70% of the NHS budget is spent on managing patients with LTCs but care is often fragmented and inefficiently co-ordinated, with patients having to navigate multiple appointments across different specialist teams.

UCLPartners and North Central London have tested a new approach, aiming to improve how care is managed and delivered, with fewer outpatient appointments, better decision making and easier access to services.

Primary and secondary care data was used to pro-actively identify patients who had the most complex mix of conditions and the highest number of outpatient appointments.

A small team of GPs and hospital-based LTC specialists in nephrology, clinical pharmacology, respiratory medicine, diabetes and palliative care then came together online or face-to-face to review and discuss their care.

Clinical coordinators carried out in-depth reviews of care for 1,149 patients, with 922 patients then discussed and reviewed by the specialists and GPs, with input from cardiology and mental health services.

Of the 922 patients:

• 85% were not receiving optimal treatment. Of these patients, 54% had their medications changed and 61% were offered weight management, smoking cessation or smoking support.
• 51% were on incorrect pathways, at risk of non-attendance, with poorly timed or unnecessary appointments. Half had appointments cancelled, timing optimised or arrangements put in place, such as translation services, to improve attendance.
• 41% faced barriers to prioritising their health. These included mental health conditions and unstable housing. They were connected to voluntary sector, mental health and community services for support.
• In the most deprived areas, over half of discussions were judged to be high value. These patients were largely ‘under the radar’ and needed support to prioritise their health, navigate services and bring together fragmented care.
• 98 multi-disciplinary meetings totalling 196 hours were held across eight Primary Care Networks – saving staff and patients over 200 hours.
• For every 1,000 patients, overall savings are projected to reach £193k, with a further £678k projected to be saved through optimising patients’ treatment.

Dr Mel Heightman, Respiratory Consultant and Strategic Clinical Director at UCLH and Clinical Director for the long term conditions service, said:

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 clinical care and holistic support they need.

Kate Petts, Managing Director, North Central London Health Alliance at UCLPartners, said:

‘Bringing together hospital-based specialists and GPs in this way has the potential to reduce health inequalities by providing better support for people living with long term conditions in deprived areas.

UCLPartners is now helping to embed this way of working within Haringey and developing it for Camden as part of their neighbourhood approach for 2026/27.  We’re also linking closely with West North London Integrated Care Board to make proactive care a key part of its strategic plan for neighbourhoods. 

Read a summary of key insights and learnings.

Read an evaluation of the development and early intervention phase.