Introduction
Patients with long term conditions (LTCs) and co-morbidities currently often experience fragmented and inefficiently co-ordinated care. Some 70% of healthcare spend is on managing patients with LTCs. By tackling these issues, we have a significant opportunity to improve patient experience and outcomes.
Between December 2024 and April 2026, North Central London Health Alliance developed a test and learn programme. The aim was to offer integrated, pro-active care for people experiencing multiple long-term conditions. Specifically, it explored how hospital-based specialists could collaborate across specialties and back into primary care to support patients, challenging the traditional dependency on a hospital visit as the only way to get specialist input and providing opportunities for consultants to support people with multi-morbidity.
In the video below you can hear more from the patient’s perspective about navigating the system.
The programme explored whether pro-active identification and case-management for people with complex multi-morbidity could drive a reduction in planned care utilisation. The goal was to understand whether, by driving an immediate reduction in outpatient attendances, it was possible to demonstrate a positive return on investment. Ultimately, the programme aimed to improve health outcomes, with a focus on patients in areas of high deprivation.
The challenge
Long term conditions present a wide range of challenges that lead to poor patient experience, outcomes, and inefficiencies.
- 1 in 4 adults in England have at least two health conditions, with over 26 million living with a diagnosed long-term condition and 10 million adults having two or more.
- Life expectancy is 10-15 years earlier for those in deprived populations. The intersectionality between deprivation, multimorbidity and complexity drives further health inequalities where services are disjointed and ineffective.
- Managing patients with long term conditions equates to 70% of the total healthcare spend, accounting for 50% of all GP appointments, 64% of all hospital appointments and 70% of hospital bed days.
In North Central London (Barnet, Camden, Enfield, Haringey, and Islington), where our programme was focused, the number of people with Long Term Conditions is growing and continues to grow.
- 430,000 people in NCL are living with at least one long term condition.
- The number of people with complex long-term conditions is rising 7% faster than overall population growth.
- Each year, approximately 150,000 people in NCL experience more than 10 acute care encounters
- The number of people with LTC is expected to grow to 8% by 2030.
Multiple appointments across different specialist teams can be confusing, time-consuming to navigate and it’s too easy to lose sight of the issues that matter to the patient.
Feedback from our lived experience advisory group reflects the human cost of this fragmentation—patients and carers described feeling like they were “in a plane with no pilot,” with their personal needs often overlooked or lost between services
The solution
In response, system leaders across NCL came together through the Provider Collaborative to develop and test a new coordinated care model for people with complex long-term conditions. This model was co-designed by clinicians, operational leaders, and patients through dedicated design workshops, drawing on learning from existing integrated care initiatives. With a test and learn approach, the programme aimed to design improved models of care to bring changes across the system in the management of long-term conditions by
- Appointing primary care network (PCN) test sites
- Creating bespoke, risk-stratified patient lists using both primary and secondary care data
- Establishing a clinical team of link consultants aligned to each PCN, supported by a central coordination team
- Conducting in-depth patient reviews using full access to all EPR systems
- Building a network of specialist advisors who support care planning without requiring new referrals
- Holding joint case discussion meetings to create and implement shared care plans, fully documented and visible across primary, acute, and community systems
This approach enabled consultants to shift from reactive, siloed care to proactive, joined-up support, with strong links to community services – improving patient outcomes, experience, and the overall value of care delivery.
Key features
Case finding: Early intervention is key to supporting people to maintain health. However, to be efficient and sustainable, case finding must draw on the full range of information, needs to be ‘sense-checked’ and prioritised and align to a coherent model of care. A methodology was developed for identifying people with complex multi-morbidity who were likely to benefit from coordination. This has since been refined, evaluated and is now being automated with the use of AI being explored to support this case finding.
Coordination: Seven hospital-based consultants from a range of specialisms were recruited for one session a week. Each linked into a PCN. They acted as a point of contact for the PCN and as a bridge across specialties.
Case management: Dedicated case managers were appointed – one clinical and one administrative coordinator, each working across four PCNs. Coordinators compiled cross system summaries drawing on both primary and secondary care records and, importantly, ensured follow-through of actions and communication back into patient records.
Patient involvement
To share their thoughts and help inform the design and delivery of the service we set up a lived experience advisory group to work alongside us. The group brings together individuals living with or caring for someone with multiple long-term conditions and had invaluable insights to share.
Key findings
- 1,149 patients had desktop reviews of their care records. 922 patients were case managed between specialists and GPs across 98 MDT meetings
- 51% of patients had scope for improved coordination. These patients were found to be on incorrect pathways, at risk of non-attendance, with poorly timed or unnecessary appointments. Just over half of this group had appointments cancelled, timing optimised or access arrangements put in place to improve take-up of appointments
- 85% of patients reviewed were not treated to target. In over 50% of cases, medications were changed, 61% had weight management, smoking cessation or smoking support initiated or proposed
- 49% had identified barriers to prioritising their health. Connections were made with voluntary sector, mental health and community services
- Cost per case was £153 per patient. The gross projected saving was £193k for 1,000 patients and the return on investment was 0.07. The additional net cost benefit associated with treatment optimisation is estimated to be £678k for 1,000 patients.
Read a summary of key insights and learnings
Read an evaluation of the development and early intervention phase of the service.
Learning
Responding to multi-morbidity is a national issue and the programme has shared learning with other provider collaboratives in the London region, on national webinars including NHS Providers and with colleagues in neighbouring systems. The programme is featured in the Kings Fund report on approaches towards complex long term conditions. We have documented early learning with publications in the HSJ and through LinkedIn blogs and presented a session at NHS Confederation Expo.
Scaling success
Based on our promising results in 2024/25 the NCL Health Alliance secured funding to continue and expand the programme for 25/26. We were able to scale our approach from individual PCNs to delivering at a neighbourhood footprint in two of our boroughs. By operating at a Neighbourhood level, we will explore the opportunities to create a seamless service for patients with long term conditions embedded alongside the development of Integrated Neighbourhood Teams.
Based on the success of the programme, it is now being embedded within Haringey and Camden as part of their neighbourhood approach for 2026/27.
Through the programme we explored how more integrated data (from primary and secondary care) could inform clinicians about which patients would be suitable for the service, and how to coordinate new care plans across organisational boundaries.
These challenges are being addressed in the form of two new digital projects for 26/27: improving digital infrastructure for case finding and improving communication for neighbourhood MDT teams.
For the first project we are working closely with the data science team at West and North London ICB and the AI Centre for Value-Based Healthcare to develop a digital app which can be used to identify complex multimorbid patients who may benefit from a more proactive and integrated care approach. The platform draws on linked care records from the London Data Service and uses machine learning techniques to present key patient data such as biometric markers (blood pressure, blood glucose, liver function, kidney function, obesity etc) as well as the patient’s use of healthcare services in west and north London, all in one place for the first time.
The second project explores how individuals in different parts of the system can communicate as one team and coordinate actions from a neighbourhood MDT, to make sure that new care plans, changes to medications, referrals to different services and social care support are effectively delivered for patients.
Find out more
- Read the latest update from the team on lessons and reflections from the programme. Our latest blog explores some of the challenges around sharing patient information.
- Read more about the why it is important to address complex long terms conditions in this comment piece for the HSJ.
- Read about how our lived experience group is helping to guide us on how we develop the long term conditions service.