North Central London (NCL) Health Alliance (the Alliance) is an 'all in' provider collaborative which includes all providers in the system and the NCL GP Provider Alliance.
Patients with long-term conditions and co-morbidities often experience fragmented and inefficiently co-ordinated care with approximately 70% of healthcare spend on managing patients with long-term conditions. Data collected and analysed by the Alliance forecast that the number of people with long-term conditions in NCL was increasing (8% by 2030) which would have a significant impact on health and care services.
Many of the people in this cohort had multiple appointments at different sites and providers across the system, which was both confusing and time consuming for patients. To address this and to reduce unwarranted variation and inequality in health outcomes, the Alliance sought to bring healthcare closer to home for these patients and developed a test and learn approach. This involved a model comprising five primary care network (PCN) teams, led by clinicians with integrated consultants, primary care leaders, and mental health consultants.
Action taken
The teams took a data-driven approach with a deep dive into population health data and healthcare utilisation data which allowed them to service map to help them better understand their local population. Alongside this they held in person workshops which brought together clinicians from across the system who had never previously met.
They also created a single point of access for each PCN team. This is led by a secondary care consultant with a multi-morbidity focus, who links to a lead GP and is supported by administrators and clinical coordinators.
The clinical model involves the analysis of integrated care board and GP held data, which is then assessed by risk to create a patient treatment list (PTL). The PTL is desktop reviewed by the long-term condition consultant, before a multi-disciplinary team (MDT), including a PCN GP, discuss the patients and the next steps, with the option of advice from specialist teams. This then leads to patient contact to flag any care changes and the coordination of secondary care actions and non-clinical community, social and mental health actions.
Outcomes and impact
Insights from the first set of MDTs across three of the PCN teams showed that 75% of the patients being reviewed were in the right patient cohort, and from this group over 60% of patients have had a secondary care appointment cancelled.
The most common action that has facilitated appointment cancellation is the giving of specialist advice resulting in preventative actions being identified for both GPs and the co-ordination teams.
Teams are now building better links to social care, community services and mental health teams and focussing on how patients can be better supported in neighbourhood settings though integrated neighbourhood teams.
North Central London Health Alliance is a large 'all in' provider collaborative that includes all NHS providers across the system, including primary care, acute, mental health, specialist, and community providers. See further information about the work of the North Central London Health Alliance here.