Gponline article: Promoting integrated care – what does it mean?


Dr Andrew Steeden and Dr Aumran Tahir discuss the opportunities of their new Integrated Care Pilot in North West London.

Dr Aumran Tahir: the Integrated Care Pilot addresses major issues that normally prevent the delivery of widespread integrated care

Integrated care was featured strongly in the Government’s response to the NHS Future Forum last month. The duty to promote integrated health and social care will be required for both the new Clinical Commissioning Groups and the NHS Commissioning Board. But what does integrated care mean in practice – and how can it work?



As more people develop long term conditions or serious medical problems and patients’ use of hospitals continues to grow 3–4 times more rapidly than population growth, the challenge is to improve quality, especially patient outcomes, whilst reducing costs.

The Integrated Care Pilot So it makes sense to target the care of people with diabetes and those aged over 75, who represent 10% of the population and 28% of the budget in North West London with a new initiative to improve integrated care. The Integrated Care Pilot (ICP) in North West London will adopt an innovative approach to the care of patients who often have complex health problems and related social issues.

Reducing hospital stays The ICP uniquely builds capability for primary, community, social and hospital healthcare services to work collaboratively and safely support patients at home, so reducing unnecessary hospital stays. It plans and co-ordinates care across settings in five boroughs serving an initial population of 383,000 people and aspiring to serve 750,000 residents.

Small steps make a big impact. If one emergency admission could be prevented per month for each participating GP this could save the local health service £14m a year and release this money to invest in community based services.

Investing in resources for community care We have invested in “out of hospital” resources: £80 for each elderly patient and £40 for each patient with diabetes in the pilot. This allocation funds additional care planning and case management, the time of clinicians to engage in multi-disciplinary working and the deployment of more primary, social and community care.

Whilst integrated care is not a new idea, the ICP is thought to be genuinely new because of the way it addresses major issues that normally prevent the delivery of widespread integrated care. These are: a governance structure, so all organisations share and work to the same objectives; shared financial incentives; delivering care within agreed guidelines; information technology that supports integrated care; and a sufficient scale.

At the heart of the pilot is the planning and co-ordination of care across patient settings by Multi-Disciplinary Groups (MDGs). MDGs include GPs, acute consultants, community specialists, mental health and social care professionals. They work together in local groups supported by representatives from all providers held jointly accountable for delivering care.

An innovative IT tool was developed to help the MDGs to:

  • Proactively plan care by identifying high risk patients using population segmentation and risk stratification.
  • Co-ordinate and plan care for patients (sharing these plans across settings) and monitor progress.
  • View patient medical information from multiple settings.
  • Spread best practice by tracking and evaluating the performance of GP surgeries and MDGs.

At a time when the NHS is under pressure to reduce costs, our model of integrated care could provide the opportunity to develop services which still deliver better patient outcomes while also releasing efficiency savings. We will know if this will have worked by carrying out a robust evaluation to track impact.

Dr Andrew Steeden, South Kensington GP and Dr Aumran Tahir, AT Medics GP, Co-Directors of North West London Integrated Care Pilot.