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Getting everyone round the table

It was clear before we set up our integrated care pilot (ICP) that a lot of provision of care was disjointed and there was a great deal of variation.

It is hard as doctors to understand the complexity of care providers and how it all fits together, and patients were telling us they, too, struggled with that complexity.

In addition, information was often not being shared between us, with GPs, nurses, consultants and mental health and social care teams working in silos. On top of this there were actually disincentives to us working collaboratively.

From a financial perspective, north-west London faces a £1bn financial gap in 2014/15, which must be closed while improving the quality of care for the local population.

What we did

We chose to focus on the elderly and patients with diabetes because they make up 10% of the population in north-west London, but account for 28% of the acute spend. They are also patients for whom small changes can have a big impact.

Our model is based around the setting up of multidisciplinary groups (MDGs). Each group includes GPs – who are largely responsible for co-ordinating the care of identified patients – practice nurses, community matrons, district nurses, mental health workers, social workers, and acute specialists.

We were not prescriptive about the size or boundaries of the groups and we have ended up with 10 MDGs covering Westminster, Kensington and Chelsea, Hammersmith and Fulham, Ealing and Hounslow. Groups comprise between five and 17 GP practices and cover 38,000 to 75,000 patients.

We’ve also not been overly prescriptive on what the MDGs do – some meetings discuss complex patients while others tackle themes that need addressing. The pilot is funded through the SHA.

For over-performance against the 2008/09 baseline, local commissioners pay 100% of the tariff, but acute providers receive just 30% with 70% top-sliced by NHS London.

We approached NHS London to invest that surplus in the ICP and it was keen to support the plans. There is also money available from north-west London commissioners for projects that reduce readmissions. In all, this provided a start-up budget of £4.3m.

The individual budget for each of the MDGs was calculated at a rate of £80 per elderly patient and £40 per patient with diabetes.

Half of this is to be spent on care planning – for example, the extra appointment time needed for nurses and GPs to spend with patients.

A quarter goes to fund case conferences, 5% for performance reviews and 20% is held in reserve to fund out-of-hospital initiatives developed by the MDGs.

The elderly and patients with diabetes are stratified into risk groups, a care plan developed according to the MDG-agreed pathway and patients are invited in to discuss their plan with a nurse or GP.

For complex patients there is an MDG case conference held every month. These involve the primary care team, a consultant, and a representative from social care to discuss gaps in care or management of complex cases that cross professional boundaries.

On a quarterly basis there is a performance review to monitor the agreed outcomes for these patients and to share learning across MDGs.

Underpinning all this work is a specifically designed information tool. It enables the initial patient identification and risk stratification.

It uploads data from the GP system and adds in activity data from the acute providers, mental health trust and community services. There is also a daily update on who has attended A&E and the urgent care centres. And we hope to have at least some data from social care on board in the next few weeks.

It provides a joined-up view of the patient record in terms of factors such as medications and number of admissions. But it also provides a joined-up view on care planning and shows everybody what each of the sectors should be doing to follow the agreed care protocols.

Finally, it allows the MDG members to view outcomes at the patient level, practice level, MDG level or across the whole project.

A board made up of leaders from the acute trusts, primary care, social care and NHS London has been set up to oversee the ICP. On behalf of patients, representatives from Age Concern and Diabetes UK sit on the board and have voting rights.

Ultimately we are making sure patient care is consistent, safe and the best quality it can be, while avoiding duplication and the risk of patients falling between the gaps.

Lessons learned

The pilot launched in June 2011. Initially many GPs were reluctant to sign up to the scheme, but local champions spent a lot of time and energy getting people on board.

There were fears about workload and although there is more work involved there will be payback in the better management of these complex, challenging patients.

Thanks to the hard work of the project leaders, substantial barriers of suspicion and misunderstanding between the different sectors involved in the ICP have been broken down to create an environment of collaboration in a relatively short space of time.

This project is currently commissioned by North West London NHS, but in time will become the responsibility of the CCGs. Most CCG chairs are on the board and the MDGs have tended to mirror CCG boundaries.


For type 2 diabetes, patients are stratified into newly diagnosed, controlled or off target, and detailed care packages put in place for each of these groups. Likewise, elderly care pathways involve risk assessment and care planning packages.

It is expected that the care pathway put in place for the over-75s will pay off even more quickly than the pathway for diabetes because of the immediate impact of the planned interventions. MDGs are expected to use the funding for additional out-of-hospital care, approved by the ICP board, to ensure that at least half their patients over the age of 75 are given an integrated care plan and appropriate care co-ordination.

Some examples of initiatives already run by the MDGs include paying specialist diabetes nurses who are usually based in secondary care to manage some of the complex patients identified by the MDG. Another MDG is setting up an email system for GPs to access quick advice from consultants.

The aim of the ICP is to reduce hospital admissions by 30% and nursing home admissions by 10%.

We calculate that for a population of 380,000 we could reduce health and social care spend for people with diabetes by £2.1m after the first year and a further £4.8m after five years, and £7m after the first year and a further £5.4m over five years for elderly patients.

The future

We clearly need to carefully monitor the success of this pilot against the targets set at the outset. And there will be learning between MDGs on the positive and negative aspects of their work.

But we are confident that the ICP is already paying dividends in terms of a consistently high standard of patient care across health and social care sectors.

We also would like to move towards shared budgets for health and social care.

If we hit our targets and make the necessary savings, that money will be available for reinvestment – 50% to commissioners and 50%. We are developing protocols for how this reinvestment in healthcare will work.

Dr Aumran Tahir is co-director of the ICP and clinical director of AT Medics

Dr David Gable is co-chair of the ICP IT committee and a consultant in diabetes, endocrinology and general medicine at Imperial College Healthcare NHS Trust



60-second summary


Initiative Integrated care pilot across north-west London that draws down money from the SHA to fund multidisciplinary groups that meet to discuss the best care plans for elderly patients and patients with diabetes

Start-up costs £4.3m budget available for the first year

Staffing Two GP co-directors and 11 operational staff

Savings Predicted savings of £9.1m in first year and additional £10.2m by five years

Outcomes – Patients identified and care plans in place

– Multidisciplinary groups meet monthly to discuss complex cases

– Aim is for a 30% reduction in hospital admissions and 10% reduction in nursing home admissions

Contact Dr Aumran Tahir – | Dr David Gable –


MDGs in action


Case study

The case of an 81-year-old man with severe pain from multiple lumbar spine compression fractures was presented at an MDG conference.

He was being prescribed buprenorphine patches to be applied by the district nurse once a week and was also on co-codamol and oramorph. Yet despite repeated referrals he was having no contact with district nurses.

His unpredictable pain was also the cause of frequent 999 calls and A&E attendances – but there was little they could do for him. The GP had referred to social services, physiotherapy and discussed him with the acute pain team, but no further advice had been given.

As a result of his case being discussed by the MDG, the GP was advised to consider other pain medications such as a lidocaine patch and neuropathic agents. A plan was made to inform the London Ambulance Service to contact the GP or out-of-hours service before transferring him to A&E. Psychological support on coping strategies was discussed and the community matron was tasked with following up his case with the district nurse service.



A team of 11 operational staff plus two GP co-directors has been recruited specifically to ensure delivery of the service. It was agreed the team would be hosted by one of the local community providers – Central London Community Healthcare. It is responsible for the IT, communication, liaison and governance for those involved in the pilot.

MDGs can also choose to spend some of their budget hiring their own staff.

All other staff are employed as before but remunerated for time they spend on appointments and conferences associated with the ICP.