Integration based on sophisticated risk profiling of patients, particularly those with long term conditions (LTCs), has started to deliver results for health services and their patients in east London.
Dr Jagan John, a GP and clinical lead with NHS Barking and Dagenham Clinical Commissioning Group (CCG), said that risk stratification provided the data that shaped the development of an integrated model of care for at risk patients and new integrated teams of health and social care professionals based in practices.
Croydon Clinical Commissioning Group’s (CCG) efforts to reverse the rise in emergency department (ED) attendances have taken the form of a coalition of local health care providers.
Having inherited a significant financial deficit and with high rates of ED attendance, emergency admissions and readmissions set against low levels of patient satisfaction, the CCG developed a strategy for transforming the whole system – starting with redesigning emergency and urgent care.
Two Bradford clinical commissioning groups (CCGs) hope to save around £500,000 annually after developing a new pathway that means most diagnosis and treatment of deep vein thrombosis (DVT) takes place in primary care.
The new pathway is also improving patient care and outcomes.
Dr Matthew Fay, a GP and long term conditions lead for NHS Bradford City CCG and a key figure in developing the new pathway, says the radical overhaul was driven by clinical recognition that local performance could be improved.
A GP-led service treating patients with alcohol misuse disorders in primary care has increased the numbers receiving treatment, improved outcomes and reduced pressure on expensive consultant-led services.
Wandsworth Clinical Commissioning Group (CCG) commissioned the Fresh Start service after a 12 month pilot. During that time the service outperformed the alternative option of a local enhanced service (LES) on both outcomes and cost-effectiveness grounds.
An end of life care service involving two voluntary groups and a community trust commissioned by NHS Greenwich CCG has allowed more people to die in their preferred place of care - the main indicator for palliative care.
Initially commissioned in 2011 by the former Greenwich Primary Care Trust on a two year “test and learn” basis, the Greenwich Care Partnership is based at Greenwich & Bexley Community Hospice, the prime contractor. Marie Curie Cancer Care and Oxleas NHS Foundation Trust provide services on a sub-contractor basis.