People with long-term conditions (LTCs) account for around half of all GP appointments, two-thirds of outpatient appointments and 70 per cent of hospital bed days. Those at greatest risk include people from disadvantaged backgrounds, minority ethnic groups and those with serious mental illness. In an increasingly sub-specialist healthcare environment, these patients often feel overwhelmed by complexity or under the radar altogether.

This session will share learning from an ICS-wide programme, led by NCL Health Alliance (UCL Partners), to improve coordination of care and outcomes for people with complex LTCs.

We’ll highlight learning on:

• risk stratification and exploring the use of AI to identify patients with multiple LTCs who are at clinical risk as a focus for care planning
• consultants linking across acute specialties to avoid unnecessary appointments and in-reaching to primary care
• connection of this model of care into integrated neighbourhoods

We’ll share how a small group of acute consultant physicians are working proactively with primary care network sites within each borough. They are acting as a ‘specialist generalist’, backed by coordinators, supporting GPs in the management of their complex patients, aiming to avoid hospital appointments and exacerbations of care.