2025 Agenda

Managing multi-morbidity: sharing early learning and experience from North Central London

12 Jun 2025
Charter 5
Collaboration / partnerships / patient or public engagement , Integration – system / place / neighbourhood

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.

Amy Bowen
Amy Bowen, Director of System Improvement - NCL ICB
Mel Heightman
Dr Mel Heightman, Consultant Physician - UCLH
Ammara Hughes
Dr Ammara Hughes, GP Partner - Bloomsbury Surgery
Peter Landstrom
Peter Landstrom, Group Chief Executive - Royal Free London NHS Foundation Trust
Rachel Lissauer
Rachel Lissauer, Transformation Director, NCL Health Alliance - UCLPartners
Kate Petts
Kate Petts, Managing Director, NCL Health Alliance, - UCLPartners