How ICSs are delivering through change - three case studies

Overview

North Central London (NCL) ICS is a leading example of how care can be shifted from hospitals to communities, despite significant system pressures. Central to its success has been its neighbourhood health approach. Like many systems, NCL has a hospital-centric model, spending just over half its budget on acute services, despite 90 per cent of patient contacts occurring in primary care.

Vision and approach

As a system convenor, NCL ICB has embedded a data-driven population health approach and neighbourhood working at the heart of its shared vision. Through engagement with residents and partners, NCL has set a clear direction, mapped people’s needs and created the conditions for co-design of integrated care pathways. 

Collaborative culture and strong cross-sector partnerships

NCL’s strong tradition of cross-sector partnership working has enabled transformation beyond the capacity of any single organisation. Progress has depended on a shared belief in system-wide benefits, strong clinical leadership and trust between partners.

The NCL Health Alliance exemplifies this culture. The ‘all in’ multi-sector collaborative has worked with the ICB to support high-risk patients with comorbidities, who represent a large share of healthcare demand and cost. In 2023, NCL introduced a system-wide general practice model for planned and proactive care through its Long Term Conditions Locally Commissioned Service. This provides holistic, person-centred care to a risk-stratified group, with outcome-based payments at the primary care network level. 

Aligning commissioning priorities

NCL has made progress aligning commissioning priorities across organisations, partnerships and collaboratives. It has secured ringfenced funding for inequalities and committed 5 per cent of its capital budget to the local care estate. Its medium-term strategy prioritises targeting inequities, population-focused commissioning, aligning services around cohorts and using a shared outcomes framework. Technical work is underway to shift resources toward planned and preventative care with provider leadership and the introduction of neighbourhood ‘integrators’.

Delivering the shift: key interventions

A standout initiative is the multi-agency care and coordination team (MACCT), led by Haringey GP Federation and Whittington Community Health operating in Haringey. It brings together GPs, social workers, therapists, mental health practitioners and voluntary, community and social enterprise (VCSE) sector staff to provide integrated care to higher-risk adults living with frailty and long-term conditions.

In October 2024, Camden launched its first integrated neighbourhood team (INT) in east Camden, co-locating staff from general practice, community services and Camden Council. The INT aims to strengthen frontline collaboration, streamline processes and test innovative models of care.

These examples build on ‘core offers’ for community and mental health services, underpinned by two foundational reviews in 2021, which provided the evidence base to standardise and integrate previously inconsistent services across boroughs. 

Measuring success

• The MACCT has supported over 2,500 patients, predominantly over 65s living in areas of high deprivation, reducing A&E attendance and hospital admissions by 30 per cent and enabling more people to live independently for longer.
• In Camden, early evaluation shows that stronger relationships and smoother day-to-day working are fostering more joined-up support and pathways, with local people receiving more coherent and holistic care in one place.
• The core offers for community and mental health services have helped secure £55 million of additional funding for community health services over five years, reduced adult waiting lists by 5,500 patients since early 2024, and are projected to save 66,000 occupied bed days by the end of 2024/25.

Next steps

As NCL ICB merges with North West London ICB to become the largest in the country, development of the neighbourhood health model and local partnerships will remain a central priority and vehicle for person-centred health and care.

Overview

In 2022, Devon ICS (One Devon) launched a five-year digital strategy to modernise its health and care services. At the time, many services still relied on paper records, and electronic systems were fragmented. Patients had limited digital access to their health information, and Devon’s rural and coastal geography, ageing population and infrastructure gaps added further challenges.  

Vision and approach 

Digital transformation is seen as a key enabler across One Devon’s strategic goals: urgent and emergency care, planned care, diagnostics, children, young people and maternity, and digital innovation. With a parallel focus on maximising the value of existing digital investments, it also supports the system’s financial recovery through joint procurement, infrastructure consolidation and standardisation.  

Delivering the shift: key interventions 

Devon has made major progress, especially in building a shared digital infrastructure. The EPIC Electronic Patient Record (EPR) system – first used in Royal Devon University Healthcare NHS Foundation Trust (FT) - is now being rolled out in Torbay and South Devon FT and University Hospitals Plymouth NHS Trust. 

Meanwhile, the Devon and Cornwall Care Record (DCCR) provides a single summary of patient data for 321 organisations and 45,000 users across Devon, Cornwall and the Isles of Scilly. It enables real-time data sharing across a range of providers, supporting patients to receive the right care without having to repeat their story.  

In adult social care, Devon’s Digitisation of Social Care (DiSC) programme – delivered by NHS Devon, local councils and care-sector bodies – has supported 182 providers in moving from paper to interoperable digital records that will enable better data sharing with the wider health and care system.  

Finally, Devon has created the award-winning GP in the Cloud (GPITC) service, developed with local partners. The service allows GPs, nurses and other staff to access core GP systems remotely, meaning they can consult from anywhere in the UK.  

Measuring success 

EPIC EPR replaces paper records and enables patients to access test results, appointments and care teams via the MY CARE app. With all acute trusts in Devon soon to be using EPIC, it means that by the end of 2026 MY CARE will be available to everyone in Devon.

Devon and Cornwall were the first to implement the National Record Locator within the DCCR, which now holds around 35,000 electronic Patient Escalation Plans (eTEPs). An added benefit of the DCCR is that paramedics can access records and eTEPs via mobile devices, helping them honour patients’ end-of-life wishes. 

By March 2025, 93 per cent of CQC-registered care homes had adopted DSCRs, exceeding the national target of 80 per cent. 

GPITC has supported flexible working, rapid cross-site cover and business continuity for practices and PCNs. It has also contributed to faster, more reliable access to records and online consultation platforms, underpinning ‘digital first’ contact and improving the experience of patients and staff.  

The DiSC programme achieved high uptake in a complex provider landscape, leaving a strong foundation for future improvements. 

The One Devon Dataset (ODD) supports population health management and more strategic commissioning. This pseudonymised, linked dataset helps NHS organisations and councils in Devon to segment patients and profile risk. 

Next steps 

One Devon’s digital strategy offers a practical blueprint for ICSs shifting from analogue to digital. Devon will continue its formula for achieving progress by prioritising areas of momentum and a focus on inclusion, sustainability and collaboration. It will also continue development of the ODD to use more data from other health and care services, plus the introduction of new risk stratification models to identify patients who would benefit from earlier intervention. 

Overview

Cardiovascular disease (CVD) is the leading cause of premature death and health inequalities across Greater Manchester (GM) with heart and circulatory diseases killing more than one in four people and costing an estimated £2.53 billion annually. GM’s stroke admission rate is the highest in the region, with stroke the leading cause of disability, accounting for a significant portion of social care spend and an estimated societal cost of £36 billion per year. Now, GM is positioning itself as a national ‘prevention demonstrator’, backed by the 10 Year Health and Plan. The community and the health care system are benefiting from a sustained and concerted effort to shift from a sickness to prevention model. 

Vision and approach

The prevention demonstrator is based on the recognition that people need support to address ill health, crime and anti-social behaviour and prevent escalation of social issues, poor educational outcomes or economic inactivity. A cross-sectoral, integrated team provides a local, person-centred, preventative system of care and support in a neighbourhood, joining up health with the full range of local support. 

GM has long been leading the way on prevention, having leveraged opportunities arising through devolution, establishing a strong governance structure, the GM population health strategy and a sophisticated, integrated data system. 

Delivering the shift: key interventions

GM’s CVD need tool, just one of several successful prevention initiatives, demonstrated in year savings of up to £6.2 million and prevented nearly 700 strokes, by identifying unmet clinical need (defined as gaps in good care) using routinely collected GP data. The tool analyses data sets to identify high-risk cohorts needing support, recognising the link between CVD and health inequalities. 

Measuring success

Feedback from clinicians has been overwhelmingly positive with one GP commenting that “the ability to highlight patients at greatest prioritisation through the tool has fundamentally changed our approach to call and recall. We would previously try to contact patients twice and then move on, but the demonstration of their unmet need has changed our approach – discussing with patients the benefit of undertaking their reviews and leading to increased engagement.” 

While it is widely recognised that prevention is better than cure, through this initiative, GM has been able to address a long-held challenge by quantifying the impact of prevention initiatives.

Next steps

GM will continue to build its case as a prevention demonstrator, engaging with leaders and chief executives on long-term plans for growth and prevention, including associated outcomes working towards ten-year prevention plans. This includes expanding the CV need tool to address frailty, followed by people with multiple long-term chronic conditions.