Learning from the integrated care pilot in west london.

Key messages We implemented a system to integrate care for patients with diabetes and/or over the age of 75 in an urban area with a population of 1.2 million. Within five months, all the acute, mental health and community trusts, and all the local authorities had signed up to participate, along with 84% of GP practices in the area. Patients and practitioners found the system of benefit in improving communication and collaboration. The first phase of the Outer North West London Integrated Care Pilot (ONWL ICP) has shown that it is possible to implement large-scale, multi-agency change in a short time to enable coordinated care for patients with long-term conditions. The second phase needs to more purposefully integrate with local programmes of work, including training the chairs of the monthly case conferences as leaders of transformational change who can lead annual cycles of interorganisational continuous quality improvement. Why this matters to us We are clinicians and managers who have been closely involved in the planning and implementation of the integrated care system described here. We feel that current systems are fragmented and do not support delivery of holistic, coordinated care. We are convinced of the benefits of multiple agencies working together to share their expertise of patients' social, psychological and physical needs.