Introduction
The Learning Together Group was co-developed as a patient safety improvement initiative through a partnership between Community Health Services (CHS), Primary Care, Barts Health, and the Integrated Care Board (ICB) in Tower Hamlets.

Led by Dr Alex Harborne, Clinical Director at East London NHS Foundation Trust (ELFT), the initiative aims to strengthen shared learning from incidents occurring at organisational interfaces and to improve collaboration across the local health system. The 2025 Collaborative Working Award at the ELFT Staff Awards recognised the impact of this work.

Background
The ‘Learning Together’ patient safety groups have established new processes to support shared learning across care interfaces. In June 2024, quarterly reviews of patient safety incidents between primary care and community services were introduced for the first time. 

Building on this success, we launched a second Learning Together group in November 2024 to review discharge-related incidents and strengthen collaboration between community services and The Royal London Hospital through bimonthly meetings. A third group meets monthly to review issues at the Single Point of Access and community services interface, enabling rapid identification and resolution of referral pathway concerns. Learning and improvement actions from all three groups are reported to the local Quality and Governance Group and the Tower Hamlets Neighbourhood Steering Group.

What has been achieved
Primary Care /Community Health Services Learning Together Patient Safety Group:

• Nearly a 40% reduction in insulin incidents involving external partners                                       
• Clarity of process of urgent and routine communication of patient safety events
• Quarterly reviews of reported incidents/GP alerts/concerns with members of the group 
• Quick resolution of issues relating to communication 
• Discussion of GP alerts, identifying where improvement is needed, for example, working with the hospital pharmacy team to improve the prescription pathway from outpatient clinics to community services to reduce workflow into the GP team
• New and updated GP End of Life prescribing information published by St Joseph’s hospice in response to our GP incident feedback
• In-person ‘Cluster review’ to review insulin incidents with system partners in 2025 and recommendations shared across Tower Hamlets/NEL/ 

NHS England

• New SOP developed for insulin communication
• Insulin QI now working across interface RLH/ Home Care Providers / GP / Mental Health

Royal London Hospital /Community Health Services Learning Together Patient Safety Group:

• There has been a 40% reduction in discharge incidents                                                                      
• Clarity of process of escalation for urgent patient safety concerns 
• An in-person Multidisciplinary Team meeting took place in the hospital in April 2025 with community and hospice staff following a MAAR chart end-of-life incident occurring at the interface. Recommendations from the group were shared, including improvements in digital, policies and procedures and education.
  • Community input into hospital policy and procedure
  • Community incident learning shared each month at hospital medicines improvement meeting
  • Barts Pharmacy and Community pharmacy collaboration 
  • Barts Diabetes nurses joined ELFT QI
  • Barts and ELFT joint MAAR chart QI, following the MDT of MAAR chart incident 

Single Point of Access (SPA) / Community Services Learning Together Patient Safety Group:

• Following the introduction of regular monthly interface meetings, staff were actively encouraged to report incidents to enable thorough investigation and resolution. As a result of improved collaboration and local problem-solving, reported incidents decreased by 70%. This reduction has been sustained for more than eight months, demonstrating a lasting improvement in the safety and effectiveness of the interface.         Improvements to hospital and community referral forms and processes
• Problem-solving and addressing referral issues, e.g., reducing the number of missing referral sources - community noticed that the referral source was often missing; after alerting the SPA team and the issue being identified, there was a huge improvement

Introduction

This neighbourhood and community-based approach aims to achieve the following system outcomes:

• To proactively identify and support those with the most complex needs, likely to be most at risk of poor health or care outcomes and serious harm, including self-harm
• Approach rooted in a sense of shared ownership for improving the health and wellbeing of populations and improved outcomes for residents
• Cultural shifts towards a holistic psychosocial model of care, recognising and addressing the social determinants of poor health such as poor housing, debt and isolation.
• Sophisticated shared understanding of service & population data for ongoing learning.
• Financial & resource shift from acute to community as per the 10-year plan.                                             

Working Definition of Complex Care Cohort - NHS, England Neighbourhood Guidance 25/26 identifies the Complex Care cohort (Complex Lives cohort) as those with chronic, co-existing physical & mental health conditions requiring high levels of support, usually from multidisciplinary teams. This 7% of the population is associated with 46% of hospital costs. 

The guidance details the characteristics of the Complex Care Cohort as those with:

• Multiple long-term conditions: often co-existing physical & mental health issues.
• High health service usage: frequent, often unplanned, hospital attendances (A&E) and emergency admissions.
• Frailty: older adults with physical or cognitive frailty (e.g. dementia).
• Social complexity: issues such as homelessness, substance misuse, or involvement with the criminal justice system.                                     Specific needs: palliative care requirements or complex physical disabilities.                   

Relationship between HIU and Complex Care
As noted above, high intensity use of health services is one aspect of complex care needs but is not the sole indicator of it. NHS guidance on high intensity use is someone with 10+ A&E attendances (over 12 months) or 5+ calls to ambulance services (monthly). A Newham HIU task and finish group and other best practice initiatives recognised the importance of a proactive and preventative approach to the issue, which recognises other factors in complexity, rather than solely determining need by the amount of usage of health resources alone. 

The approach aims to address complex care issues with both clinical and non-clinical support, such as help with housing or debt, and community activities to address loneliness and support self-management of conditions. Therefore, the approach proposes the use of a population data tool to identify patterns of need in the population of Newham rather than being driven solely by intensity of health usage.     

Key Aspects of the Approach 
Use of population & other data to identify complex care cohort.

• Locality multi-disciplinary team to support the complex care coordinators working with the most complex patients in the borough.
• Clinical Complex Care Coordinators for each locality who can intervene at an appropriate level, building patient motivation and commitment to self-management as well as refer to other agencies across the system. They will not be solely sign-posters or administrators.
• Complex care coordinators will build strong connections and working relationships with clinical and social resources in the statutory and voluntary sector.
• GP-led MDTs will be maintained and unaffected.                                                                                             

Proposed Actions 
Establish working group to support development of model – agree membership and governance. 

• Identify a complex care cohort of patients, focusing on those with the most severe conditions and most at risk of serious harm.
• Develop business case for care coordination role in each locality, including benchmarking against best practice examples. 

Consider learning from job descriptions of Complex Care workers in the Lincolnshire Model, as strongly person-centred focus on a 4-step relationship-building approach to achieving goals and self-management.  

• Work within Localities to establish the core multidisciplinary team to support complex care work
• Develop an evaluation framework for complex care to ensure outcomes/test success.
                                                                                      

Introduction 

This is a commencing development: Neighbourhood Health Teams - Provider Collaborative Model Introduction

• Neighbourhood Health Teams – central to delivery of 10-year plan
• Currently, services are not commissioned or delivered through neighbourhoods
• No consistent neighbourhood or frailty model across Central East – many  good examples we can evaluate
• Start with a clinical model for Neighbourhood Health Teams for people identified through the Rockwood Frailty Score – build from there
• ICB will commission for neighbourhood health teams for people with frailty from April 2027                                                              

Neighbourhood Health Teams – Clinical Model for People Identified Through the Rockwood Frailty Score 

This clinical model aligns: 

• National neighbourhood health and integrated care design principles
• The Integrated Care Board (ICB) care model: proactive, multidisciplinary, person-centred care delivery 
• Population health management approaches
• The model focuses on early identification, prevention of deterioration, coordinated multidisciplinary intervention, and rapid response to avoid unnecessary escalation to hospital-based care.  

NHTs - Clinical Model for People Identified Through the Rockwood Frailty Score: Prevention - 

Identify frailty early and prevent deterioration - Use population health management and Rockwood Frailty Score stratification to proactively identify patients at risk. Undertake holistic assessment of physical and mental health, social isolation, housing, nutrition, mobility, falls risk, and carer needs. Deliver anticipatory care planning and preventative interventions. Promote vaccination, strength and balance programmes, social prescribing, medication optimisation, and management of long-term conditions. Outcomes - Reduced progression of frailty, improved wellbeing, reduced avoidable admissions, increased patient activation.                                                                                                   

NHTs - Clinical Model for People Identified Through the Rockwood Frailty Score: Self-care - 
Support people to remain independent and manage their own health safely - Develop personalised care and support plans with patients and carers. Provide education, coaching, digital enablement, and condition-specific self-management support. 

Ensure access to community assets, voluntary sector support, carer support, and proactive follow-up. Enable shared decision-making and advance care planning conversations where appropriate. Outcomes - Increased independence, improved confidence in self-management, reduced dependence on urgent care services.                                                

NHTs - Clinical Model for People Identified Through the Rockwood Frailty Score: Early Intervention - Reduce clinical risk and proactively manage deterioration - Establish proactive multidisciplinary team (MDT) review processes for people with moderate frailty or rising risk. Use risk stratification, remote monitoring where appropriate, medication reviews, falls prevention, nutrition support, and proactive management of exacerbations.

Ensure regular review of high-risk individuals and clear escalation plans. Coordinate safeguarding and carer risk management where required. Outcomes - Reduced clinical deterioration, improved safety, reduced crisis presentations, better continuity of care.   

NHTs - Clinical Model for People Identified Through the Rockwood Frailty Score – Complex Care Co-ordination
Coordinate care for people with high frailty and complex needs - Allocate a named care coordinator and implement integrated MDT management for people with severe frailty, multimorbidity, cognitive impairment, or frequent service use. Deliver comprehensive geriatric assessment principles, shared care plans, regular MDT reviews, and coordinated interventions across organisations. 

Ensure integration between primary care, community services, social care, mental health, acute services, and voluntary sector partners. Include carers as partners in care. Outcomes - Improved experience of care, reduced duplication, reduced hospital utilisation, improved care continuity and patient outcomes.            

NHTs - Clinical Model for People Identified Through the Rockwood Frailty Score – Crisis - Deliver rapid coordinated response to deterioration or acute need - Provide same-day multidisciplinary response for frailty-related deterioration, including urgent assessment, home visiting, rapid community intervention, and direct access pathways. Support admission avoidance and facilitate safe discharge where hospital care is required. Ensure escalation plans, end-of-life preferences, and advance care plans are visible across services. Deliver coordinated post-crisis recovery and follow-up. Outcomes - Reduced avoidable admissions, reduced length of stay, improved recovery, care delivered in the most appropriate setting.                                                                                                                       

 Neighbourhood Health Teams – Operating Principles
1. Proactive Population Health Management 

• Use shared data and risk stratification to identify patients
• Segment populations according to level of need and risk 
• Target interventions proactively rather than reactively 

2. Multidisciplinary Team-Based Care 

• Operate through regular MDT meetings and shared care planning 
• Integrate physical health, mental health, social care, and voluntary sector support
• Deliver coordinated care around the individual rather than organisational boundaries 

3. Person-Centred and Strength-Based Practice 

• Focus on “what matters to the person” 
• Promote independence, resilience, and wellbeing 
• Recognise carers as key partners in care delivery 

4. Care Coordination and Continuity 

• Ensure named clinical and care coordination responsibility for high-risk individuals 
• Enable information sharing across providers and settings 
• Maintain continuity through transitions between care phases 

5. Home First and Community-Based Care 

• Deliver care in the least restrictive and most appropriate setting 
• Prioritise admission avoidance and supported discharge 
• Strengthen community and neighbourhood capacity                                                                                           

Neighbourhood Health Teams – Measures of success

• Reduction in non-elective admissions for frailty cohorts 
• Reduced emergency department attendance 
• Improved patient-reported outcomes and experience 
• Increased uptake of anticipatory care planning 
• Reduced falls and medication-related harm 
• Increased proportion of care delivered in community settings 
• Improved continuity and coordination of care 
• Improved support for carers and unpaid carers                                                                                  

Delivery Plan 2026-27 - Providers: 

• Build collaborations with primary care to deliver NHTs / INTs
• Involve residents in the design
• Evaluate good practice so we can codify and scale
• Develop frailty model for proactive support for frailty cohorts tailored to neighbourhood needs
• Enable integrated, multidisciplinary working, not single-organisation solutions
• Shared ownership of neighbourhood outcomes                                                                                              

Delivery Plan 2026-7 - ICB:

• Identify existing services and investments that support neighbourhood delivery to enable better 
  alignment
• Support primary care to lead and deliver neighbourhood health
• Develop the NHT specification (single and multi-neighbourhoods)
• Deliver key enablers:
• Risk stratification tool
• Data sharing
• Estates opportunities
• BCF and other investment