This page details the high level findings and outcomes for service users, staff and the wider south east London system from the implementation of complex case management within the multi-morbidity model of care (MMMoC). This element of the programme ensured holistic support for people with complex long-term conditions, closer to home.
To see our complete findings on the impact of complex case management on people with complex long-term conditions, click here to see our report.
Our challenge
- A growing number of people are living with multiple long-term conditions (mLTCs), especially cardiorenal metabolic (CRM) conditions, such as chronic kidney disease (CKD), high blood pressure and diabetes, and need coordinated and joined up support
- Care often feels fragmented, with repeat appointments and referrals
- CKD is common but often not found or coded early enough
- Missed diagnosis can lead to worse outcomes and unsafe medicines
- GP and hospital service face high demand and people can “bounce” between services
Our ambition
- Give people with complex needs holistic, person-centred care based on what matters to them
- Build integrated neighbourhood teams (INTs) so staff work as one team across settings.
- Improve clinical outcomes and service user satisfaction for all service users with CRM conditions.
- Reduce avoidable pressure on services by meeting needs earlier and closer to home.
MMMoC: The wider programme of work
- Offered a comprehensive, holistic approach to LTC care across the whole pathway
- Enabled integrated, multidisciplinary working at scale
- Improved outcomes and experience for service users and staff
- Supported system sustainability and preventative transformation
Complex case management: the approach
What we did
- Complex case management ran across 6 boroughs and 12 Primary Care Networks (PCNs), delivered by integrated neighbourhood teams.
How it worked
- Teams used population health tools and local knowledge to find people at highest risk of cardiorenal metabolic conditions
- People had longer, holistic appointments (around 30 minutes) and a co-made care plan.
- Teams used short mental health checks (PHQ-2 and GAD-2) from the start.
- Staff discussed complex cases in multi-disciplinary team (MDT) meetings with specialist support.
Scale of delivery
- Over 1000 people received complex case management support across south east London
- DNA rate was about 6%
- 100+ MDT meetings took place, with over 425 cases discussed
- Teams estimate 66 referrals were avoided and 64 were fast-tracked.
Data was collected from March 2024 to September 2025
Involvement across the south east London system
- 250+ stakeholders co-designed model (9 workshops)
- Bi-monthly Community of Practice for shared learning
- Integrated neighbourhood teams across 12 Primary Care Networks
- Roles included pharmacists, nurses, GPs, care coordinators, social prescribers and mental health practitioners
- New and innovative roles were created to join up care, e.g. multi-specialty pharmacists and geriatricians embedded in renal care
- ARRS-funded roles helped make MDT working more sustainable
- Involvement across voluntary, community, secondary and primary care contexts.
“Working in an integrated manner led to positive patient outcomes”
Value: Service user
A survey collected experience of 126 service users in complex case management. Responses were similar across age, ethnicity and gender.
- 88% of patients said that they would recommend this service
- 85% of patients said that there experience of the service was positive
- 81% of patients said that they feel involved in decisions about their care
- 70% of patients said that the health care team took time to understand their personal and social needs
“I had some concerns about my health which [name] listened to and responded to proactively. As an older person it was so good to be able to talk to a health practitioner face-to-face and actually feel heard”
Outcomes: Population impact
This section highlights the immediate increase in activity after the intervention began for those identified with the most complex needs in the MMMoC (1,057 service users):
- SGLT2 inhibitor prescribing rose by 15.5 percentage points.
- Statin prescribing rose by 4.3 percentage points.
- uACR testing rose by 19.5 percentage points.
- Mental health screening (PHQ-2 and GAD-2) rose by 46.6 percentage points.
Value: Workforce
A survey collected experience of 71 members of staff involved in the MMMoC.
- 7 in 10 members of staff reported increased job satisfaction
- 85% of staff feel that care is more holistic
- Almost three quarters of staff felt the integrated model was more sustainable
- 80% of staff felt greater trust in multi-disciplinary team working
Outcomes: System and service use
Complex case management of service users living with complex long-term conditions resulted in:
- Care closer to home: multidisciplinary teams met more needs earlier in primary and community care, reducing pressure on specialist services
- Better use of services: GP appointments fell after the intervention, suggesting some needs were managed in a more joined-up way
- Fewer hospital visits: outpatient attendance fell for the short list after the intervention, including in cardiology, renal and diabetes clinics
- Better outcomes, lower costs: dialysis demand and CRM risks are managed proactively
What next?
The MMMoC has become the blueprint for long-term condition care and integrated neighbourhood working in south east London.
The complex case management part of the model will continue to:
- Scale neighbourhood case management across south east London
- Focus growth in areas with the greatest need and deprivation
- Make integrated team-based case management routine, with protected time and clear roles
- Keep building the shift from single-condition to joined-up multi-condition care
What are we most proud of?
Our complex case management (short list) has:
- Given people more time to plan their care around what matters to them
- Created genuine holistic LTC care, improving testing, medicines and blood pressure control for a high-need group.
- Reduced repeat appointments and referrals through joined-up working
