Integrated Care

The NHS Long Term Plan has emphasised the importance of integrated care to the future of the health service. This section looks at case examples and resources for delivering integrated care in paediatrics and child health.


The Government published the NHS Long Term Plan in January 2019, which presents a vision for the future of the NHS in England and includes ambitions for the next 10 years. The NHS Long Term Plan has emphasised the importance of integrated care to the future of the health service. But what is integrated care and how can it benefit children, young people and their workforce?

In the video below, NHS England and NHS Improvement introduce ‘Connecting Care for Children’, a paediatric integrated care programme in North West London with GP child health hubs bringing together primary care, mental health acute and community services to look at all aspects of a child’s health and wellbeing.

Resources and case examples of integrated care models around the UK:

Developed by the Child Health in Practice Group, this integration checklist aims to support healthcare professionals in conversations about integrated care with colleagues in their local/regional areas. The checklist provides the first step to local planning and delivery of integrated services for paediatrics and child health.

Development of a standard ambulatory care model for managing acute illness in children and young people at home. Receiving referrals from both Primary Care and Secondary Care, the acute care model produces a more streamlined and quality service that is safe, timely, equitable, effective, efficient and child and family-centred. Five clinical pathways over a 12-month period were created in this new model, with 174 families receiving all their care at home in 9 months.

The Healthier Together Programme is developed in partnership with parents and healthcare professionals across Dorset, Hampshire and Isle of Wight to promote integrated working across health and social care to ensure consistency across the urgent care pathway, and provide access to high quality resources promoting self-care for families.

Respiratory Futures is a new focal point for the UK respiratory community building on the findings of the Respiratory Alliance and reaching across the traditional boundaries of primary and secondary care. An independent network comprising stakeholders from the public and private sectors, they bring people together to respond to the challenges and realise the opportunities the sector faces. A virtual, first port of call for respiratory disease information, taking the role of the honest and supportive broker, facilitating innovative project partnerships.

Connecting Care for Children is a paediatric integrated care model which has been used to implement whole system change and to improve the way children’s care is commissioned, delivered and experienced across North West London. It addresses the disproportionately high rates of paediatric A&E and paediatric outpatient attendance across the region. Since 2014, this work has been driven by paediatricians at Imperial College Healthcare NHS Trust working with local GPs, commissioning leads and social care partners, and has since inspired other regional hubs around England.

A cluster is a group of approximately six neighbouring primary care centres. There are four clusters in Aberdeen City and six in Aberdeenshire. A cluster clinic is where all referrals from that cluster are cared for by a single senior decision-maker who is a paediatrician. Cluster clinics take place in a primary care/community setting within their cluster boundary. Children attending a cluster clinic are seen by either a GP with training in paediatrics or the responsible paediatrician.

The Programme for Integrated Child Health (PICH) was the first integrated child health programme in the UK.  It was developed by the London School of Paediatrics in 2014 to help paediatric trainees better understand and start practising integrated child health care, and from 2015/16 PICH was adapted to also incorporate participation from GP mentors and participants. The programme provides a framework for learning and inspiration – their toolkit supports other trainers and organisations to set up their own versions of PICH, and is available to download from their website.

NHSX and NHS Digital have added additional information to over 54 million patients’ Summary Care Records in England (up from 3 million records in April 2020). Summary Care Records now provide authorised health and care professionals with more information about a patient’s medications, allergies, adverse reactions to medications, medical history, reasons for medications, care plan information and immunisations from their GP record and COVID-19 specific information such as suspected and confirmed status.

Building on the route map set out in the NHS Long Term Plan, ‘vanguard’ sites have been developing regional integrated care systems across England since 2016. From April 2021, Integrated Care Systems will require all parts of the health and care system to work together and take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve. A wide range of case studies, webinars, podcasts and videos have been produced by NHS England to support integrated care as part of this development.

Supporting and managing children and their families during the COVID-19 pandemic is proving a significant challenge for GPs and clinicians working in primary care.

As part of the AHSN Network’s Health and Care Reset campaign, the RCGP, RCPCH and AHSN Network held a joint webinar looking at the issues and support available. Topics covered included an overview of COVID-19 in children, identifying and managing non-COVID-related illness, and the wider impact on pregnancy and new-born babies.

To download the presentation, visit the AHSN Network website here.

Watch a recording of the webinar below:

The RCPCH Ambassadors programme was initiated in 2019 in response to the planned devolution of service, workforce and financial planning responsibilities to Integrated Care Systems in England by September 2022. They are a network of volunteer RCPCH members that use their clinical expertise, local knowledge and medical experience to create change for children and young people in their area by engaging with their local systems. Visit the RCPCH website to find out more about their roles, where they are based and how you can also apply to be an RCPCH Ambassador.

Resources developed by local integrated models of care for primary care colleagues, and children and young people and their families: