HTN Now Awards 2023/24: Integrated Health and Care System Transformation

Here, we share the finalists in the category of Integrated Health and Care System Transformation.


Overview: North West London ICS expands the deployment of Elsevier’s Care Planning to support wider adoption of evidence-based practice.

Why? To help drive towards ICS-wide consistency of acute hospital care and ensure that evidence-based practice is widely adopted amongst the nursing workforce.

What happened? Elsevier is pleased to announce the expansion of its Clinical Decisions Support (CDS) solution, Care Planning, across the North West London Integrated Care System (ICS), serving a population of 2.1 million people across eight boroughs. This is an extension of the initial partnership with Imperial College Healthcare NHS Trust, which integrated Elsevier’s Care Planning across the nursing team in 2020, to reinforce evidence-based practice at the point of care. Following successful implementation, the deployment of Care Planning across the ICS will help to reduce variation in patient care, further improving the nursing team’s operational efficiency. A total of 319 evidence-based, patient-centred care plans will be made available to thousands of nurses, across the four acute trusts in the ICS. The content has been pre-built and will be delivered via a structured, normalised database, to ensure predictable and timely integration with the organisation’s EPR.

Looking ahead. Work will continue in North West London to make further improvements, as well as to provide learnings for other ICSs looking to undertake similar work.


Overview: Mobile health solution Lifeness is designed to enhance obesity treatment. With a significant increase in weight loss outcomes and user engagement, Lifeness proves to be a promising solution, transforming lives and redefining the fight against obesity.

Why? Obesity, a multifactorial chronic disease, demands regular follow-ups for successful long-term weight loss. However, the healthcare sector often grapples with limited resources and a lack of user-friendly technology tools. As little as 10 percent of patients are successful in long-term weight loss.

What happened? Lifeness used a design-thinking approach with inputs and testing, in a clinical setting, from patients and healthcare professionals. It offers a smartphone app for patients and a cloud-based web-app for health professionals which enables patients to communicate and log parameters like body weight and mood. Lifeness was made to support autonomy, increase motivation in treatment and improve treatment results. In order to test the effect of the m-health tool compared to other e-health solutions, a six-month trial was conducted in collaboration with UiT The Arctic University of Tromsø, with 27 adults suffering from obesity. The m-health group used Lifeness, while the control group used standard follow-up tools such as telephone, email, or SMS. The m-health group lost an average of 12 kg (-10 percent of body weight), whereas the control group lost just 2.5 kg (-2 percent of body weight) over six months. The m-health group demonstrated significantly higher weight loss and total percent weight loss after six months compared to the control group. The m-health group unanimously agreed that Lifeness had a positive impact on their overall treatment, weight-loss, and motivation.

Looking ahead. While Lifeness has already demonstrated notable improvements, more research is needed to explore its full potential. This case study stands as a testament to the potential of m-health solutions in tackling global health issues.

Redmoor Health and North Central London ICB

Overview: In 2019, a five-year funding stream through the Digital First Programme was set out to address the needs of digital transformation. North Central London ICB has commissioned Redmoor Health as a strategic partner for digital transformation, with this marking the second year that Redmoor Health has been commissioned to work alongside NCL.

Why? To support primary care to move toward a digital-first approach, where patients can easily access the advice, support and treatment they need using digital and online tools.

What happened? The consultants delivered nine main elements of support to NCL ICB including digital champions, a digital journey planner, social media managed service, GP websites, data quality, practice support and workshops, online consultation video consultation, online records access, and case study development. At the start of the programme, Redmoor Health provided NCL with a Digital Maturity Index to help quantitively measure improvement; etween Aug 21 and Oct 22, the number of practices with a maturity of three or more rose from 36 to 53 practices. Other results include: digital champions rising from 43 from 25 across 30 PCNs; the number of practices where patients can book online increasing from 64 to 70; and practices where more than 50 percent of people are able to order online increasing from 32 to 67. With Redmoor Health implementing its social media managed services in NCL, 94 GP practices have signed up for  social media, with an additional 3 PCNs. NCL GP practices have also had access to 25 educational webinars covering social media topics, and NCL commissioned Redmoor Health to support the improvement of GP practice websites. Overall, the number of practices scoring 75 percent or more on the DMI’s website audit on quality and accessibility increased from 19 to 40 practices.

Looking ahead. Redmoor Health will continue to offer support to North London ICB across all of these areas.

Sweatco Ltd

Overview: SweatCo is a NHS diabetes prevention partner working alongside SW London ICS to tackle Type 2 Diabetes by creating a specialised programme ‘Prevention Decathlon’ prescribed to at-risk individuals.

Why? Living with obesity or being overweight has a significant impact on both a person’s health and quality of life. More than 2.1 billion people—nearly 30 percent of the global population—are overweight or obese. It is the second-largest preventable cause of cancer, costing the NHS approximately £6.5 billion annually.

What happened? Sweatcoin partnered with South West London ICS to build a programme prescribed to those at risk of Type 2 Diabetes – a disease costing the NHS around £10bn each year. 70 patients with an average age of 56 years old were recruited through health checks run at a range of faith centres. The 10-week Diabetes Prevention Decathlon Programme trial included a structured education programme, group activities and encouraged team sports. Competing in assigned teams, patients were encouraged to increase their activity levels in between sessions to win ‘Sweatcoins’ which they could redeem in exchange for prizes such as a Kindle, headphones, weighing scales or a healthy eating recipe book. In addition, a CVD Prevention Decathlon Programme was developed and deployed in South West London ICS and in South East London ICS for 2024, with an additional 22-week primary care check in, to further demonstrate the behavioural change results achieved by users. Results of the trial demonstrated an average weight loss of 3kg, with one in 10 of those likely to lose 10 percent of their body weight. In terms of movement, patients increased their daily step count by 45 percent between the start and end of the programme, with one patient reporting movement of 336 percent more than before the trial.

Looking ahead. This ongoing collaboration with the NHS aims to expand beyond addressing diabetes and cardiovascular disease, supporting other chronic long term lifestyle diseases,  as well as other regions across the UK.