New models of care
© Dr Roy Hamilton 2026. All Rights Reserved
I designed an integrated model of care built around four core principles – care, collaboration, education and support – that I see as fundamental to improving patient journeys across multiple long-term conditions.
The framework was developed in response to challenges such as fragmented care, therapeutic inertia and increasing complexity within healthcare. It aimed to encourage closer collaboration across primary care, multidisciplinary teams and wider system partners, while embedding education and practical support into everyday care.
Central to the model was the importance of understanding lived experience when designing healthcare systems.
Although designed as a broader model for long-term condition management, the framework was later tested within a pilot project exploring integrated approaches to diabetes and cardio-renal-metabolic care.
Worcester City
Diabetes Support Team
An ICB integrated pilot bringing together primary and secondary care to improve outcomes for people living with diabetes and cardiometabolic conditions.
CVRM clinics in Primary Care
180+ Holistic CVRM reviews as a neighbourhood team pilot project. Multifactorial interventions. Average HbA1C reductions of 22 mmol/mol.
CVRM group starts
First-of-its-kind CVRM group start clinics using behavioural science techniques such as anchoring and framing across multiple PCN practices, achieving 100% patient satisfaction.
If you would like to learn more about the integrated model of care or discuss completed projects and collaborations, I would be delighted to hear from you.