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Camden Integrated Care Service
(CICS)
GP Practice Guide
Guidance for Camden GPs on services provided by the
Camden Integrated Care Service including referral
pathways and criteria
Version 6: Reviewed & updated 30th November 2016
Introduction and Summary
CICS aims to provide patients with access to secondary care clinicians in a community
environment. Central to the service model are clinics bringing specialist clinicians to treat
patients in a community setting and weekly MDT meetings specifically for frail and
elderly patients.
CICS offers practices and patients a responsive service that can be locally tailored to
patient needs by managing co-morbidities and frail patients in the same location and at
the same time, with cross cutting services on site to further support individual needs.
Services and Locations:
CKD, Joint Diabetes/CKD, Diabetes IPU
Location: Mary Rankin
St. Pancras Hospital. 4 St Pancras Way. London NW1 0PE
COPD, Epilepsy, Heart Failure
Location: South Camden Centre for Health
Stephenson House. 154 Drummond Street. London NW1 3HP
The Partnership of Providers
The integrated service will be delivered by the following partnership of providers:
CKD – Mary Rankin Unit
Dr David Wheeler
Consultant Nephrologist
Sarah Milne
CKD Specialist Nurse
Sinead Burke
CKD Dietician
Royal Free Hospital
Royal Free Hospital
Royal Free Hospital
Joint Diabetes/CKD – Mary Rankin Unit
Sarah Milne
CKD Specialist Nurse
Manraj Basi
Diabetes Specialist Nurse
Royal Free Hospital
CNWL
Diabetes IPU – Mary Rankin Unit
Dr Mark Vanderpump
Consultant Endocrinologist
Dr Sarita Naik
Consultant Endocrinologist
Vanessa Sawmynaden
Diabetes Specialist Nurse
Manraj Basi
Diabetes Specialist Nurse
Katie Hacker
Diabetes Specialist Dietician
Chris Warner
Diabetes Specialist Podiatrist
Royal Free Hospital
UCLH
CNWL
CNWL
Whittington Health
CNWL
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Ruth Miller
Shantell Naidu
Diabetes Specialist Nurse
Diabetes Nurse Consultant
Royal Free Hospital
CNWL
COPD – South Camden Centre for Health
Dr Melissa Heightman
Dr John Hurst
Heidi Ridsdale
Travis Edwards
Consultant
Consultant
Physiotherapist
Nurse
Epilepsy – South Camden Centre for Health
Dr Dominic Heaney
Consultant
Dr Rebecca Liu
Consultant
Paul Turner
Nurse
UCLH
RFL
CNWL
CNWL
UCLH
Royal Free Hospital
Royal Free Hospital
Heart Failure – South Camden Centre for Health
Dr Simon Woldman
Dr Martin Thomas
Dr Carol Whelan
Percy Watungwa
Frailty MDT
Dr Stuart Mackay-Thomas
Consultant
Consultant
Consultant
Lead Nurse
GP
UCLH
UCLH
RFH
CNWL
Frailty Lead
** The first Thursday of every month will see the diabetes service offered from Abbey Medical Centre as
before. Diabetes Specialist Nurse Clinics, for follow-up patients, will also continue to be held at Belsize
Priory.
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The Referral Process
Referral Routes
COPD
Diabetes IPU
CKD
Epilepsy
Heart Failure
Joint
Diabetes/CKD
• All GP referrals to CCAS via choose and
book
• Triage by specialist practitioner
• Secondary care referrals to “stepdown” patients when appropriate.
• SEE REFERRAL CRITERIA
IAPT
• Referral form to be sent via email:
[email protected]
Memory Clinic
• Referral form to be sent via email:
[email protected]
How to refer via CCAS
Referrals must be made via Choose & Book to CCAS in the following way:
1. Complete the CICS Proforma for CKD, Joint Diabetes/CKD, COPD, Heart
Failure, Epilepsy service.
Or complete the Camden Diabetes Integrated Practice Unit Referral Form for
Diabetes IPU.
2. Create a Choose & Book referral via your GP clinical system.
3. In Choose & Book select Specialty/Clinic Type: General Medicine then Service:
Camden Integrated Care Service (CICS)
4. Send UBRNs (Unique Booking Reference Numbers) to CCAS.
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Referrals will be entered onto Emis Web by CCAS.
These will then be viewed and triaged by the respective discipline.
All referrals will be reviewed by a specialist leading to one of the following outcomes:
o an onward hospital referral
o a community assessment
o a virtual assessment with a management plan feedback to the GP
What levels of service should practices and patients expect?
Patients should be offered an appointment within 4 weeks of the receipt of the referral.
Following the appointment the practice will receive a letter from the c l i n i c i a n
within 1 week of the appointment
DNA Policy
If a patient does not attend (DNA) an appointment without prior notice, they will be
contacted by the admin team to re-book the appointment. If they fail to attend a
second time, they will be discharged back to the GP.
Community Clinic Administrative Support
Mary Rankin Unit - The community clinics will be supported by a small administration
team available from 9am - 4pm Monday to Thursday and 9am to 2pm on Friday.
Please note there is no fax.
Telephone No:
020 3317 2438
South Camden Centre for Health – Reception and administrative support for the
Centre is provided including booking follow-up appointments. Operating hours are
Monday to Friday 8am to 6pm.
Telephone No: 0203 182 1701
CICS assistant operations manager for South Camden Centre for Health is
Jessica Bromwich
([email protected])
Tel: 020 3182 1710
Patient Transport – South Camden Centre for Health
If transport is required for a patient, this should be identified on the referrals form and it
will be booked via CICS admin. If on booking an appointment at South Camden
Centre for Health, the patient indicates they will need transport this will be arranged.
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Monitoring and Feedback
Patient feedback
Patient leaflets on how service users and carers can feedback any comments,
compliments or complaints are available.
Comments & Concerns
In the first instance, if you have any concerns, please contact Jessica
Bromwich, CICS assistant Operational Manager ([email protected])
Tel: 020 3182 1710
Monitoring the service
Monitoring will be via the multi-disciplinary clinical governance groups and Steering Group.
Condition Specific Referral Criteria
1. Diabetes IPU
2. CKD
3. COPD
4. Heart Failure
5. Epilepsy
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1. DIABETES IPU REFERRAL CRITERIA
Referrals to be made via CCAS
For the Diabetes IPU service, both the initial and any follow-up appointments will
subsequently be made by the service’s administration team at Mary Rankin.
Consultant
Inclusion Criteria
Exclusion Criteria
Type 1 DM not engaging with
hospital
Already attending hospital HbA1c (within last
month)
diabetic clinic
Full lipid profile,
Microalbuminuria
screen Renal
Liver
Poorly controlled Type 2 DM
Diabetes
Specialist
Nurse
(DSN)
Poorly controlled type 1 and 2
diabetics
Education on hypoglycaemia
Preconception advice
DESMOND Recently diagnosed <1yr Type 2
(DSN group DM
education)
Existing Type 2 diabetes who have
not yet attended group education
Required pre-referral
test results
Already attending hospital HbA1c (within last
month)
diabetic clinic
Full lipid profile,
Microalbuminuria
screen Renal
Liver
Patients
who
have
attended DESMOND
previously
Requiring interpreters /
non English speaking
English speaking
Willing to attend group education
Dietician
Newly diagnosed Type 2 DM
Non English speaking so unsuitable
for DESMOND
Severe mental health
/learning difficulties or
any other condition
making group education
unsuitable
Height
Weight
BMI
Type 2 DM requiring weight
management
Carbohydrate counting for pts on
multiple insulin injections
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Podiatrist
Newly diagnosed diabetics for initial
foot screen and education
Longstanding diabetics
with no foot problems
Patients with previous history of foot
ulcer
Pts with foot deformities/skin
changes/infection/inflammation/pain
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2. CKD REFERRAL CRITERIA
CKD referrals will be screened by a Consultant nephrologist.
Both the initial and any follow-up appointments will be made by the service’s
administration team at Mary Rankin
Inclusion Criteria
Exclusion Criteria
Isolated proteinuria (protein:creatinine
ratio (PCR)> 100mg/mmol)
Urgent referrals direct to Urinary symptoms
hospital:
Medical history
Proteinuria and microscopic
haematuria (PCR> 45mg/mmol)
Acute Kidney Injury
(Acute renal failure)
Malignant hypertension
Hyperkalaemia (K+>7
mmol/L)
Nephrotic syndrome
Macroscopic haematuria (after
negative urological evaluation)
Fall of eGFR of 25% during first 2
months on ACEI / ARB
Stage 3 CKD plus:
Progressive fall in GFR (>15 mL/min
over 12 months)
Anaemia (after exclusion of other
causes)
Persistently abnormal serum potassium,
calcium, phosphate, (uncuffed sample)
Suspected underlying systemic illness,
e.g. SLE, vasculitis, myeloma
Uncontrolled hypertension (e.g. BP >
150/90 on 3 agents)
Stages 4/5
All patients should be referred to or
discussed formally with a nephrologist
and renal replacement therapy (RRT)
or conservative therapy considered,
even if it is not anticipated that RRT will
be appropriate.
Required pre-referral test
results
Medication (with dates
of starting and stopping
ACEI/ARB if applicable)
Examination e.g. BP,
oedema, palpable
bladder
Urine dipstick for blood
and protein
Urine culture and PCR
(if protein present)
FBC
Serum creatinine and
eGFR, urea, sodium,
potassium, albumin,
calcium, phosphate,(all
within last month) +
cholesterol, HbA1c (in
diabetes)
Historical creatinine
results and eGFR
reports with dates if
available Result of
renal ultrasound if
available
Exceptions may include if the CKD is
part of terminal illness or function is
stable & appropriate management
implemented with treatment plan.
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3. COPD REFERRAL CRITERIA
The service is a COPD service only and does not cover any other primary diagnosis.
Those patients who have a diagnosis (suspected or confirmed) other than COPD
should be referred for an outpatient appointment at the acute trust as should those
patients whose diagnosis of COPD is in doubt.
Inclusion criteria for CICS/
Community COPD nursing
service
Confirmed
COPD plus:
Exclusion Criteria (such patients
require referral to Respiratory
Consultant at the acute trust)
Pre referral
investigations required
Diagnosis
of Severe disease where a
Spirometry
surgical referral for transplant
might be indicated (Stage 3 or
Chest X-ray
4 disease, aged <60)
New diagnosis at Stage 3
or 4 not requiring referral
Diagnostic difficulty (if full lung
to acute trust
function testing rather than
spirometry is required)
Frequent exacerbations
(>=3 year) despite therapy
Assessment/management of
Anyone who has been
respiratory failure – e.g. if O2
hospitalised because of
sats <92% (where the patient
their COPD
may need an ABG/ Long term
oxygen assessment
Management of acute
exacerbations
Supported Discharge
Symptomatic despite
optimal therapy
Rapid decline in annual
spirometry
Difficulty with
compliance/concordance
Need for Pulmonary
Rehabilitation
Prominent anxiety /
depression (for psychologist)
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4. HEART FAILURE REFERRAL CRITERIA
Inclusion Criteria
Exclusion Criteria
Required pre-referral test
results
None
Must have a pre-existing diagnosis of Be thought to require
heart failure
assessment for
advanced heart failure
therapy (e.g. transplant,
left ventricular assist
device therapy,
ultrafiltration, cardiac
resynchronization
therapy)
Both the initial and any follow-up appointments will subsequently be made by the
Service’s administration team at South Camden Centre for Health.
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5. IAPT REFERRAL CRITERIA
If you're not sure a referral is appropriate, complete the form any way, and someone
from IAPT will signpost patients to another relevant service.
How to refer
Complete the referral form and send it to: [email protected]
Inclusion Criteria
Exclusion Criteria
Required pre-referral test
results
People aged 18 years or above
Anyone in a current
episode of acute
psychosis or in crisis or
anyone who is actively
suicidal
None
People suffering with anxiety and/or
depression or where aspects of their
emotional wellbeing or relationships
compromise management of their
condition.
Anyone who has a
severe alcohol/ drug
dependency
Anyone currently under
the care of mental
health services
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6. MEMORY CLINIC REFERRAL CRITERIA
Inclusion Criteria
Exclusion Criteria
Camden residents over 65
years old with memory
problems.
Generally patients
years of age.
Patients under 65 with
significant history of
alcohol/substance misuse, or
significant mental health
issues may be offered an
assessment
Required pre-referral test
results
under
65 Results of a blood
screen
(TFTs, Vit B12/folate,
FBC, ESR, Calcium,
LFTs, U&Es, Glucose )
Camden Community Memory Service offers Specialist service for early assessment
and intervention for people with memory problems in Camden. The service provides
assessment, investigations, diagnoses and support to service users with early onset
memory problems, dementia or Alzheimer’s. The memory service provides cognitive
stimulation therapy, a carers' support group and a diagnosis group.
The first appointment will be held in the patient’s home, with the Consultant and
memory service practitioner subsequently jointly seeing the patient (and carer) at
either South Camden Centre for Health or the Peckwater Centre.
Any further follow-up appointments will be undertaken in the 2 clinics by the memory
service practitioner nurse / therapist.
Referrals are generally preferred from GPs to ensure that ‘dementia screening tests’
have been carried out beforehand. Referrals can be accepted from other health care
professionals, with agreement from the GP.
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7. Epilepsy REFERRAL CRITERIA
The service is an Epilepsy service only and does not cover any other primary
diagnosis.
Those patients who have a diagnosis (suspected or confirmed) other than Epilepsy
should be referred for an outpatient appointment at the acute trust as should those
patients whose diagnosis of Epilepsy is in doubt.
Inclusion criteria for
CICS/
Epilepsy Service
Exclusion Criteria
(such
patients require
referral to
Neurologist
Consultant at
the acute trust)
Confirmed diagnosis
of Epilepsy plus:

• Patients with unmet
needs (e.g. frequent
seizures or changing

needs)
• Women of childbearing
age
• Complex care needs
(drug and alcohol
misuse,
psychopathology such
as anxiety and
depression).
• Transitioning to adult
services and over 18
years of age
• Learning disability
register
• Presenting to A&E with
epileptic seizures in the
last year and
admission to A&E in
the last year
• Patients needing a
review of medication
• Dissociative (nonepileptic) seizures –
known or suspected
 First seizure
patients
Pre referral
investigations
required
Patients requiring drug
monitoring during
pregnancy
Seizures caused by
alcohol misuse, without
diagnosis for Epilepsy
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