DEVELOPING INTEGRATED NEIGHBOURHOOD TEAMS 2: Understanding Neighbourhood Working & Positioning INTs
Nick Downham, Professor Becky Malby and Paul Jansen.
As we discussed in our previous insights blog, integration it is something the NHS as a system has been struggling with for decades; our experience is that the struggle it not because of lack of genuine commitment but rather because it requires a different set of principles about how work is done and organised – to move from coordination to true integration (unity of effort[1]).
Understanding different forms of neighbourhood working
Integrated Neighbourhood Teams (INTs) mean different things to different people, as do neighbourhood working or partnership working. In some situations, the term INT is used to describe all neighbourhood working development, from low to high acuity and from reactive to proactive work. For others, the term INTs denotes more proactive community-based work on issues such as obesity. As always, language is important, and different interpretations lead to confusion and potentially blurred intent.
To help with local system discussions, we have developed this Neighbourhood Working ‘Bubble’ Diagram. It has proven to be extremely useful in understanding, clarifying, and facilitating discussions about all forms of neighbourhood working, including INTs.
Neighbourhood Working Bubble Diagram - Downham, Jansen and Malby
Note that there is deliberate overlap with these segment bubbles. This overlap is significant as it fosters integration, reduces fragmentation and allows for the fluidity in people’s care requirements.
The purple bubble: INTs
The original stepping off point for INTs was the Fuller Stocktake in 2022. This highlighted the necessity for INTEGRATED team-based care for individuals with complex needs.
Effective care for complex people (health and social complexity[2]) requires highly integrated team-based responses; team-based working that demands collective accountability, a reorientation of specialist support, role overlap, and unity of purpose. The key is to simplify the response, considering roles and teams that reduce the number of individuals involved and shift from an often-defensive task orientation to focusing on what truly matters to the person in their context. After all, it is much easier to integrate care and increase continuity if fewer people, with a wider range of skills, are involved in the first place…. This is a common principle across many high-performing health systems.
Interestingly, there is less emphasis on this group as broader neighbourhood working planning evolves. One reason for this could be that the other bubbles are less challenging, as they do not challenge professional and organisational norms in the same way, and that the other bubbles provide a stepping stone to the more fundamental integration of this purple INT bubble, as confidence and trust between system partners grow. Alternatively, people may be drawn to more downstream work. Whatever the reason, we believe the requirement for this work has not gone away and remains highly challenging, as meaningful integration goes against the increasing control and task orientation in our work.
The blue bubble: individual providers, such as a general practice
Individual health and social care providers should only escalate a person’s care into integrated multi-agency models when efforts to keep the person within their own professional practice are not enough and care would be ineffective. Thus, the need for robust INDIVIDUAL PROVIDERS of health and social care continues to exist.
From the perspective of general practice, it will continue to provide highly reliable care and serve as the foundation for not only neighbourhood working but also the wider system. Practices will need to focus on the effectiveness of their care (rather than just volume), maintain access, reduce unwarranted variation, and develop systems for multi-morbidity care. They will continue to require support in adapting to their changing context. It is important to note that, despite the small size of the bubble, the volume of interactions in general practice, in particular, will far exceed those of other types of neighbourhood working.
The green bubble: integrated working with high continuity
This is typically the world of PCN enabled responses to individuals with greater complexity. This could involve clinical complexity, but in many cases, social complexity poses the real challenge. The broader capabilities created by PCN roles, such as social prescribers, the enhanced COORDINATION and team-based continuity facilitated by care coordinators, and the increased collaboration with communities enabled through asset-based community working are all key enablers. Special care must be taken to avoid micro-silos between professional groups within PCNs and to understand the overall effectiveness of this integrated working. The main focus here is co-design and co-provision of care with the assets[3] in the community.
The peach bubble: integrated approaches
Proactive and preventative approaches that centre on strong partnerships and COLLABORATION with not only social care, but also the voluntary and community sector (VCS) and other community groups and leaders. The core starting condition is meaningful co-production with communities – because for much low, medium and much high complexity need [4], it is not formal services that control outcomes.
The glue that makes wider integrated approaches work in this world of collaboration is trust and relationships, not contracts. This is enabled by ensuring time in portfolios to form and maintain relationships over time. Sometimes this is not viewed as core work, but the fact remains it is vital for proactive and preventive wellbeing-focused models – after all, you cannot outrun population ill-health with a reactive model.
In conclusion:
As with our opening statement, aspirations for integrated working and for a greater shift for community working are not new ideas – despite the current revised emphasis. The challenges of achieving these things remain considerable. They challenge our traditions of contracting, measurement, control, professional boundaries and an often-paternalistic model of care.
This Neighbourhood Working Bubble Diagram has proven useful in our work with local systems, providing the basis to begin to understand different interpretations and intentions of neighbourhood working.
We hope these insights are useful. There is more to come. If you have any comments or queries, feel free to drop us a line at contact@pcnacademy.org.uk
About the Primary Care Network Academy team for this work :
The Primary Care Network Academy is an independent team with deep knowledge of the context of health and social care, but also experts in the fields of community collaboration, primary care systems improvement, team-based care, integration and development of new models of care. More on the Primary Care Network Academy can be found here: https://www.pcnacademy.org.uk/developing-ints
Nick Downham is a leading healthcare quality, systems thinking and organisational development specialist. He runs a small consultancy, Cressbrook Ltd, which is committed to helping organisations, professionals and communities be their most impactful in helping people live healthy lives. More on Nick can be found here: www.cressbrookltd.co.uk
Professor Becky Malby is a professor of healthcare leadership at the University of York. She is also an honorary fellow of the RCGP and leads the National Universal Healthcare Network, focusing on equitable NHS services. More on Becky can be found here: https://beckymalby.wordpress.com/
Paul Jansen is the co-founder of Trust Works, which delivers interactive, fun and thought-provoking programmes that inspire and provide practical tools and skills to organisations who want to explore concepts of self-management, empowerment and autonomy. More on Paul can be found here http://www.trust-works.co.uk/
What we do to help you
We can WORK WITH YOU directly on any of the things above, either hand-on to provide energy and support you and your organisation towards rapid change or just in a LIGHT TOUCH advisory role > contact@pcnacademy.org.uk