Evidence-based, co-designed Integrated Neighbourhood Teams delivering personalised, proactive preventative care
A single Primary Care Network (PCN) INT consists of: 1. INT Coordinator: A skilled admin who ensures appropriate information gathering and smooth running of INT meetings, remaining action-focussed. 2. Neighbourhood Expert: A social prescriber or voluntary sector representative who supports the whole team in building knowledge of available interventions and links into, for example, social care community coordinators.
3. GP: A named GP from the PCN, who attends both weekly meetings and has delegated responsibility for any clinical decision-making by the INT. 4. Four Key Workers (Occupational Therapist, Social Worker, Community Trust Rep, Mental Health Trust Rep): Contribute their professional perspective about cases discussed. Act as the key point of contact for specific residents supported by the INT.
What did we do? Birmingham’s journey towards impactful INTs began with detailed analysis of service use across the system. By combining patient- level data from all partners in Birmingham and Solihull Integrated Care System, it found that 57% of services were being used by the top 5% of service users. Having identified this high frequency user cohort, further analysis, including multi-disciplinary case reviews, enabled system partners to further understand the impact of delivering preventative interventions to these individuals. This evidence was then used to co-design a new operating model for Birmingham’s INTs, including the membership of the team, the services they would provide and new ways of working. Four interventions were found to match 75% of the needs of the target cohort, including community mental health, social prescribing, structured medication reviews and social care assessments. This understanding of the specific needs and volume of the target cohort was central to the design of the new team.
Understanding the challenge Like much of the country, Birmingham’s health and care services were under significant pressure from rising demand. As a result, residents were not always achieving their best outcomes whilst the financial position of the health and care system was becoming increasingly unsustainable. The scale of this challenge nationally has received a great deal of focus in recent years, with widespread agreement that the shift towards more preventative health and care services is essential in helping people live longer, healthier lives and in ensuring the performance and sustainability of the health and care system. The publication of the Fuller Stocktake Report in 2022 provided an early vision for the reorientation of health and care towards more proactive, personalised services by building ‘Integrated Neighbourhood Teams’ (INTs). It also highlighted the need for local systems to drive the change themselves, requiring primary, secondary, social care and voluntary services to work together to design and deliver an impactful new model of care for their population. The challenges presented by integrated ways of working are well known, alongside the difficulty with proving the impact of preventative services within a timeframe that supports significant and recurrent investment. However, the approach taken by Birmingham has led to hugely positive results in a relatively short space of time, generating significant national interest and providing a proven model for other systems to adapt and adopt for their own contexts.
The new model was trialled across two PCNs in east and west Birmingham, where activities and an agreed set of KPIs were closely monitored to allow the model to be iterated and optimised. Scaled up, there is an opportunity for 20,000 people in the city to be supported by INTs, preventing at least 15% of the 850,000 contacts with health and care services each year.
OUTCOMES
Impact and legacy Results from the two pilots showed a significant stabilisation in service use for individuals receiving an intervention from the INTs. This included: A 32% reduction in primary care appointments A 15% reduction in A&E attendances. Residents supported by the pilot reported an overwhelmingly positive experience – with an average feedback rating of 4.3 out of 5. The work and its early impact has generated significant national attention, with visits from senior leaders from NHS England and health sector membership bodies such as NHS Providers and NHS Confederation, and is helping to inform other health and care systems around the country looking to mobilise their own INTs.
Our role Newton played a central role in the
diagnostic, design and set up of the two INT pilots. At the heart of this was the alignment of leaders across health and care system partners, using the data and evidence to enable them to proceed with confidence in realising their joint vision for the residents of Birmingham. Over 200 members of staff across the system were involved in the design process from social care, primary care, the acute, community and mental health providers, the voluntary sector and the Integrated Care Board. Not only did this ensure that the design of the new teams and services benefited from the full breadth and depth of clinical and operational experience within the system, but also helped to build the belief, commitment and new integrated ways of working that would ensure the effectiveness and sustainability of the new model.
This genuinely gives us the chance to make a fundamental difference to people for the long term.” CEO, Birmingham Community Healthcare NHS Foundation Trust
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