How to build an effective integrated neighbourhood team

The pace has been picking up following the Fuller Stocktake and the government’s goal of creating a neighbourhood health service on developing Integrated Neighbourhood Teams.

Thinking continues about how these teams are constituted and how they work with services that need a larger footprint than the smaller scale generally covered by INTs but the most significant issue is not what they are but how to create them.

I was asked by National Association Primary Care to look at their recent work in this area and review what we have learned about previous attempts to create integration and the implications for the latest changes.

Where to start? I often see presentations that envisage starting the process of building INTs with data analysis and understanding population need. This is very important but the place to start is actually with the staff. Getting staff on board, giving some hope, particularly in general practice that things will improve, addressing the team working issues and building the team need to come first. More engaged staff are more productive, innovative and more likely to help build something that works.

The concept of a “team of teams” that underpins the INT concept in many places tends to assume that there are teams already in place. This may not be true. Many health and care staff spend most of their time with patients and clients. They often work for different organisations and the amount of interaction with others team members may be relatively small. The definition of the team, who is in it, whether there are shared goals and other important things that make teams real may be absent.

A multidisciplinary team of staff who understand each other’s roles and where the focus is on the patient and the local population and its needs rather than on the execution of tasks can shortcut much of complexity that has been created

Referrals, poor process, and complexity are a major problem. Many areas have a very complex set of services with highly bureaucratic referral processes that waste time and too often are about saying no. Simplifying these, reducing the requirements for referral, increasing access to advice is an important early step. Doing things that quickly improve the working life of staff demonstrates that you can make change and will also help patients.

Segmentation and understanding the needs and demand in the population are clearly important. Where previous initiatives have been less successful they have not capitalised on the insight generated or incorporated it into everyday work. The key learning is about where to intervene. The top of the pyramid – the most needy and high risk are often less impactable than is assumed. Working with other segments of the population who have multimorbidity, medium levels of complexity or a dominant major chronic condition can have a more rapid impact on the demand.

Getting enough reach for effective prevention is a challenge. There is a limit to what can be achieved in short one to one consultations. To be effective some more impactful ways of interacting with groups and reaching out to the wider community to address the determinants of poor health and support people with chronic conditions will be needed. Working more closely with community groups and deploying community health and wellbeing workers can provide an important part of this.

A multidisciplinary team of staff who understand each other’s roles and where the focus is on the patient and the local population and its needs rather than on the execution of tasks can shortcut much of complexity that has been created.

Alison Leary points out that the ‘taskification’ of roles and the downplaying of professional judgement that the result of diluting skill mix has often been higher costs, poorer quality and less rewarding work.

Better trained and more skilled staff are more likely to understand the holistic needs of the patient and how to mobilise support from the rest of the team.

Basic infrastructure has often been neglected. It’s great to get an enhanced team but staff need places to sit, digital technology that works and other basics.

The acute sector has been left out of many previous conversations on integration. Many specialists have a lot to offer to INTs. An INT of 50,000 people generates over 60 outpatient appointments a week in cardiology alone. New ways for specialists to work with primary care are already out there, they need to be more widely adopted.

Previous top-down attempts at change in this area have been disappointing and there is clearly a problem with the classic national approach of piloting and trying to roll out models that means that a different method will be needed this time. This area illustrates the limited number of effective policy tools that are available nationally. Bottom-up change is needed with support at place and ICB level providing coordination between INTs and other support.

Any national programme needs to be very different from the usual model of templates, high level of specification and obsessive monitoring. The key lesson is that this all takes time and investment and that policy makers have generally lacked the patience for this.