The programme is helping Birmingham and Solihull (BSOL) to lead the way in delivering the Government’s vision of creating a neighbourhood health service, placing greater emphasis on preventing ill-health by shifting care from hospitals to community and harnessing the latest technology to improve care.
Introduction
Integrated Neighbourhood Teams (INTs) are multi-disciplinary teams of GPs and general practice staff, community nurses, physiotherapists, occupational therapists, mental health specialists, social workers and other council services, voluntary organisations, care homes, end of life care and hospices, and community network teams.
Each INT serves a population of between 30,000-50,000 people. Services include social prescribing, medication review, healthy lifestyle advice and support, community mental health support, and support for carers and families. The INT has strong links in voluntary organisations, care homes, end-of-life care and hospices, and community network teams.
The INTs are part of the wider Community Care Collaborative programme of work being delivered by Birmingham Community Healthcare NHS Foundation Trust.
There are currently five Neighbourhood Teams who are piloting the programme and helping to shape its development and design. These teams are focussed on those citizens with a range of complex health and care needs who often use services more frequently, as well as trends within their local areas, and discussing how both can be better supported using the new collaborative approach.
The challenge
Individuals with a range of complex health and care needs tend to drive a great deal of demand for services across primary care, acute providers, community health, mental health and social care. Historically information about this activity would be held by the individual organisations.
As a result, it was not possible to build a picture of overall use of services across the system and whether individuals were being supported at the right time with the right intervention. This oversight is key to being able to improve outcomes, whilst simultaneously avoiding unnecessary hospital attendance and admissions, as well as overall increase in care needs.
Mission
To develop a new data driven approach to improving citizen outcomes by effective data analysis, breaking down cultural and organisational barriers, myth busting and building cross organisational trust. Improvements should be led by analysis of this data.
Implementation
In March 2023, BSOL launched a period of intensive analysis, engagement, and design into INTs. To provide the necessary senior and corporate cross-sector dialogue, appropriate forums were put in place with senior representatives from all partners, operational and financial sponsors at director level, finance managers, informatics, digital and data teams, estate and services, and primary care.
Investment into digital systems was made and in a first for the BSOL system, patient-level activity data was linked across primary care, acute providers, community health, mental health and social care in such a way that a complete picture of a person’s journey through all these services can be seen.
The joining together of data, facilitated and analysed by BCHC, demonstrated that over the past 12 months, 57per cent of collective activity across the services involved was supporting just 5per cent of individuals, defined as frequent service users (FSUs). This also made it clear that for this 5per cent, an ambitious and innovative delivery model was required to address their needs.
As a result of the findings, each INT was given a list of the 5per cent of individuals who were making up the largest proportion of collective activity.
When a member of the INT came to interacting with a given individual, they were able to see what made up the activity for that person over the last 12 months, such as the volume of GP appointments, community health visits, and ED attendances.
This could then be supplemented through access to a newly created shared care record, which allowed INT colleagues to see notes from those appointments and to decide how they would approach the creation of a bespoke care plan with the individual in question.
Continued linking of data and analysis of the service use of those individuals meant the impact of these interventions could be tracked. The work so far has only been possible because of a strong foundation of partnership working and support from system leaders in Birmingham and Solihull. The system has been strengthening partnerships and maturing their system working for many years.
In particular:
- A firmly held belief that to sustainably deliver services takes a joint effort across primary, secondary, social and voluntary sector services.
- Design services around delivering the best possible outcomes for residents, not around existing organisational sovereignty, structures or financial flows.
- Provide opportunities for organisations to take a lead on different priorities to deliver the goals.
Outcomes
While the work is still at a relatively early stage, a recent evaluation from east and west INTs (December 2023-December 2024) showed a significant reduction in service use for individuals who are receiving an INT intervention, including reduction of:
- 32 per cent in primary care appointments
- 15 per cent reduction in ED attendances
- 77 per cent reduction in long term care packages being put in place
- 25 per cent in outpatient appointments
- 15 per cent in community trust contacts
- 28 per cent inpatient spells and bed days in hospital The plan is to align an Integrated Neighbourhood Team to all 35 primary care networks across Birmingham & Solihull over the next three years.
Contact
Email: [email protected]
Website: Integrated Neighbourhood Teams