Integrated Neighbourhood Teams will bring together primary care, community care, voluntary sector services, social care, public health and mental health services into a single integrated offer. This integrated care offer will cover preventative care, proactive care, planned care and urgent/reactive care.
The delivery of care from an Integrated Neighbourhood Team will primarily be based on a Multi-Disciplinary Team approach and will make use of the whole community to enhance health outcomes and reduce inequalities.
Integrated Neighbourhood Teams (INTs) will have an interface with wider Integrated Care Board programmes but delivery will be kept local. INTs will aim to promote and embed collaborative working, reduce solo working, reduce duplication and simplify care pathways.
In Hounslow Integrated Neighbourhood Teams are a way of working to promote more joined up working with Partner Organisations, building on existing structures to provide a core support system around the delivery of the integration. The Integrated Neighbourhood Team essential offer will be based on:
- Streamlining access to care & advice for those that get ill but use health services less frequently.
- To give people more choice about accessing care & make sure it is always available when they need it in their community
- Providing more proactive & personalised care with support of a Multi-Disciplinary Team to those with complex needs but not necessarily limited to those with Long-Term Conditions.
- Helping people stay well for longer with a joined approach to prevention.
- To support better management of the demand & capacity & build resilience and sustainability.
|
Priority Area |
Objective |
Milestones 2023/24 |
How will we measure success in April 2024? |
|
1. Integrating NHS and Housing for Multi-Disciplinary Team working at neighbourhood level – alignment with the council’s localities approach |
To improve the interface between housing and healthcare providers To address housing queries for Integrated Neighbourhood Team services e.g. social prescribers |
July 2023: Make initial conversations with Housing. Understand their geography as part of mapping exercise From October 2023: Setup a Strategic forum for NHS & Housing to use as a platform to understand and improve the Housing and Health Care needs of residents. From January 2024: work with Housing to make this part of Multi-Disciplinary Team model |
Attendance at MDTs |
|
2. Alignment and coordination with the Family Hubs and Community Hubs |
To align with the opportunity that has been presented by the Council’s localities approach, to create both joint physical spaces and virtual teams around the community spaces being created to support vulnerable residents Linking in Chiswick Health Centre and utilisation |
September 2023: agree milestones with London Borough of Hounslow colleagues as part of rollout of the family and community hubs November 2023: Explore what Integrated Neighbourhood Team activities could be provided from the family and community hubs |
Health services are mapped onto Family Hubs & Community Hubs Some joint collocated services are operational |
|
3. Working with the hospital on mapping hospital consultants into community multi-disciplinary team clinics |
To work with ChelWest to work on the opportunity to map hospital consultants into community multi-disciplinary team clinics in order to share expertise, learning, and prevent hospital referrals being required |
September 2023 Agree priorities for mapping with Primary Care colleagues October 2023 Begin engagement with Chelwest to understand their ambitions and priorities January 2024: Agree priorities and mobilisation plan and with which PCNs (based on population need) |
Number of joint clinics completed by March 2024 |
|
4. Mapping community nursing services into Integrated Neighbourhood Team footprints |
To work with Hounslow & Richmond Community Healthcare Trust to integrate community nursing more closely with Primary Care Integrate working cultures |
TBC |
New Community Nursing structures as of April 2024 |
|
5. Improving Integration that should already be happening |
To improve integrated functions that should already be happening e.g.:
|
July- August 2023: Scope what is not working well Q3 2023/24: work with key partners to understand what can be done to improve these integrated functions Q4 2023/24: Implementation of agreed changes |
Data touch points with Primary Care Network Clinic Directors each quarter- is the satisfaction improved? |
|
6. Local Workforce |
TBC |
TBC |
TBC |