DEVELOPING INTEGRATED NEIGHBOURHOOD TEAMS 1: Learning from the Humber and North Yorkshire Heath and Care Partnership (HNYHCP) Integrated Neighbourhood Teams Leadership & Development Programme
Nick Downham, Professor Becky Malby and Paul Jansen.
Dr Helena Ebbs, Clinical Place Director, HNY ICB and GP.
PCNA INT Development
“Integration is different to collaboration. We know and do a lot of collaboration, but do we really know about integration? Do we know what it means?” Senior Service Leader
Why we care about integration
Integration is our answer to leaders, professionals, people using care and their carers’ frustrations with experience and outcomes (effectiveness, cost, safety). People want fewer handoffs, more continuity, and to tell their story once. Professionals want to meet needs with less fragmentation as part of a real team that can make decisions and follow them through. Leaders want more effective and cost-efficient care.
And so, we as a system reach for integration again, often without looking back at the lessons of our previous attempts and often without acknowledging just how hard it is to move from collaboration (shared intent) to integration (shared action and accountability) across organisational and professional boundaries. Meaningful integration goes against the tide of the increasing control and task orientation levels in our work. It is something we as a system have been struggling with for decades.
What are Integrated Neighbourhood Teams?
Integrated Neighbourhood Teams (INTs), as detailed in the Fuller Stocktake, aim to provide effective and personalised care for individuals with complex needs by integrating physical, mental, and social care at neighbourhood level.
INTs are increasingly seen as central to achieving two of the three ‘left shift’ priorities (1) outlined by the current government: transitioning from hospital care to community care and shifting from treatment to prevention – emphasising proactivity. In short, when focusing on the universal challenge of enhancing productivity, INTs offer the potential to be a significantly more effective model of care for many complex individuals - by doing what matters rather than what fits for those with complex needs.
We have been working with colleagues in Humber and North Yorkshire to support their development of Integrated Neighbourhood Teams, and this is some of what we are learning as we do the work.
Seven key insights from our work:
1) Who are INTs for, and what are they a solution to?
Having a solution looking for a problem is a well-known path in the NHS. Integrated Neighbourhood Teams need to be meeting real needs, not assumed needs. When we ran a community co-discovery event with a PCN seeking to understand the needs of complex older adults, the message was what was important for those complex older adults was not biomedical. What mattered to them was not the blind prolonging of life, but it was network, security, relationships, dignity (being listened to) and sense of purpose. The expectations of citizens, contrary to many assumptions, are extremely modest.
Part of the challenge is to consider what makes someone’s situation complex. Is it just biomedical needs or is social complexity(2) just as important? Are we mindful of the distorting nature of our systems of labelling needs and what we can learn from long-term frequent attendance patterns? We have set out the issues where INTs could be the best answer here (3).
Central to the work on new models of care is the notion of Needs > Function > Form (4).
Needs > Function > Form
BUT, much INT work starts backwards - with Form (such as setting up a team and governance) and then goes looking for needs to meet – a solution looking for a problem that ends up with far less effective working.
Finally, as much as we need to think about what INTs are for and what might be different, we also need to be clear about what they are not for. The first of our PCNA INT guiding principles (5) is to meet needs that can only be met with a team-based response. You don’t want to use a team-based response to meet needs that can be met with simpler models – such as community assets or liberated professionals like a GP or district nurses. Good, effective team working requires headroom, good communication and development – as such teams are not ‘free’ – they have a cost. It may well be that with development, needs can be held by simpler models and thus higher levels of continuity achieved. We only want to aim our INTs at work that can genuinely only be done by a multi-professional, multi-partner team.
2) “If all that INTs end up being is another MDT meet, then we have failed” (Programme participant)
People working on INTs recognise the limitations of many Multi-Disciplinarily Team (MDT) meetings. Just convening mixed professionals for an MDT meeting does not mean that the work is any different, nor does it suggest that our response to needs is any more integrated or effective. We must go beyond the MDT meeting (6).
In our work nationally, we have found differing views on the intention of an MDT meeting. As the image below shows, is the intention to coordinate professionals to do their bit? Surely we are aiming for more? We need to be careful not to treat an MDT meeting with a wider group of professionals as the finish line for this work….
What is MDT working?
3) “Integration – citizens expect it, but we rarely do it…” Participant
The terms integration and integrated are used freely, but achieving it has been challenging for decades. Part of the reason for these challenges is we often fix the symptoms, rather than the root causes of fragmentation. For example, we overlay communication and coordination mechanisms (like a single point of access or MDT meeting) on top of fragmented systems – rather than work to de-fragment (integrate) in the first place - such as by creating meaningful ‘role generosity (5)’ and collective accountability (5) - both of which reduce avoidable transitions – a source of colossal Failure Demand (7). The aim here is to enable professionals to work in each other’s shoes. To do this, we need to remove the structures and systems in our work that encourage our professionals to concentrate on their bit rather than what matters.
4) “Candid dialogue is really powerful” Participant
The work disclosed is often different to the work done (8). In other words, discussions often filter and sanitise the gritty reality. Improving integration across multiple professionals, settings, teams and community partners requires carefully designed dialogue.
“It was great to get a different lens to see this work” Senior service leader
How the conversation is set up is critical for forming relationships and trust. If we cannot speak openly about the real work, we won’t get the valuable learning and insights to do something different. Traditional deployment and programme structures do not tend to allow for this.
Making sense of the INT challenge
5) “Careful with one size fits all” Participant
The places across most ICBs tend to be different. Different geography, needs, starting positions, community capabilities, history and relationships across primary, secondary, community and social care. Clearly, standard ‘cookie cutter’ models don’t fit. Not just because effective change in human systems of work (9) requires people to ‘own what they create’ but, as the Health Foundation says, just because an innovation has been successfully piloted, it doesn’t follow that other organisations can adopt it overnight (10) - or perhaps at all.
6) It is challenging work
Developing integrated responses to needs and challenging system complexity, traditions, and age-old structures is some of our system’s most difficult work. It requires the skills of reflection and challenging our assumptions about how work is done and by whom.
“Not knowing [the solution] is ok – we can trust the process” Senior service leader
Our health and care systems have been battling with fragmentation since the dawn of organised medicine and the welfare state, so we need to be okay with it being complex, difficult, and not very neat. If it were easy, it would have been done years ago. Our models of care, fragmented or not, are a product of ideas and assumptions. For something to be different, we need to recognise and let go of these ideas – letting go of what is comfortable and familiar. This won’t happen until people feel safe and supported in doing so.
7) A massive opportunity
National, regional and local stakeholders have different views on what INTs are, who they are for and how to develop them. Some prioritise transactional implementation work, such as getting an MDT up and running. Others concentrate on INTs being a vehicle for connecting and coordination, some on holistic integration, others see INTs as a way of streamlining access, and some aim to tackle inequalities.
It is obvious that a unified, crystal-clear answer does not exist, and perhaps it does not need to – given the variation in needs and places. We see this as a massive opportunity. Given the flux in our system, this is the moment to do something genuinely innovative and meaningful to meet complex, local needs – making a difference to citizens, professionals and the wider system.
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
A PDF of this blog can be found here.
About this work:
In the Humber and North Yorkshire Health and Care Partnership, INTs are essential to assisting the population to Start Well, Live Well, and Die Well. To complement the work already begun on INTs, HNYHCP is supported by the Primary Care Network Academy (PCNA) in its INT Leadership and Development programme.
This programme is carefully designed to bring together the multiple partners involved in INT development through a series of expertly facilitated workshops. It aims to surface assumptions, perspectives, and tensions and move towards fulfilling the promise of INTs. Ultimately, it focusses on more effective care by doing what matters rather than what fits for those with complex needs.
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/
(2) More on the impact on social complexity in primary care can be found here: https://www.cressbrookltd.co.uk/innovation-in-primary-care-and-primary-care-networks-new-perspectives-on-the-work/
(3) More on long term frequent service users: https://beckymalby.wordpress.com/2024/05/18/integrated-neighbourhood-teams-what-is-the-problem-ints-are-the-answer-for/
(4) More on Needs, Function, Form can be found here: Linked in blog post
(5) Our carefully developed PCNA Ten Guiding Principles for INTs form the core of our approach to making INT working an effective reality.
(6) More on going beyond the MDT meet: https://www.pcnacademy.org.uk/blogs/beyond-the-mdt-meet
(7) Transitions and handovers can be a source of Failure Demand: https://www.cressbrookltd.co.uk/sources-of-failure-demand-in-healthcare/
(8) The wise words of human systems expert Steve Shorruck: https://humanisticsystems.com/2020/10/28/proxies-for-work-as-done-1-work-as-imagined/
(9) Chin & Benne, General Strategies for Effecting Change in Human Systems, 1969
(10) https://www.health.org.uk/features-and-opinion/blogs/innovation-is-being-squeezed-out-of-the-nhs
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