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Wouldn’t it be strange if, after decades of system change designed to create more person and community centred care, it turned out it was about relationships all along?

In November 2021, Dr Claire Fuller was asked to produce what became known as the Fuller Stocktake.   Endorsed by NHS England and the Chief Executives of all 42 ICSs in England, the Stocktake described how future Integrated Neighbourhood Teams (INTs) would bring together “previously siloed teams and professionals to do things differently to improve patient care for whole populations”:  preventing ill-health, improving same-day access to care, and supporting all those living with complex needs.

Two years on from the publication of the Stocktake every system, place, and primary care network in England is somewhere on the journey towards this vision.  Nowhere started from scratch.  However, for most people, the vision remains unrealised.

Many of our initial conversations around the Stocktake focussed on trying to unpack the idea of an INT.  We asked ourselves questions like “What are we trying to integrate?”; “How do we define a neighbourhood?”; and “Who is in the team?”.  It was relatively easy to see how existing multi-disciplinary teams of professionals supporting people with specific long-term conditions might fit this model, but what if you are trying to create the equivalent for the whole population – including people who are not frequent users of health and care services, and those at high-risk but who are not yet unwell?

Our core learning from the last two years is if we approach the concept of an INT as a question of organisational structures and forms, we will fail.

We have undertaken “whole system” modelling of capacity and demand on health and care services across multiple geographies, down to Lower Layer Super Output Areas (LSOAs) covering 400 to 1200 households and in places with upwards of 500,000 residents, including health and local authority activity, workforce and broader demographic data, and what fundamentally have we learnt?

People do not fit in neat boxes.

We live, study, work, play, and receive care in ways which are as unique as each of us.   How we define our household, our neighbourhood, our community, our team changes depending on circumstances and over time.

The team that provides co-ordinated support to a family with a child who has learning disabilities looks very different from the team supporting an older person approaching the end of their life.  Claire Fuller was right – it is, in reality, a team of teams.  But those teams need to be able to form around identified needs, as they are identified, with professionals stepping in and out to fill gaps as needed.

Total Football is a concept which will be equally familiar to fans of the Ajax and the Netherlands teams of the 1970s and fans of “The Richmond Way” today.  A philosophy with origins that go back almost a century,

“Total Football is based on the key principle that no outfield player should have a fixed position. Their roles are fluid, with individuals encouraged to frequently interchange to create devastating attacking patterns of play. The method requires high levels of football intelligence, technical ability and communication, with players constantly required to adopt new positions depending on their team-mates’ movements.” (FIFA)

As Hogan, Meisl, Reynolds, Michels, Cruyff, Guardiola, Lasso and others identified, this needs not just versatility amongst those on the field, but conditioning, awareness, communication, confidence – and, not least, bravery.   Team members must not only know their core role, but understand and value everyone else’s role too.  Success depends on professionals comfortable working with a high degree of autonomy, driven by the belief at all levels that only through working differently will we achieve a better outcome.

All of this can be helped or hindered by wider developments, including around governance, technology, shared assets, the way funding flows – the team is always much bigger than the starting eleven on the pitch.   And yet, none of these substitute for the freedom to act and the sure and certain knowledge that we are being supported at all times and on all sides in doing so.

In this context, we need to spend less time worrying about what constitutes a neighbourhood or who is on our team.  In our “Total Healthcare” world,

  • for an INT to work, everyone has to be on the team – not just those currently working on frailty or complex needs, not just those in the NHS, in specific parts of the local authority or in the voluntary and community sector, but everyone – including those providing domiciliary and residential care, patients, carers, local businesses, wider civil society;
  • whether we define our footprint as Richmond or the Netherlands, within this we all understand the evolving needs of individuals and households and that this is what matters most, not simply where people live or who currently provides their care;
  • and, fundamentally, to succeed in this model of integrated working, the role people play must be able to change depending on those circumstances and needs, with the confidence that any gap will always have someone ready and able to step in.

The moment we adopt fixed positions, we simply create new silos.  There is no single style of play that has proved consistently successful, but we know what doesn’t work.  Whilst we are down already, there remains plenty to be ambitious for.

When done well, Total Football feels like you have more players on the pitch than ever before.   It looks effortless.  We can all appreciate how much shared hard work, joint training and coaching sits behind this.   It is incredibly hard for people who have grown up being told their whole career that their role is X, and that others’ role is Y, to behave differently; but in a world of growing demand, growing inequality, and worsening outcomes, we will only make progress through starting, trying, doing, learning and improving as we go.

And in the end, perhaps we will find that this is actually what we were all working towards from the beginning….