Creating integrated neighboured teams will be very hard, but it’s vital for the care of the public and for the future of the NHS that we succeed in doing it.

Lessons from developing motivations over 40 years from Paul Corrigan

Integration in the 1980s

A decade ago, I remember starting work with the NHSE Better Care Fund to help create neighbourhood teams.

But luckily, I am the same age as the NHS, so I go back even further to remember my first work around integration (only it didn’t involve the NHS). In the 1980s I was teaching social workers in Islington at the Polytechnic of North London.

The local authority decided that it would provide much better services to the public if it not only integrated its services but also localised them. Over time it created 24 local neighbourhood offices which included a wide range of local authority services, especially in that borough local housing and social services, but also environmental health and refuse disposal.

Challenges of Professional Distinctions

As the head of the local social work training at the Poly I was involved in these discussions, and a decade later from 1993 when I went to work as Head of Quality at Islington Council it became much more a part of my day-to-day work. Each locality had a primary school (at the time run by the local authority) and relationships between the integrated neighbourhood team and the Heads were crucial. The development of neighbourhood policing at the time meant it as easier to work with the police as well.

Each neighbourhood covered about 8,000 to 10,000 people and had a purpose-built base. The motivation for the local authority was to create a much more streamlined service, one that did not have different groups stumbling over each other trying to do that same or similar thing

This was not easy.

The professional distinctions between the different staff demanded a hierarchy that put one of their own in charge of them. The notion that each locality could have a generic manager was a difficult one for professions to agree; but when the neighbourhood manager proved their worth, the office and team worked well together. How they did that was by demonstrating the efficacy of the manager’s title. What they were doing was managing the neighbourhood – not social workers or any other group of staff, but the locality.

Their job was to bring the generic knowledge that comes with what we now call ‘Place’ into the work of the whole team. For example, the local police on the beat might have picked up the development of a drug problem in the locality, but not the resulting change in parental behaviour with their children that had resulted. This put greater pressure on any unstable family relationships by ‘keeping kids at home’. It was the job of the neighbourhood manager to ensure all the staff who worked in that locality were better informed about the changing reality of living there.

GP Involvement and Patient-Centered Care

You will have noticed that the NHS as an organisation was absent from this. In the 1980s and 90s it was left entirely to the local GPs themselves whether they wanted to work with the neighbourhood teams. Some did and some did not – it all depended on how they viewed their work on health and sickness. Some, as in 2023, saw local social and economic conditions as a crucial part of their practice. Others didn’t. GP involvement was patchy and voluntary but where it happened primary care had a big impact and also learnt about working as a Place.

In 2013 when I was working on the development of practice for the Better Care Fund a lot of this came back. What we didn’t have in 2013 was a strong local authority policy around neighbourhood to push for implementation. The initial motivation that argued for working together between frontline local authority and NHS staff was the money from the joint Better Care Fund: “work together and you will get this working together resource”. This acted as a bigger incentive to the cash-starved local authority staff than the NHS staff at the time (many of whom saw this as their money in any case.)

What I felt was different in these discussions was a different form of motivation. Most of the people in the room were immediate managers of frontline staff. You heard about the life of an 85-year-old woman with multiple long term conditions and the chaos of her experience of the many different people whose task it was to help her outlined (including different nurses coming at the same time, different hospitals demanding the same tests, a complete lack of co-ordination between professionals). We agreed in the end that each older person would need an Excel spreadsheet to keep in touch with their care. Each member of staff in the room knew their bit of this, but very few appreciated how collectively they were imposing chaos on an already frail human being.

Getting the patient ‘in the room’ became a vital part of motivation. When National Voices developed with patients their “I” statements, it was possible to ensure that those statement were in the room all the time. And what was (and has been since) powerful about those statements was the fact they were so moderate and reasonable. Why shouldn’t we be able to ‘only tell your story once’ and why not insist that “I am given information that is relevant to me and which I understand’? When you put these wishes before health and care staff, they feel reasonable; and then, after a few minutes, they feel impossible actually to achieve.

This is what integrated neighbourhood team care is all about. It is people asking for entirely reasonable joined-up care where they are respected as the key to that care. And yet, as things are currently constructed, staff in the various parts of the system feel this is impossible.

The Future of Primary Care: Integrated Neighborhood Teams

Move forward to 2023 and there is a further motivation behind all of our current work on integrated neighbourhood teams. The NHS has recognised that, constructed as it us at the moment, primary care cannot survive the volume of demand that comes from a sick aging population. The phrase used most often in primary care is that people feel overwhelmed. In reality, the current model is being overwhelmed, and if it doesn’t change it will not survive.

Last year’s Fuller Stocktake report made it clear that the three different models in primary care need their own methods of organisations – and for primary care to survive, it will need the strong help that comes from being integrated with a wide range of other services. The current drive for integration comes with the motivation that without help from a wide range of others NHS led primary care will not thrive (and may not survive).

Yes, creating INTs is difficult, but it’s clearly something that the public want and need; and it’s something that the primary care service of the NHS will not survive without.

So let’s get on with doing it.