Integrated Neighbourhood Teams in Nottingham City
The story so far…
Since 2022 Nottingham City Place Based Partnership has been working to provide care centred around the individual and address the wider determinants of health and wellbeing across a neighbourhood footprint. This Integrated Neighbourhood Working has brought partners together to improve the co-ordination of services for people. As part of that work, the aim now is to spread Integrated Neighbourhood Working across all of Nottingham and Nottinghamshire’s Primary Care Networks and neighbourhoods in the form of Integrated Neighbourhood Teams. In the city we have launched Integrated Neighbourhood Teams or INTS, to support those people with the most complex health and care needs.
What is an Integrated Neighbourhood Team?
An Integrated Neighbourhood Team (INT) brings together partners, working collaboratively to provide person-centred care, improve the co-ordination of services, and to address the wider determinants of health and wellbeing across a neighbourhood footprint. An INT will support people with the most complex health and care needs.
Some members of the INT may operate on a smaller footprint within a neighbourhood. This will be locally determined, considering Primary Care Network (PCN) structures and building on the existing integrated working within communities.
Who is in an Integrated Neighbourhood Team?
Members of an Integrated Neighbourhood Team may include – but is not limited to : people working in physical and mental health services (including GP surgeries, community nurses and therapists, pharmacists, optometrists, dentists, acute specialists, local mental health teams), care navigation services, social care, local councils, local voluntary and community groups, housing and employment services, domestic violence support services, police, fire and rescue.
Proposed Governance: Neighbourhood Health and INT Programme
INT Governance Structure and Workstreams – The INT governance structure below has been designed to provide clear accountability, transparent decision-making, and strong collaboration across all services. By aligning clinical leadership, operational oversight, and community-based support, the structure ensures that patient care is delivered safely, effectively, and consistently.
The governance model supports our INTs in working across organisational boundaries, enabling us to respond to the needs of our identified patient cohorts with a unified approach. It establishes clear lines of responsibility, promotes multidisciplinary input, and ensures that strategic priorities are translated into everyday practice.
Dr Andy Foster GP Partner and Deputy Clinical Director, Nottingham City Place Based Partnership will be leading on developing the INT outcomes, gathering insights from staff, patients and partners to evaluate the INTs. Your insights will help us to develop and measure the success of the INTs and continually improve the outcomes and benefits INTs deliver.
Seven workstreams are currently underway to support the INT roll out:
Pathfinders
Cohort implementation
Workforce organisational development
Estate
Digital
Co-production
Communication.
INTs: Cohort data
The City Place Team is working with the System Analytical Intelligence Unit (SAIU) and health data analysists to develop an algorithm to identify a cohort of patients aged 55+ with the most complex needs and who place the greatest demand on healthcare services and would benefit most from an integrated neighbourhood team approach. The cohort is likely to evolve as the programme develops.
The patient cohort was prioritised based on the segments below and data packs have been developed to breakdown the cohorts through utilising demographical data.
The following patients will be invited into the INT:
1. End of Life and Organ Failure
2: Frailty or Dementia (excluding End of Life)
3: Patients with three or more long-term conditions
In addition to this, they have had:
Three or more GP appointments within the last three months AND
One or more emergency admissions within the last 12 months AND
Are under the care of CityCare Community Matron, Community Nursing or Community Falls and Rehab Service AND
They are not a permanent care home resident.
The INT will target an interim cohort of patients with complex needs who are most likely to benefit from enhanced community-based interventions, therefore the INT aims to deliver coordinated, person-centred care that reduces hospital admissions, promotes independence, and improves quality of life.
The cohort model will be developed through a phased approach, informed by feedback from INT triage and MDT panels, and enriched with social care data.
Proactive Care Integration
In addition to the cohort identification, we will be identifying patients within these cohorts who are linked to the Proactive Care LES. Early analysis shows approximately 110 patients across pathfinder sites currently receiving proactive, personalised support. This approach helps prevent health crises, maintain independence, and improve outcomes, shifting from reactive care to proactive management. These insights will be central to reviewing and refining INT patient cohorts and work is taking place to analyse if these patients will be a definitive criteria within the cohort identification process.
National Neighbourhood Health Improvement Programme
Nottingham City has been chosen alongside 42 other areas by the Department of Health and Social Care and NHS England to participate in the first wave of the National Neighbourhood Implementation Programme (NNHIP).
Led by the Nottingham City Place-Based Partnership, partners will trial new neighbourhood systems for health and care delivery. The programme, which will eventually be rolled out across the country, will initially focus on supporting adults living with multiple long-term conditions.
While NNHIP does not come with new funding, it will provide access to valuable resources including a dedicated national coach, subject matter experts, three regional workshops, and a knowledge hub for peer-to-peer learning.
The implementation of Neighbourhood Health Services is expected to support government ambitions to shift care delivery away from hospital settings, make better use of digital tools instead of traditional analogue processes, and shift the focus from treating sickness to preventing it.
Amanda Sullivan, Chief Executive of Nottingham and Nottinghamshire Integrated Care Board said: “This is fantastic news for Nottingham and the Nottingham City Place-Based Partnership.
“Being accepted onto the National Neighbourhood Health Implementation Programme, means Nottingham will be at the forefront of testing and shaping new neighbourhood systems.
“It will provide access to valuable resources which will help us strengthen our neighbourhood approach and establish Neighbourhood Health Services that will deliver the best health and care services for people living in Nottingham.”
“Making better use of digital tools lifts the administrative burden off staff, freeing up more time for clinical care, and shifting the focus from treating sickness to preventing it builds an all -round healthier society.
“Through this programme, we will work with national teams to test neighbourhood health systems, particularly to support adults living with multiple long-term conditions.”
Introducing our National Neighbourhood Improvement Programme coaches
Ian Razzell
Ian has joined us as the national coach for the NNHIP, and brings with him a wealth of experience which includes transformational change and organisational development. He has worked in health, education, and with local authorities, and recently worked with 10 integrated care boards and across general practice to support transformational facilitation and improving patient access.
He said: “I’m delighted to join the Nottingham City Neighbourhood Health Programme as its national coach. With a voluntary sector, local authority, health and social care and population health background that spans 40 years, I am looking forward to working across all groups and partners to identify innovative ways of working as a neighbourhood-focused team of teams.”
Manik Arora
Manik will be working together with Ian to bring together teams from across the health, social care and the community, and help shape what neighbourhood health looks like nationally. Manik said he believes that Nottingham’s selection to take part in the NNHIP shows that the city is ‘serious’ about changing how people’s health and wellbeing is supported.
“Out of 141 applications from across England, Nottingham has been chosen and that feels brilliant,” he said.
“This programme is about something simple but powerful – putting communities at the heart of what we do. Instead of telling people what they need, we’re asking ‘what matters to you?’ and working together to make it happen.”
Over the next 12 months, Manik said he will be getting support from Ian to bring together teams from across the health, social care and the community, and help shape what neighbourhood health looks like nationally.
He said: “This isn’t about following a rigid plan. We’re building on what already works well in Nottingham, testing new ideas and creating real relationships with the people we serve.
“It’s a chance to be a part of something bigger – a movement to shift care closer to home and focus on keeping people well, not just treating illness.”
Get involved in the Nottingham City Neighbourhood Health Group
Nottingham Neighbourhood Health Group
A special Linkedin group has been set up for those involved, or interested, in Nottingham’s journey as part of Wave One of the National Neighbourhood Improvement Programme.
The group is platform where we provide updates on Nottingham’s NNIP projects and milestones, examples of what is working in local communities, and the opportunity to connect with colleagues, partners and community members who are all passionate about driving change.
Integrated Neighbourhood Teams newsletters
Find out more about Integrated Neighbourhood Teams in Nottingham
Listen to our series of podcasts about the introduction of Integrated Neighbourhood Teams and what it could mean for people in the City.
Join our Nottingham City Neighbourhood Group on Linkedin to get involved in the heart of Integrated Neighbourhood Team discussion and development.
Nottingham City has been chosen as one of 43 areas across the country to take part in the first wave of the National Neighbourhood Implementation Programme.
The Nottingham City PBP is part of the Nottingham and Nottinghamshire Integrated Care System (ICS).
We will work together to create happier, healthier communities
and reduce the gap in healthy life expectancy across
Nottingham city.
