Celebrating collaborative working within Integrated Neighbourhood Teams in Westminster and Kensington and Chelsea

Our teams working in the bi-borough partnership in Westminster and Kensington and Chelsea have been working collaboratively with various partners to deliver better outcomes and improve health and care services for the communities we serve.

The landscape of NHS services is changing the bi-borough partnership of Westminster and Kensington and Chelsea, which has resulted in the development of three Integrated Neighbourhood Teams (South INT, North INT and Westminster INT).

Integrated Neighbourhood Teams (INTs) work collaboratively to support services to provide care in a more integrated way across health, social care and public health.

The INTs include GPs, district nursing, voluntary sector organisations, the local authority, as well as many other organisations and services that provide specialist help and support if needed.

Working as part of INTs ensures that we provide the best care to our patients by:

• Streamlining access to care and advice, providing more choice about how they access care and ensuring it is always available in their community when they need it.
• Providing more proactive, personalised care with support from a multidisciplinary team of professionals for patients who may have more complex needs.
• Helping patients stay well for longer as part of a more ambitious and joined up approach to prevention.

The South Integrated Neighbourhood Teams (SINTs) currently includes CLCH, Age UK, West London GP Federation, the Royal Borough of Kensington and Chelsea, and Brompton Health and Kensington & Chelsea South Primary Care Networks. The SINTs help to deliver preventative care at a neighbourhood level, by sharing resources and information.

They have adopted a population health management approach including risk stratification to gain a deeper understanding of the resources in local communities and to deliver co-ordinated care at a local level, recognising the expertise from diverse health and social care professionals. They have been instrumental in multi-disciplinary team (MDT) working to deliver better outcomes, whether it is site based or virtual. The Digital Frailty MDT is an example of this and the work the team have done was shortlisted at the 2023 Nursing Times Award.

To mark the fantastic work that the team have been doing, they held an end of year celebration event to reflect on how collaborative work has helped to improve services across frailty, mental health, and deprivation.

Zaby Begum, PCN Clinical Lead – Brompton Health at CLCH, said: “It is fantastic to see partners coming together to deliver care in such an integrated way to improve patient care and their experience. I am very proud of everyone involved.

“The SINTs have set up shared objectives and priorities on social isolation and loneliness. The teams look forward to continuing their work to engage with even more partners and colleagues across the SINTs to improve patient access and care by tackling health inequalities in the local community in the new year.”