Integrated Neighbourhood Teams - What Are They and Why Are They Important?

An Integrated Neighbourhood Team (INT) is a multi-disciplinary team approach across health and social care that delivers coordinated holistic care, catered to the individual, within a specific community or neighbourhood.

The 10-Year Plan defines these teams as a mixture of GP professionals, community nurses, mental health clinicians, adult social care staff, and partners in the voluntary sector. Leadership teams typically include a neighbourhood lead, social care lead, nurse lead, health development coordinator, and GP lead, with some teams also including local residents to ensure genuine community voice in decision-making.

Through co-production, INTs ensure care is tailored to individual needs whilst avoiding duplication of efforts and ensuring smoother transitions across health, social care, and community services.

INTs perform a variety of functions to provide comprehensive care across the community, including holistic assessments, care coordination, preventative care, chronic disease management, rehabilitation services, mental health support, social care support, medication management, health education, palliative care, crisis intervention, and community engagement.

These services deliver better joined-up front-door care navigation to ensure no population is left vulnerable or underserved, focusing on the individual's whole needs not just their health. By acknowledging the wider social determinants of health across the community, INTs offer better facilitated early intervention to prevent further health and wellbeing decline.

The table below demonstrates some of the ways INTs work and the services they provide: 

The 10-Year Plan addresses capacity pressures through what the NHS calls "the left shift" - the movement of activity out of hospitals to care delivered closer to home. This shift proves particularly valuable for people with long-term conditions such as frailty, heart disease, or respiratory issues like COPD, who account for nearly 70% of hospital stays.

Delayed discharges continue to present significant capacity challenges, with 272,283 bed days lost in December 2024 alone as 13.3% of patients were not discharged when they should have been. INTs help address this by providing the coordinated community support that enables people to return home safely and remain independent.

INTs enable communities to improve outcomes, create sustainable and high-quality care deliveries, and improve quality of life by increasing accessibility to services across a local authority. This person-centred approach to care improves health outcomes whilst supporting the needs of vulnerable populations.

Proven Impact

Real-world evidence demonstrates measurable benefits:

• Derbyshire Integrated Neighbourhood Teams avoided 2,300 ambulance callouts through better support for elderly people living at home.
• Seacroft Local Care Partnership in Leeds reduced emergency hospital admissions by 25% through improved frailty support.
• East Staffordshire PCN saw a 26% reduction in clinical interventions for those supported by social prescribing.

Prevention and Early Intervention

The 10-Year Plan emphasises working more closely with social care, housing, education, and voluntary, community, and social enterprise (VCSE) organisations to support people before their needs reach crisis point. This local insight represents what the Plan calls a "superpower" - enabling co-design of services with communities rather than for them, reducing health inequalities through locally-tailored solutions.

Cost Effectiveness

Research demonstrates impressive returns on investment:

• Public Health Wales research published in the British Medical Journal showed preventative health interventions return £14 for every £1 invested.
• Ways to Wellness demonstrated that an earlier investment of £491 per family avoids £8,795 cost to the healthcare system and £34,811 cost to the public sector and wider society.

Neighbourhood Health Centres serve as regional hubs for multidisciplinary care, bringing services under one roof where possible and operating 12 hours a day, six days a week - including evenings and weekends. This improves accessibility whilst reducing reliance on acute services.

The expansion of virtual wards and remote monitoring models is central to driving both the community shift and the shift to digital. As of March 2025, there were 12,825 virtual ward beds in England - an increase of 11,856 beds from March 2024. Virtual wards saved services over £50m in the last year and kept over 15,500 people out of hospital.

Despite their benefits, INTs face challenges including ensuring effective collaboration across diverse professionals, overcoming varying professional cultures and differing priorities, seamless integration between sector systems, and demonstrating effectiveness through clear metrics.

The 10-Year Plan acknowledges that delivering this shift at scale requires sustained investment, digital enablement, and significant boosts to the community workforce. Local systems such as Integrated Care Boards will be held accountable through delivery plans emphasising outcomes over activity, with progress monitored via metrics tracking community capacity, unplanned hospital use, and patient-reported experiences.

The government's guidance explicitly states that multidisciplinary neighbourhood teams must incorporate social prescribing as part of personalised care offerings, recognising that factors driving poor health often sit outside conventional NHS reach.

Both INTs and social prescribing are complementary strategies aiming to provide holistic care by addressing medical and social determinants of health within local communities through collaborative approaches, community engagement, and effective use of resources.

Investing in technology solutions enhances INT effectiveness by improving workflows, streamlining care navigation, and enabling better outcomes.

Electronic Patient Records and Integrated Care Platforms

Access Rio EPR provides the foundational infrastructure for comprehensive, longitudinal patient records, supporting the 10-Year Plan's commitment to a Single Patient Record. The system centralises patient information, enabling better coordination amongst team members whilst managing both administrative and clinical processes.

For multidisciplinary teams needing to see the same information at the point of care, Access Intelligent Care Platform (AICP) provides unified views across multiple Rio systems with real-time data access, comprehensive patient search capabilities, and secure data sharing.

Social Prescribing Integration

At Access, our Elemental social prescribing software is fully interoperable with leading clinical software, social care case management software (Access Mosaic), and third-party solutions to improve communications and collaborations across INTs. All stakeholders have access to information in one centralised place, avoiding duplication whilst allowing more time for co-producing social prescriptions aligned with wider care plans.

Our Marketplace module creates a fully up-to-date directory of services highlighting support groups and interventions available across communities. Integration with Access Rio EPR ensures social prescriptions align with patients' overall care plans by providing access to patient records.

Additional Technology Benefits

Technology solutions also enable:

• Telehealth services for remote access and specialist collaboration
• Streamlined workflows ensuring accountability and timely information exchange
• Population health management to identify at-risk populations
• Online training to improve working culture and stakeholder engagement

The 10-Year Plan has elevated INTs from an emerging model to the default approach for delivering community-based support. This isn't about reducing standards - it's about re-centring the system so care happens where it makes the most difference, empowering patients to receive care in familiar environments, supported by professionals who understand their circumstances.

At Access Elemental Social Prescribing, we know the importance of collaboration and co-production to tackle health inequalities across communities. Our software is fully flexible and interoperable with multiple systems, enabling you to manage referrals effectively and offering a centralised place to store, manage, and analyse data for better data-led decisions.

For more information on how our social prescribing software can improve co-production within your INT, contact us today.

Let us show you first-hand how we can streamline your front-door services to improve care navigation as well as help you utilise available funding opportunities to improve your services further across your INT.