1. Integrated working- Integrated Neighbourhood Teams &
Neighbourhood Networks
Nic Roper, Area Manager- Suffolk County Council

2. What’s the background?
Long standing knowledge that integrated care will provide a better health and care system for people – but in East and West Suffolk partners were struggling to make this a reality at scale
The Health and Care Review – started in December aimed to create a shared view of a future integrated system
The vision and service model has been signed up to by all partners, and has informed the Suffolk Better Care Fund Plan
Partners are now committed to delivering the new model of care – Connect Sudbury and Connect East Ipswich are the forerunners for the new system
2 main building blocks for integrated working in Suffolk: Neighbourhood Networks & Integrated Neighbourhood Teams

3. The Neighbourhood Network: a person’s support network
Community Groups
Employment
Neighbours
Clubs
Local Shops
Schools
Family
Local Services GP
Friends
Integrated Neighbourhood Team (INT) –
multi agency team
Church
Supporting the individual to remain healthy, active and engaged in their community

4. Integrated Neighbourhood Team (INT) –
Local Shops
Integrated Neighbourhood Team (INT) –
multi agency team GP

5. Neighbourhood Network aspirations
Information- Good clear, easily accessible local information, supporting independence, self reliance, confidence and self-care
Connectedness - Easy or supported access for individuals to connect with others. Good knowledge within organisations about others
Age and disability friendly communities- Accessibility to employment, services and leisure opportunities etc
Voluntary and Community Sectors- Thriving, supportive alliances of local voluntary sector organisations. Well known and well used local groups and activities
Behaviours- No wrong door; widely adopted strengths-based approach; warm handovers; respect between people and organisations within a person’s Neighbourhood Network and statutory services for knowledge and skills held

6. Developing community capacity- what’s already happening?
Local networking events
Dementia Friendly Communities
New Infolink website:
Voluntary and Community Sector scoping
Introduction of Local Area Coordination
Community pharmacies
Community Safety
Health and Wellbeing Board and voluntary sector partners’ campaign to reduce social isolation and loneliness across the age range

7. The Neighbourhood Network & the Integrated Neighbourhood Team
Community Groups
Employment
Neighbours
Clubs
Local Shops
Schools
Family
Local Services GP
Friends
The people and places that keep people resilient and happy.
Where NN overlap – communities of interest
Church

8. The Integrated Neighbourhood Team
Early intervention
Local Area
Co-ordinator
VCS
Self Management
CYP
Prevention
District/ Borough Council
ACS GP
Primary care
Suffolk Community Health
Home First
Police
Housing
Interface Geriatrician
Mental Health
Person centred
Getting to know each other:
INT Directory
Workplace shadowing
Life Timeline tool
INT Toolkit

9. The Community Health & ACS Social Care part of the team
Early intervention
Local Area
Co-ordinator
CYP
Self Management
VCS
Prevention
District/ Borough Council GP
Primary care
Home First
ACS/ Suffolk Community Health
Police
Interface Geriatrician
Mental Health
Housing
Person centred
Key deliverables for Health & ACS:
Tight integrated partnership which is co-located with shared processes, changing business as usual
IT pilot but also interim tactical solutions for joint assessments, single plans, single view/ accountable worker
Generic skill bases
Operational Manual

10. Creating opportunities for wider integrated working-
an Enhanced Health & ACS MDT….
Housing
VCS
MDT Co-ordinator GP SW
District Nurse
Community Matron OT
Physio
Mental Health Link Worker
Practice Staff
Home First
CYP
Local Area Co-Ordinator
Police
District/ Borough Council
Creating enhanced MDTs:
Learning from the best
Effective Risk Satisfaction/ case finding

11. … possible other wider Enhanced MDTs
MDT Co-ordinator GP SW
District Nurse
Community Matron OT
Physio
Mental Health Link Worker
Practice Staff
Police
Mental
Health
ACS
Ambulance Service
CCG
ACS
GPs
High demand families
Health & ACS MDT
Care Homes
Learning from the ACS & Health Enhanced MDT
Hot desking opportunities
Co-location opportunities
Integrated Learning Sessions
Data sharing protocols

12. Phased implementation
Health & Social Care integration
INT Directory
Workplace shadowing
Operational manual
INT Toolkit
Co-location
Hot desking
Learning sessions
IT pilot
MDTs
GP Practice 1
GP Practice 2
GP Practice 3
GP Practice 4
GP Practice 5
Wider multi agency integration