How can integrated neighbourhood teams (INTs) tackle health and care inequalities? A policy evidence brief

Abstract

The policy challenge

Tackling health inequalities requires sustained, multi-sectoral collaboration across health care, social care, and local and national authorities. Integrated neighbourhood teams (INTs) are increasingly discussed as a key component of an integrated strategy which can increase equity in health and health care – these involve micro-integration of health and care at the neighbourhood level. However, despite their potential, there is currently no evidence-informed approach guiding their design, implementation, and evaluation in relation to health inequalities.

Key evidence to inform policy

There are four key principles for designing and delivering INTs to maximise their impact on reducing health inequalities: 1) locally sensitive, autonomous, and needs-based approaches, 2) trust between health care services and disadvantaged communities, 3) accessible, co-located, multi-sector services for disadvantaged groups, 4) integrated IT systems and information governance.

Further considerations and implications

Further research is needed to establish a robust, equity-focused framework for the implementation and evaluation of INTs. Policy makers and health care leaders should focus on ensuring funding allocation according to local need, fostering community partnerships, co-locating health and social care services, and standardising IT systems and information governance to maximise the potential of INTs to reduce health inequalities.

Highlights

• •Integrated Neighbourhood Teams are a promising model to tackle health and care inequalities through place-based partnerships.
• •Building trust with disadvantaged groups and investing in community engagement are essential for improving health equity.
• •Co-located, accessible services that cover health, social care, and welfare can support the wider determinants of health.
• •Integrated IT systems are important for seamless, coordinated care delivery for all patients.

1. Current policy challenges

Health inequalities are projected to widen over the next two decades, with people in the most deprived areas expected to develop major illnesses a decade earlier than those in wealthier areas [1]. Reversing this trend requires sustained, multi-sectoral collaboration across health and social care services, local and national authorities, and community organisations. In response, in many countries including the UK, national health systems have committed to integrated care models which are widely seen as a way to improve cost-effectiveness, patient experience and outcomes and reduce health inequalities [[2], [3], [4]]. The goal is to ensure equitable access to effective health care services across populations which - more often than not-requires addressing the broader social and economic factors shaping people's lives and health.

Integrated care models require coordination for planning and resource allocation at the strategic level, while multidisciplinary teams working within local communities are needed in the every-day delivery of care. Recent discussions on health systems’ reforms emphasise the need for a more community-based approach, advocating for multidisciplinary models that integrate primary, community, and mental health services at a neighbourhood level [5]. For example, in the UK, integrated neighbourhood teams (INTs) operate as core local networks of existing health and social care services and voluntary sector organisations which attend to local communities of about thirty to fifty thousand people to improve access, continuity and prevention in a collaborative manner [3]. Several areas have already developed integrated neighbourhood teams, but there is substantial variation in their function.

There is increasing recognition that INTs can significantly contribute to health system recovery after the pandemic and the provision of holistic care outside hospitals [3,5]. However, there is still a lack of evidence-informed guidance on how they can contribute to reducing health inequalities. Local evaluations in the UK suggest that most often INTs aim to address the needs of older frail patients or people with multimorbidity and other vulnerabilities [[6], [7], [8]]. However, this evidence has not been translated yet into a comprehensive operational and/or evaluation framework about how INTs can promote equitable care. Here we explore the published literature to identify key principles that should guide the design and delivery of INTs to maximise their potential in reducing health and care inequalities.

2. Approach to collating evidence

This policy brief, draws policy and practice recommendations on what works to address inequalities through INTs based on the most relevant and robust direct evidence or transferrable evidence. We conducted searches across the Living Evidence Maps of the Health Equity Evidence Centre [9], PubMed and grey literature, using combined terms for “integrated neighbourhood team”, “health inequalities” or “disadvantaged groups or areas”, and did some additional snowball searching. Our inclusion criteria covered studies that explicitly described integrated neighbourhood teams or primary care models organised within limited geographical areas or communities. Given the limited availability of studies focusing on inequalities (n = 5) we decided to also include papers that offered useful insights regarding the facilitators and barriers to effective integrated neighbourhood or community care teams, even if they did not focus on inequalities (n = 17). This resulted in 22 studies included in our synthesis which was conducted narratively across four themes as presented below.

3. Key evidence to inform policy and practice

We identified four key principles that should guide INTs' development to support disadvantaged groups (Fig. 1). Adhering to these principles can maximise INTs’ potential to address health and care inequalities.

Fig. 1.

Overview of reducing inequalities through Integrated Neighbourhood Teams.

3.1. Locally sensitive, autonomous, and needs-based approaches

Strategies sensitive to local needs within communities are the key starting point for delivering equitable care [10,11]. Given their focus on neighbourhoods (i.e., administratively defined local populations at which multidisciplinary teams coordinate integrated and preventative care across health, social, and community services), INTs are well-positioned to understand and address the needs of their catchment areas and promote tailored interventions to the groups that experience disadvantage and unmet needs in the specific context. Developing a locally sensitive approach and context-specific strategies to address inequalities requires some autonomy. INTs need autonomy to independently identify groups who experience health and care inequalities, set priorities, define desirable outcomes and relevant indicators, and determine resource needs and allocation. With some autonomy to adapt their services to specific neighbourhood contexts, INTs can provide more flexible models of care with variations in day-to-day operations, workforce composition, and communication modes. A review of health inequalities interventions in primary care showed that flexibility is a key principle of equitable care because it improves access and engagement with services [11] especially for disadvantaged groups who experience a combination of practical and psychosocial barriers in navigating health services.

However, while autonomy is essential, a broader framework to ensure consistency across different teams and meaningful evaluation needs to be available [8]. Balancing local autonomy with alignment to national health inequalities frameworks (e.g., the Core20PLUS5 framework in the UK [12]) is crucial for optimising the effectiveness of INTs in addressing health and care inequalities across diverse neighbourhoods but also for keeping professionals engaged with INT care models [6]. Additionally, ensuring that best practices and insights are shared across different teams, through knowledge exchange initiatives among service providers, communities, and decision-makers, can help build a living evidence base to inform INT design and implementation [6,8].

Autonomy in implementation is not possible without flexibility in resource allocation and importantly funding distribution proportionate to local need. Research demonstrates that allocating health care resources based on need can reduce health inequalities, particularly in avoidable mortality [13]. Further, emerging evidence from a study on a new district nurse staffing model shows that currently, workforce distribution often correlates more with the age of people living in a certain area. However, the authors demonstrate that more equitable workforce distribution can be achieved by accounting for key predictors of need beyond age, including deprivation levels, chronic conditions, mental health status, and living conditions [14]. A shift towards needs-based workforce allocation at the neighbourhood level has the potential to ensure that care models can be tailored to local groups including those most disadvantaged and reduce health inequalities.

3.2. Trust between health care services and marginalised communities

Equitable health care is most achievable when all stakeholders—health care professionals, patients, families, and communities—actively engage in care design and delivery [11]. A realist review of health inequalities interventions in general practice emphasises that addressing the needs of disadvantaged populations requires fostering a sense of community where marginalised individuals have a voice in decision-making and care delivery [15]. However, meaningful engagement is only possible when there is trust between health care services and the communities they serve. Evidence from US studies shows that autonomy in the design and implementation of neighbourhood teams, apart from having the benefits discussed above, it also fosters a sense of trust between service providers and users, particularly among disadvantaged groups who find it challenging to engage with impersonal services and institutions [8].

The COVID-19 pandemic reminded us, among other things, the critical role that trust in health care services plays for engaging disadvantaged groups with services. The strategies used for tackling vaccine hesitancy among ethnic minority groups and disadvantaged populations demonstrated this quite accurately [16]. We saw how general practitioners (GPs) who were trusted in their communities and were willing to collaborate with local faith and grassroot leaders achieved the best results in increasing vaccination rates [17]. Such evidence echoes research from the US showing that relationships of trust between service providers and users increases engagement as it enables shared priority setting and decision making, which in turn ensures the tailoring of care models to the needs of disadvantaged groups in the neighbourhood [18]. For example, a qualitative study involving focus groups with 100 participants from African American and Latinx communities revealed that trust and open dialogue enabled marginalised patients to express the social barriers they faced in accessing care and managing their health [19]. This in turn translated into providers understanding better the needs of those patients and promoting more tailored solutions [19,20].

There are several evidence-informed strategies to build trust and promote meaningful engagement with disadvantaged communities in neighbourhood-based health care which include [[18], [19], [20], [21]].

• •Proactive outreach through direct engagement in patients' living environments.
• •Delivering preventive services in familiar and accessible community venues.
• •Ensuring relational continuity in general practice to foster long-term relationships.
• •Conducting individual interviews in safe and familiar settings.
• •Facilitating group-listening sessions, led by trusted community members.
• •Collaborating with community groups (e.g., faith organisations, and charities).
• •Involving family members and informal caregivers in health care.
• •Regular attendance of health care providers at community events, local forums, and networks.

3.3. Accessible, co-located, multi-sector services for disadvantaged groups

Proximity and co-location of services are key features of INTs which can improve service accessibility for disadvantaged populations [3]. Research indicates that co-locating complementary health services—such as specialty mental health care within primary care—alongside social welfare and legal advice services significantly improves care access and engagement among disadvantaged patients, particularly those from lower-income and minority ethnic backgrounds [[22], [23], [24]]. Additionally, co-located services enable the comprehensive assessment of patients’ unmet health and social needs which is key for holistic person-centre care models [[18], [19], [20],22].

Co-location reduces the practical barriers to accessing care, making it easier for patients to access available services [[23], [24], [25]]. Importantly, it also minimises stigma associated with the use of certain services (e.g., mental health care or legal aid). Evidence suggests that embedding mental health services within community settings creates non-judgmental environments, reduces stigma and increases engagement for disadvantaged groups [26,27]. As a result, accessible co-located services that account for the material and psychosocial needs of patients with complex needs can improve service utilisation and adherence to care plans. As evidence shows these elements eventually contribute to better health outcomes for vulnerable patients [[23], [24], [25]].

Beyond health care, the integration of welfare and legal aid services within primary care has been found to improve mental health and psychological well-being, with evidence showing reductions in depression, anxiety, sleep disturbances, and substance misuse among disadvantaged patients [25,28,29]. Additionally, these services directly address the social determinants of health as they enable access to benefits and social support and have both direct and indirect positive impact on patients’ living conditions [28]. Qualitative studies on INTs emphasise that bi-directional referrals within these teams enhance service delivery by ensuring seamless support. They also improve patient experience, with service users appreciating having qualified professionals advocating for them in the system [18,22]. Co-located services can also benefit INT health care professionals by creating opportunities for knowledge exchange and increasing their capacity to address social determinants of health [28,29].

However, studies highlight that professional and social hierarchies within INTs can create tensions. For example, an evaluation of INTs in the UK showed that social care staff reported feeling overshadowed by health care professionals, while community service providers reported feeling neglected by acute care teams [8]. Further, differences in terms and conditions between different professional groups often hindered collaboration and integration. Addressing such challenges requires cultivating psychologically safe environments where members of staff feel empowered to address the power dynamics within their teams, and promoting ways of communication that accommodate diverse professional needs [8,15]. Strengthening local networks which involve primary care providers, social workers, and civil society organisations, while emphasising shared ownership and participation, can also contribute to building mutual trust and respect among professionals [21].

3.4. Integrated IT systems and information governance

The effectiveness of INTs and consequently their potential to reduce health inequalities rely heavily on well-functioning, accessible IT systems and coherent information sharing across providers and sectors. Evidence from two large review studies of primary care interventions highlights the importance of comprehensive and up-to-date patient registers which cover both health and socio-demographic data [10,15]. Such records are essential for identifying individuals with unmet needs and enabling systematic flagging of those vulnerable to health inequalities, particularly for improving prevention and long-term condition management [10].

Information should be effectively shared among professionals within INTs. This requires robust, integrated IT systems that facilitate communication across sectors - including primary care, specialist services, and social care – and ensuring that all providers within an INT can comfortably access and use these systems [8]. Fragmented information and duplicated administrative tasks can result in gaps in care, disproportionately affecting disadvantaged patients. For example, asking vulnerable patients to repeatedly share their medical and social history or complete multiple forms increases the risk of disengagement and unmet needs [6,28]. This is why ensuring that care within INTs is as seamless as possible is particularly crucial for reducing health inequalities.

Finally, supporting vulnerable patients often involves navigating safeguarding and risk assessment processes. When information governance protocols are inconsistent, INT staff may feel uncertain regarding patient confidentiality, which can make them hesitant to access, share, or request necessary data. This can delay care delivery with detrimental impacts to both patient engagement with care and to their health [10]. Addressing these challenges requires clear, shared information governance frameworks that account both for patient privacy and the need for coordinated, high-quality care.

4. Further considerations and implications

Our findings suggest that INTs have a great potential to contribute to more equitable models of care provided they operate with a locally sensitive approach, cultivate trust with the communities they serve, and deliver accessible multi-disciplinary care integrated both across physical space (co-location of services) and digital infrastructures (integration of IT systems). These principles require critical reflection on governance arrangements and power organisation within INTs but also within broader local health systems. Funding allocation based on local needs, shared decision making among INT professionals and between professionals and communities, and shared information governance, all entail decisions at multiple organisational levels. They also require an inclusive, collaborative culture and staff who are capable of and empowered to engage meaningfully with professionals from different sectors and disadvantaged service users. Placing communities at the centre of INTs’ mission and renegotiating power relations among service providers is key for equitable primary care [11]. However, more research is needed to understand how governance arrangements and power dynamics are enacted in practice, how they are negotiated across organisational boundaries in different contexts, and how they can best translate into equity improvements.

4.1. Limitations of current evidence

INTs are an emerging care model, and therefore the evidence base is still limited. The findings discussed are drawn from international academic literature and UK-based reports that describe various INT models. As a result, while some key principles have been identified, further research is needed to develop a robust, evidence-based framework for the equitable design and implementation of INTs.

4.2. Recommendations for policy and practice

Based on the reviewed evidence, policy makers and practitioners should.

• 1.Ensure funding distribution is proportionate to local needs by developing effective resource allocation models at the neighbourhood level.
• 2.Collaborate with community partners to identify groups with unmet needs and tailor interventions accordingly.
• 3.Commit to trust-based relationships between health care services and marginalised communities, ensuring shared decision-making on health priorities and interventions.
• 4.Implement national guidance on accessible general practice registration and develop flexible access pathways tailored to local populations.
• 5.Co-locate primary care and mental health services alongside social welfare and legal advice to improve service accessibility and coordination.
• 6.Establish standardised information governance frameworks and invest in IT infrastructure and staff training to facilitate effective data sharing within INTs.

Ethics statement and consent to participate

Not applicable, as this study is based on a literature review and does not involve human participants.

Consent for publication

All authors have reviewed and approved the final manuscript for submission.

Availability of data and materials

The data supporting this article's conclusions are available in the referenced studies.

Authors' contributions

AG, LM and JF conceptualised the study. LL, EC, ADL, SE, CG, AGh, and PT provided contextual input on care models and supported interpretation of findings. AG, LM and JF led the writing with contributions from all authors. All authors approved the final manuscript.

Disclosure statement

This report is independent research supported by NHS England. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS England or the Department of Health and Social Care.

Funding

This review was commissioned by NHS England.

Declaration of competing interest

The author is an Editorial Board Member/Editor-in-Chief/Associate Editor/Guest Editor for this journal and was not involved in the editorial review or the decision to publish this article.

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: This report is independent research supported by the National Institute for Health and Care Research ARC North Thames and NHS England. The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health and Care Research, NHS England, or the Department of Health and Social Care.