Over a year since its launch, the dementia integrated neighbourhood team (INT) has seen many benefits from bringing different agencies together to coordinate support and improve outcomes for patients.

People living with dementia often need a range of support, but GP practices typically field referrals and messages between different services, even when medical intervention is only a small part of patients’ needs.

Dr Jess Harvey, Clinical Director for the South-East Shropshire Primary Care Network (PCN) and local GP, explained: “This complicates things and isn’t the most streamlined journey for the patient. The INT brings all those different parts of the puzzle together to enable a personalised care plan for people who are having difficulty or just need extra support.”

Integrated teams are one of the ways our ICS is working to promote preventative healthcare and tailored support as we make the shift towards neighbourhood health; bringing health services, resources and support closer to the communities where people live in line with the Government’s 10-year plan for the NHS.

Taking a neighbourhood approach to health and care, regular meetings include representatives from adult social care, memory and dementia teams, Admiral Nurses, link workers from the Alzheimer's Society, and General Practice Care Coordinators. Others such as district nurses, informal carers, relatives and voluntary sector organisations also join when needed.

Communication has improved between the meetings, reducing the need for frequent sessions. Job satisfaction has risen, as colleagues see the impact of their interventions; with the right partner taking the right action, at the right time, to help the patient stay happy, healthy and connected in their community.

Dr Chandan Aladakatti, Psychiatrist within the Crisis and Home Treatment Team and Medical Lead for Shropshire Care Group at Midlands Partnership University NHS Foundation Trust, ​said: “The beauty of three systems coming together is you have all the information you need and the right people involved to make decisions... and there is no duplication.”

Jess shared the case of a woman living alone with no family nearby: “Neighbours had been providing most of her care but couldn’t continue this arrangement after incidents like her being found wandering outside, and a pan fire in the house. The INT came together – adult social care assessed her case, the memory team reviewed her, a nurse made sure that everyone else was supported… She was placed into respite care and then got a long-term placement closer to her family. Together we found the best outcome without needing input from secondary or primary care.”

“We relate better with patients when we meet and talk about their needs,” added Chandan. “I remember a case where medics were not part of the INT but it was clear that some medical aspects were creating a block. The GP and the Psychiatrist were invited to another meeting to clarify what should happen next for this patient. And just that one meeting saved the referrals and the time gaps. It enabled the neighbourhood team to come up with a care plan.”

Jess concluded: “It’s more efficient and effective, provides a better experience for patients, carers, families, and health professionals. We've halved A&E admissions for patients presenting with dementia. It shows that when the right people act at the right time, it doesn't increase workload for any of the INT partners. Ultimately, we’ve created a blueprint for a nationwide approach.”

For further information, you can watch a video about the Dementia INT below or on YouTube.