Integrated Neighbourhood Teams

Neighbourhood Health in Camden

In August 2025, CHP, CHE and UCLH were nominated by the Camden Partnership Board (CICE) to be the integrator for Camden. In September, we were confirmed by the ICB as the integrator for Camden.

On 2 December 2025, we hosted our first borough workshop, on the next steps for neighbourhood development. Over 70 people attended from neighbourhood teams, voluntary sector, primary care champions, PCN directors, general practice and partner members from CICE, neighbourhood delivery group and operational neighbourhood leadership group.

Priority workstreams for 2026/27 Q1 and Q2

Mobilsation of INTs

• Develop a methodology to indentify and pathways to support patients across Camden by neighbourbood, who have long-term conditions and are known to multple organisations
• This is Phase 1 of the INT mobilisationm which will expand to other cohorts over

Optimising out of hospital, proactive services

• Mapping of existing sevices provided within the community, such as Virtual Wards/Hospital at Home, Anticipatory care, Rapid Response etc to expand understanding of the available services and where suitable increase equity of access. Initial focus is mapping

Community Gynaecology

• Creation of Community Gynaecology service in line with the current service specification used in the wider NCL.
• This will support delivery of community gynaecology services for Camden residents.

End of Life Care

• Mapping of existing services for residents and patients in their last year of life.
• Transform patheways to support delivery of key framework outcomes relating to end of life patients, including reduction in emergency admissions and improved patient experience.

To be scoped in Q2

Homelessness

• Map existing services for Homelessness people across Camden and ensure clarity between remits
• Reduce non-elective activity for this cohort of patients and increase preventative health and wellbeing access

Children and Young People

• Map existing services for Children and Young People and their families.
• Renew the framework outcomes for CYP services including reducing outpatients in acute services, improving outcomes and ensuring young residents start well in life.

The Camden Partnership Board (CICE) is made up of representatives from Camden Council, all NHS Trusts who provide services in Camden, Camden voluntary sector representatives, CNWL (community services), North London Foundation NHS Trust (mental health services) Royal Free London and University College London Hospital (acute services) and the two GP Federations in Camden CHP and CHE. CICE oversees the integration work.

This ‘team of teams’ includes the GP practices with patients in the East neighbourhood, along with mental health colleagues and voluntary sector partners. CHP has been closely involved in planning to set up such teams in all five Camden neighbourhoods.

CHP plays a central role in the Camden local partnership. CHP's chair, Dr Alex Warner is Vice Chair of the Camden Integrated Care Executive, the integrated steering group and plays a pivotal role in the coordination of the East INT Group, Camden’s first test and learn integrated neighbourhood team.

Achievements between April 2024 and March 2025 included:

• Bedding down the five aligned neighbourhood teams of adult community nursing and social care
• An estates strategy for the five neighbourhoods recognising the challenges of very limited available community space in Camden
• Four primary care clinical champions to neighbourhoods: East, North, South, and West Camden
• Working with Camden council to establish new joint health improvement clinical leads starting with stop smoking

East INT: progress between April and March 2025 included:

• Identifying change champions in all the organisations coming together as the East Integrated Neighbourhood Team, preparing colleagues from different backgrounds and organisational cultures and agreeing opportunities for change, in readiness for;
• Launching as the East INT in the Kentish Town Health Centre in October 2024
• Using a ‘test and learn’ process to establish which interventions were helpful bringing the new team of teams together and in improving the efficiency and staff satisfaction in working together
• Facilitated discussion about residents of the neighbourhood who were in contact with multiple teams or who the teams had found it hard to coordinate their care
• Starting to use localised data analysis from Camden public health colleagues to identify areas of unmet need and where best to target new approaches.

Paediatric Multidisciplinary Team Meetings

Multidisciplinary team meetings (MDMs) provide paediatric advice, guidance and learning once a month to discuss case referrals with a consultant paediatrician and team of multi-disciplinary professionals from health and social care, which currently includes Paediatrics, GPs, CAMHS, Health Visiting, Therapies, Asthma, Early Help and Children's Centres. The MDMs can now be accessed by all Camden GPs and are also accessible to other professionals who work and provide services in the borough for Camden children.

There is a redesign currently underway linking the paediatric MDMs with Neighbourhoods to integrate social workers and education, as long-term conditions affect many other aspects of CYP welfare. Bringing MDMs into a neighbourhood footprint places this well for a truly enhanced and joined up service. We will report once this redesign has been completed, Range of priority cohorts affected – SEN, young carers, and eligibility for pupil premium. The Start Well project aim to pilot this approach within schools.