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Integrated Neighbourhood Teams
The development of neighbourhoods is well advanced in Camden with very active senior council involvement.
The programme is aligned to the vision in the NHS Ten Year Plan and planning guidance for 2025/26. Adult social care and community nursing teams have been restructured across Camden into the five neighbourhoods. East INT team is fully established in dedicated space at Kentish Town Health Centre supported by ICB. Getting to this point had taken two years, taking learning from Manchester. Housing and community safety as well as health and social care are part of the neighbourhood teams. There is also a strong focus on civic and community powered work. Initial focus is alignment of existing caseloads but LTCs, older adults and tenants experiencing complexity are a priority. Opportunities in the West and North are being developed.
All partners regard it vital to have primary care be able to play a pivotal role in the success of neighbourhood care. Borough and neighbourhood adult and paediatric MDMs have been in place for some time in Camden and nationally recognised as key building block for neighbourhood working.
Adult Multidisciplinary Team Meetings
CHP continues to support the borough wide and four neighbourhood frailty MDMs with CNWL providing administrative support. The Teams develop and embed strong multidisciplinary team working to facilitate better care co-ordination for adults with complex needs. The MDM meetings bring together GPs, Trust consultants and specialist nurses, community nursing and social care to agree additional support people may need and to reflect on best practice. MDMs aim to support people in their home and when they need to go into hospital, support safe and effective discharge. Up to the end of Q3, 953 patients were managed in MDMs (30% new patients and 70% reviews). 422 patients were seen in borough MDMs (38% new and 62% reviews) and 531 in neighbourhood MDMs (23% new and 77% reviews) (Figures as of Feb 2025).
CHP hosts regular meetings with MDM chairs who recognize the need to align the current MDMs with the neighbourhood footprints.
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.