Lambeth and Southwark are neighbouring London boroughs working together to develop Integrated Neighbourhood Teams (INTs) that improve outcomes for residents with multiple long-term conditions (MLTCs). 

The INTs will support adults aged 18-64 who have three or more long term conditions including Chronic Kidney Disease, diabetes and Cardiovascular Disease. The INTs will also focus on those who face barriers to accessing coordinated care, including people with severe mental illness, learning disabilities, and populations with high health inequalities. Those aged over 65 will be supported through the aligned frailty INTs. 

The INT brings together primary care, acute, community, mental health, local authority and VCSE partners. The model provides targeted outreach and inreach to deliver community-based support with clinical input, underpinned by care coordination. The INTs aim to reduce fragmentation, strengthen continuity of care and embed a sustainable neighbourhood model across both boroughs. 

The programme is being led by the shared Integrator model, which is a partnership between Guy’s and St Thomas’ (who deliver community and secondary care services) and general practice: Lambeth General Practice Provider Alliance (LGPPA) in Lambeth, and Southwark Primary Care Provider Alliance (SPCPA) in Southwark. An Integrator Delivery Board provides oversight of the neighbourhood model.