Woodspring, one of six localities in North Somerset within the Bristol, North Somerset and South Gloucestershire (BNSSG) Integrated Care Board, is developing a neighbourhood health approach through the already established Woodspring Complex Care Team. This team supporting development of a a proof of concept for an Integrated Neighbourhood Team (INT) model. The programme aims to shift from a reactive, referral-led multidisciplinary model to a more proactive, structured and outcomes-focused approach, enabling earlier identification of need and more coordinated support for residents. 

The emerging model will be grounded in population health management and use the BNSSG segmentation model, based on the Cambridge Multi-morbidity tool, to identify cohorts of residents who may benefit from more coordinated support. Rather than relying solely on referrals, the approach aims to proactively identify residents with complex needs and provide personalised, strengths-based support centred on “what matters to me”. Initial engagement will be led by a Social Prescriber, VCSE support worker and Care Coordinator, ensuring that clinical, social and community needs are considered together. 

The programme places strong emphasis on partnership working across primary care, community services, adult social care and the voluntary, community and social enterprise (VCSE) sector. Co-production with residents will be embedded through a dedicated lived experience programme, ensuring that the model continues to evolve based on real feedback. 

Alongside service redesign, Woodspring is investing in workforce development, digital solutions such as shared care planning, and clear evaluation methods. Together, these elements aim to create a scalable neighbourhood model that improves coordination, prevention and outcomes for residents with complex needs.