What’s this project all about?
Becky and Jo are part of the Integrated Neighbourhood Health programme working in Bradford District and Craven. This is their story about how a new approach to working has transformed their service.
In Bradford District and Craven, we are working together towards a future where more needs are met locally, experiences of care and support are seamless across health and care services and front-line staff have more rewarding and sustainable roles.
Neighbourhood multidisciplinary teams, which can coordinate wrap-around care for people who need extra support are part of the local integrated neighbourhood health (INH) approach.
At Five Parks Primary Care Network (PCN), this happens through the Evolve Team – a multidisciplinary group that brings together primary care, community services and the voluntary and community sector to coordinate care more effectively.
Becky has led the team since December 2025 and is already seeing significant change. She said: “When I first joined Five Parks PCN a couple of years ago, it was just me. Now we’ve built a proactive team that visits patients at home who have complex health and social care needs.
“Anyone can flag a patient to us. Once we receive a referral, we visit them, assess their needs and either stabilise their situation or integrate them into the right services as quickly as possible.”
Addressing the problem
Becky has worked in the area for many years and has seen how fragmented communication can affect people’s care.
“Communication between services used to take up so much of our day. We were all facing the same challenges but often in isolation.
“You might have an elderly, frail patient living with dementia who is discharged home from hospital. We’d put proactive support in place, but then they’d fall, become unwell and be readmitted. After a long hospital stay without rehabilitation, they’d come home significantly deconditioned.”
She recalls one patient in particular:
“When he returned home, he could barely climb the stairs, let alone reach the bathroom. For someone with dementia, that loss of mobility can be make or break. If we don’t act quickly, we risk permanent decline.
“Our team stepped in immediately - increasing his care package and working with him on mobility. If we hadn’t intervened early, he could easily have lost the ability to walk altogether.”
Experiences like this highlight why integrated neighbourhood health matters and how services can work better - and smarter - together.
Networking is key
Since January, Becky has been leading weekly multi-disciplinary teams meetings. These bring together therapy services, social care, hospital colleagues and the voluntary and community sector.
“We realised we were often seeing the same patients - we just didn’t know it. The first step was building relationships and removing delays. We’ve started sharing insights, coordinating referrals and linking directly with intermediate care beds at the hospital trust. It’s about improving communication, so patients receive a quicker, more responsive service.”
Importantly, this transformation has been achieved using existing resources.
“This isn’t about extra staff or extra money. It’s about changing how we work together to enhance patient care.”
Working smarter
Jo works in community occupational therapy and physio rehabilitation services at Bradford Teaching Hospitals NHS Foundation Trust (BTHFT) and is part of the MDT. She has seen the difference this approach is making.
“The INH programme has given us permission to break down barriers and think differently. It’s about working smarter together to achieve better outcomes.
“Bringing context and insight to meetings changes everything. Previously, you might spend weeks chasing information. Now, five minutes of shared insight can shape an effective care plan.”
She highlights the importance of shared knowledge.
“That shared understanding creates a cohesive plan. There’s real learning in these meetings - you hear how others approach situations and you pick up knowledge from each other. My team has said it feels like a relief.”
A breath of fresh air
In a recent MDT meeting, a team member shared feedback:
“I am so pleased with the enhanced joint working between ourselves, social services and the therapy teams. I have noticed a positive difference already in how we are collaborating
“There seems to be closer relationships already and individual cases are moving on faster and more effectively already. It is a breath of fresh air”.
Becky said: “People recognised the drive behind this and wanted to get involved. We can’t do it without collective commitment.
“It’s about networking and working together. The value is joining it up and complementing each other in the care.”
Keeping it simple
One reason the team has made progress so quickly is by keeping things practical and focused.
Jo said: “We haven’t created anything new or complicated. We’ve taken the services we already have and broken down the internal barriers that slow us down.
“It’s simple, stripped back and practical. Small changes in the system can be life-changing for patients - like preventing someone from losing their mobility.”
What’s next
Teams across the PCN are getting involved. Pharmacy and dietetic colleagues recently joining MDT meetings to share their expertise and local knowledge.
Becky said: “The meetings are open and fluid. We invite people who can help. It’s still early days and we’re learning week by week. We’re allowing it to evolve naturally.”
Jo said: “My vision is that this becomes a core meeting - part of our everyday practice, not an additional task.
“You don’t have to start from scratch to make an impact. But you do need leadership and willingness - and we’re fortunate Becky has taken that on.”
See more on the integrated neighbourhood health - Bradford District and Craven Health and Care Partnership website.
You can also read Becky and Jo's transforming care through integrated neighbourhood health case study as a PDF.