Work is already underway in Essex to make the national vision for Integrated Neighbourhood Teams (INTs) – as set out in the NHS 10 Year Plan – a reality.
The Basildon Early Response Team (BERT), part of the West Basildon Primary Care Network, is a great example of proactive, personalised, and joined-up care by bringing together professionals from across health, social care, and the voluntary sector.
Through BERT, local residents receive timely, coordinated support that addresses not only their medical needs but also the wider social circumstances that affect their health. BERT illustrates how integrated working at neighbourhood level can improve outcomes, reduce hospital admissions, and build trust with patients and families – demonstrating the real-world impact of the Integrated Neighbourhood Team model.
What is BERT?
BERT stands for Basildon Early Response Team. It’s a local health and care service designed to support people – especially older adults and those with complex needs – by bringing together different professionals and services to provide care in the community.
Why was BERT created?
BERT was set up to:
- Help people stay well at home and avoid unnecessary hospital visits.
- Provide faster, more joined-up care by connecting GPs, nurses, social workers, social prescribers, mental health teams, and others.
- Support people who may not regularly visit their GP but still need help.
Who benefits from BERT’s help?
BERT supports:
- Older adults (especially those over 75)
- People with long-term conditions or multiple health issues
- Those with mental health or safeguarding concerns
- Families, carers, care home residents, and even people experiencing homelessness
How does BERT work?
- Referral: A GP, nurse, or other professional refers a patient to BERT.
- Team Discussion: The BERT team meets daily to discuss new referrals and decide the best support.
- Support: The right professionals (e.g., a matron, social prescriber, or mental health worker) are assigned to help.
- Follow-Up: Once support is complete, patients are followed up with a welfare call after 3 months.
What kind of help can BERT provide?
- Home visits from nurses, social prescribers or matrons
- Help with medication, equipment, or care packages
- Support with mental health, dementia, or social needs
- Referrals to services like physiotherapy, memory clinics, or wellbeing hubs
- Welfare calls to check in on patients who haven’t been in touch with their GP
What has been achieved already?
Since launching in 2024:
- Over 7,700 home visits completed
- Over 2,900 welfare calls made
- A&E visits reduced by nearly 57% for resident with complex needs
- Patients and families report feeling more supported and confident in their care
How are local residents already benefitting?
BERT has helped:
- An elderly couple with no support get care at home.
- A patient with dementia receive coordinated care from nurses, GPs, and mental health teams.
- A man struggling with hoarding get safe housing and rehabilitation after surgery.
What’s next?
BERT is growing. A second care coordinator is joining the team in July 2025.
Across wider Essex, we continue to improve how we work together to support our community.
The 10 Year Health Plan for England
The Government’s 10 Year Health Plan for England has been launched, setting out a bold, ambitious and necessary new course for the NHS.
The plan fundamentally reinvents our approach to healthcare so that we can guarantee the NHS will be there for all who need it for generations to come.
It has been shaped by the experiences and expectations of members of the public, patients, our partners and the health and care workforce across the country, reflecting the changes that people wanted to see.
Through the ‘three shifts’ – from hospital to community, from analogue to digital, and from treatment to prevention – we will personalise care, give more power to patients, and ensure that the best of the NHS is available to all.
The 10 Year Health Plan for England