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 and wellbeing. 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.
- Reduce duplication and ensure people are supported by the right service or organisation at the right time
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?
- Identify: A professional from the GP practice or partner organisations identifies a patient who would benefit from support from 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 or GP
- Help with medication, equipment, or care packages
- Support with mental health, dementia, or social needs
- Encouragement to access preventative services such as diabetes prevention pathways, weight management, smoking cessation
- 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:
- Outreach initiatives to visit homeless patients and register them with the surgery
- The Wellness Café offers a safe, welcoming environment for patients to connect with support. This alternative approached has helped patients who struggle to attend medical settings, such as a recent gentle with agoraphobia who wasn’t able to attend the GP practice
- A Digital Hub has been opened in partnership with Essex County Council to provide residents with access to laptops and support sessions to improve digital skills.
- Patient case study: A gentleman, who had trouble managing his living conditions due to hoarding and had previously declined care services due to embarrassment about his home, had been admitted to hospital. Through the Transfer of Care Hub, BERT identified that his discharge would be delayed as his home required significant changes to make is safe for his return. With his permission, while he rehabilitated in a community hospital, local services worked collaboratively with his next of kin to clear his home and put the appropriate equipment and care package in place. He was discharged back to his home and also received a home visit from the BERT Social Prescriber. Both the patient and his family were happy with the support which enabled him to return home as quickly and safely as possible. The success of this case lead to discussions with a supported living scheme to explore the possibility of assisting other patients facing similar challenges.
Feedback from professionals
“This approach allows us to think and work differently. Patients are receiving seamless care as a result of the coordinated, proactive and preventative approach. As professionals, we have a shared purpose and the relationships we have developed mean we have the right contacts to get help promptly for our patients Job satisfaction has also increased as professionals feel supported to deal with multimorbidity and complex social problems. Understanding the wider determinants influencing our patients’ health means we can think outside the box and look holistically at the factors that are affecting their health.” Dr Anita Pereira, GP at West Basildon PCN
“Working with BERT as part of the Integrated Neighbourhood Team has been genuinely rewarding. What stands out most is how closely we all work together. Daily meetings like Transfer of care hubs mean we can quickly share information, solve problems, and support each other. There’s real freedom to think creatively and adapt to what our patients need, especially those over 75 with high frailty. Because we’re working hand-in-hand with social care, housing, and local services, we’re able to give people the kind of joined-up, personal support that really makes a difference.” Samuel Owiredu Cmgr (MCMI), Interim Deputy Director– NELFT Basildon & Brentwood Adult Community Health Services and EPUT MH Adult and Older Adult Service
What’s next?
BERT is growing. A second care coordinator is joining the team shortly.
Further support initiatives are also being developed including:
- preventing cardiovascular disease through outreach services and blood pressure monitoring
- address wider determinants of health by expanding the services offered at the wellness cafe
Across wider Essex, we continue to improve how we work together to support our community.
BERT is one example of the benefits of integrated working being realised across mid and south Essex. Following the release of the 2025/26 Planning Guidance and Neighbourhood Health Guidelines, the initial focus for all our INTs will be supporting our aging population by focusing on frailty over the next year.
Frailty responds well to a holistic approach to patient care, because the physical, mental, and social factors that impact someone with frailty are often interlinked. Using the collective expertise of our Integrated Neighbourhood Teams will allow for better monitoring and management of frailty, with timely interventions that can significantly improve outcomes and enhance quality of life for vulnerable patients.
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