What we learned from Arbennek INT evaluation 

There’s no shortage of ambition in integrated care, but far too few grounded examples of what works. That’s why the work of the Integrated Neighbourhood Team (INT) in Arbennek PCN, Cornwall, stands out. 

As part of our ongoing commitment to support innovation in health and care, Future Care Capital undertook an independent evaluation of Arbennek’s INT model. 

What we found was not a ready-made blueprint to be rolled out nationally, but something arguably more valuable: a live case study of bottom-up change, built on relationships, trust, and local insight. 

A different kind of team 

At its core, the Arbennek INT brought together professionals from general practice, social care, community health, and the voluntary sector. 

What united them wasn’t structure – it was purpose. 

Using Brave AI to identify patients at high risk of unplanned hospital admission, the team began meeting monthly to proactively plan care. These meetings weren’t typical clinical reviews or strategic roundtables; they were problem-solving sessions rooted in what mattered to the patient. 

One GP reflected: 

“It’s not all medical, it’s not all clinical, why patients present to GP reception half a dozen times. In one joint visit, we sorted out half a dozen things.”1 

Of the initial cohort of 50 patients, 49 were kept out of hospital. One patient died, but their wish to die at home was honoured. In the words of one system leader: 

“You only get one chance at end-of-life.”2 

Building from the bottom up 

What made Arbennek different wasn’t just what they did, but how they did it. 

There was no grand directive, no predefined operating model. Instead, the INT formed around a small group of committed leaders and collaborators – clinicians, administrators, VCSE partners – who were willing to try something new. 

Their shared approach was described by one participant as 

“amoebic”: constantly shifting in shape to fit the needs of the patient.3 

This fluidity is a strength, but also a risk. 

As the report outlines, the team is moving from the early Forming stage through to Storming and Norming – the middle phases of group development described by psychologist Bruce Tuckman.

It’s a fragile time. Momentum is growing, but so are the pressures. Meetings are large. Time is scarce. And there is still confusion about where INTs sit within the broader NHS landscape. 

“We need to clearly stipulate where INTs sit with PCNs. There’s a huge void unless we get the vision right.”4 

People make the difference 

If there’s one thing everyone agreed on, it was the impact of local leadership. 

The Arbennek INT thrived in large part because of the personalities and persistence of its leaders. These individuals weren’t just good facilitators – they were “Cheerleaders,” as one VCSE representative put it.5 

They carried the vision, built trust, and ensured everyone in the room felt valued, even when the meetings grew to more than 30 people. 

But the report is clear: relying on individual energy isn’t sustainable. 

“If we have a leader or a manager, that’s a single point of failure. The INT should be able to function without a leader.”6 

Supporting leadership, particularly among meso-level clinicians, is essential. So too is formalising some of the processes that have so far been held together by goodwill. 

Clarity without bureaucracy 

One of the most consistent messages from participants was the need for clearer communication, not just within the INT, but about the INT. 

“What exactly is an INT?” “How is it different from a Multidisciplinary Team (MDT)?” “Where does it sit with Primary Care Networks, Integrated Care Areas, or the ICB?” 

This lack of clarity matters. It affects who shows up, how they prepare, and how effectively time is used. As one public health professional noted: 

“INTs are a great concept, but they’re time-consuming. Done properly, they’re probably the best investment we can make — but we’ve got to use our time well.”7 

The risk is that, without clear framing, participation becomes patchy. Or worse, the model gets bureaucratised, smothering the very conditions that made Arbennek’s INT work. 

What next? 

This evaluation is part of Phase 1 in a two-phase communications approach. Right now, we’re focused on sharing the learning with those closest to the project: local partners, stakeholders, and system leaders who are invested in Arbennek’s success. 

We want to say thank you for your openness, your insight, and your trust. 

The findings show what’s possible when local energy is matched with light-touch support, thoughtful evaluation, and a shared desire to do better for patients. 

In the next phase, we’ll take these insights to a wider audience, offering practical lessons for other places trying to build integrated models of care. But we’ll do it with realism. There is no copy-and-paste model. Arbennek can’t be replicated, but there are learnings we can all use. And that’s the point. 

What we can share are the conditions that made it work: 

• Strong local leadership, supported not stretched 

• Flexible structures that evolve with purpose 

• Strategic use of technology to focus care 

• A commitment to co-producing solutions with all voices at the table 

Integration isn’t about a new acronym or a shiny dashboard. It’s about people working together. And the Arbennek INT has shown what’s possible when the people in the room are trusted to lead. 

 Read the FULL report and more of the lessons learned here 

Footnotes 

1. Report page 23 – direct quote from a GP describing a joint visit with a district nurse.
2. Report page 13 – direct quote from a civil servant describing the outcome for a patient who died at home. 
3. Report page 14 – direct quote from an INT leader describing the INT as “always moving, shifting, amoebic.” 
4. Report page 16 – direct quote from a senior staff member raising ambiguity about INT and PCN alignment. 
5. Report page 20 – direct quote from a VCSE participant referring to the need for a “cheerleader.” 
6. Report page 20 – direct quote from an INT leader about the risk of over-reliance on a single leader. 
7. Report page 16 – compressed quote from a public health stakeholder about INT time intensity and return on investment.