Ian Razzell, Head of Primary Care at NHS Arden & GEM CSU and National Neighbourhood Health Improvement Programme (NNHIP) coach, shares the progress being made by early adopter sites.
Over the past 12 months, neighbourhood health has shifted from policy ambition to practical delivery. What began as a core principle within the NHS's long-term direction is now being tested at scale, supported by national frameworks, structured improvement programmes and a growing number of early adopter sites. Emerging evidence suggests neighbourhood-based models are improving coordination of care, supporting more proactive management of patients and reducing reliance on hospital services. The challenge now is embedding neighbourhood health as a core component of system delivery, rather than treating it as a pilot or add-on.
Experience from early adopter sites across the Midlands, London and the South West highlights three critical enablers: workforce, data and culture.
Using people differently
Workforce is often seen as the biggest constraint to neighbourhood health. We cannot expect large numbers of additional staff to appear in an already stretched system. The more realistic opportunity is to use existing people differently, reduce duplication and stop work that no longer adds value.
In Nottingham City, no new staff were recruited to establish integrated neighbourhood teams (INTs). Instead, existing geriatricians, community nurses, social workers, social prescribers and GPs redesigned how they worked together. The result has been more coordinated, patient-centred care that makes better use of existing capability rather than relying on workforce expansion. Leadership no longer defaults to the most senior clinician; where a patient's needs are primarily practical rather than medical, a social prescriber or social worker may lead the multidisciplinary team (MDT) discussion, with clinical oversight always available.
Staff surveys indicate higher levels of engagement and professional recognition, with multidisciplinary working increasing confidence, job satisfaction and opportunities for development. Expertise is valued regardless of organisational background or professional hierarchy, helping to create a more rewarding working environment and supporting retention. Sustaining this approach, however, requires organisations to stop or redesign lower-value activity rather than expecting staff simply to absorb additional work.
Using and sharing data effectively
Data and digital capability are central to making neighbourhood health operational: identifying the right patients, understanding their needs and coordinating interventions across organisational boundaries.
In Nottingham, analysis of local data identified a cohort of people with frailty repeatedly cycling through the emergency care system, experiencing repeated admissions and discharge. Understanding this cohort has enabled a different response. Structured multidisciplinary triage, coordinated follow-up and shared records are helping keep more care within the community, while supporting the case for a community frailty hub where patients without acute needs can be assessed and managed by a full MDT.
Patients benefit from more coordinated care delivered closer to home and family, while the system benefits from fewer GP appointments for people with frailty, fewer emergency attendances and reduced reliance on costly acute beds. These improvements are enabled by coordinated multidisciplinary working, shared information and a greater focus on prevention and early intervention.
Shared records are fundamental to this approach, allowing professionals across health and care to work from the same information rather than isolated organisational datasets. Realising these benefits depends on consistent use of shared records and proportionate information governance that enables, rather than inhibits, collaboration.
Yet workforce redesign and digital capability alone are not enough. To realise the full potential of neighbourhood health, professionals also need to think differently about how care is delivered and what matters most to patients.
A shift in mindset as much as model
Neighbourhood health asks professionals to think differently about what good care looks like: moving away from overmedicalising problems and towards understanding the broader circumstances that affect health and wellbeing. For some people, the most effective intervention may not be another prescription or referral, but action on housing, isolation, mobility or daily routine. The question shifts from "What's the matter with you?" to "What matters to you?" Patients are often present when their MDT discusses their care, helping to shape decisions around their own priorities, such as remaining independent at home. Early patient-reported outcomes and experience measures suggest this more collaborative approach is strengthening both engagement and confidence in care planning.
Neighbourhood health also gives local teams greater flexibility to design solutions rather than simply deliver predefined services. National priorities remain important, but providers are increasingly able to determine how those priorities are achieved within local resources and partnerships. This encourages local solutions to local problems and ensures services are designed with communities rather than for them. The proposed community frailty hub in Nottingham is one example: a locally developed response to a locally identified need, shaped collaboratively across health, care and voluntary sector partners.
Early success has encouraged wider adoption. Nottingham expects up to six of its nine integrated neighbourhood teams to be operational within months, with the remainder planned by next March.
Embedding the model
Neighbourhood health is still evolving, and significant challenges remain. Yet the past year has shown that, when implemented effectively, the model resonates strongly with both staff and patients. In Nottingham, the direction of travel is clear: expand integrated neighbourhood teams, strengthen the evidence base and align financial flows with the new model of care. Scaling does not mean expecting newer teams to catch up alone; moving experienced MDT members into newly forming teams for several cycles helps transfer practical knowledge that policy documents alone cannot provide. Importantly, some of the earliest teams now require very little external improvement support. What began as an improvement programme is increasingly creating a movement, with organisations and professionals actively seeking to be involved because they can see tangible benefits for patients, staff and services.
Embedding neighbourhood health at scale will require greater investment in community-based, preventative care, supported by robust evidence of impact and the confidence of commissioners and providers to move resources away from established models where appropriate.
The approach also creates opportunities to address prevention and the wider determinants of health more systematically. Housing, social isolation, financial wellbeing and healthy lifestyles are increasingly recognised as neighbourhood issues requiring coordinated local action. This broader perspective moves neighbourhood health beyond service integration towards improving the conditions that shape long-term health outcomes.
Perhaps the most significant change is cultural. In areas where neighbourhood health has matured, conversations are shifting away from organisational competition towards collective problem-solving. The question increasingly becomes, "How can I work with you?" rather than, "How can I get some of that funding?" – a subtle but important indicator of genuine system collaboration and shared ownership of outcomes.
By applying early learning and scaling what is already working, neighbourhood health has the potential to move beyond early adoption and become a consistent, system-wide approach. What began as an idea, then a programme, is increasingly becoming a movement: one that is bringing care closer to communities, improving outcomes for patients, empowering staff and creating a more sustainable future for the NHS.
This article was originally published in Healthcare Management.
