From rhetoric to reality: what is the neighbourhood health service?

While a neighbourhood health service may be at the very heart of the Government’s 10-year health plan for England, what does this actually mean? What is the vision for it?

At a simplistic level, a neighbourhood health service is described in the Department of Health and Social Care’s 10-year health plan for England as the mechanism by which to create the ‘left shift’; where resources are moved from hospitals to community-based services that deliver care closer to home. This shift from hospital to community has been the stated aim of successive governments, however, it has proved challenging and has, in many ways, failed to materialise on a national scale. The reasons for this failure are well rehearsed but include financial models which have resulted in more funding pumped into the acute sector, and the steady decline of the district nurse and community workforce. The 10-year health plan describes the ambition that a neighbourhood health service must enact this shift, replacing ‘the status quo’ of ‘hospital by default’ with care that happens as locally as it can.   

This vision for a neighbourhood health service, also set out in published guidance from NHS England, mainly positions it as a way of delivering professional healthcare services in the community. The focus is on ‘preventing demand’ for hospital care by reducing avoidable admissions. Partners across neighbourhood teams are being asked to focus on population health approaches to reduce demand on hospitals for care that could be better provided in the community, in part through early intervention with those who use services a lot. This vision of the neighbourhood health service means that where care is delivered is shifted to being in the community, for example through primary care, or diagnostics delivered in community hubs, with a goal of this being to stabilise the hospital sector and reduce demand on it. There is also an element in this vision about a neighbourhood health service supporting the NHS to be more financially sustainable through reductions in more costly hospital-based activity.  

As one of our interviewees reflected, this vision could be perceived as being quite narrow if it is just ‘focused on keeping people out of hospital and early discharge’. 

There are, however, a number of different interpretations of what neighbourhood health could mean, some of which are already being played out in different local areas.  Throughout our interviews, it became clear that there is some confusion about the vision for neighbourhood health could and should be, but there are at least three different ways of thinking about it: 

• Health services vision: This is a model of neighbourhood health predicated on health and care services being delivered in neighbourhoods. Broadly this model sees services delivered in the community on the basis of alleviating demand on services in the acute sector.  
• Total place vision: this vision sees a much wider set of partners across whole place-based systems coming together to think about how to provide a wider set of public services to neighbourhoods.  
• Community focused vision: this is a model of neighbourhood health that sees services designed with and by the communities it serves, harnessing all the assets these communities have.  

For neighbourhood health to successfully create a ‘left shift’ which provides holistic care and support for communities, all three of these components of neighbourhood health must be considered and built into health and care systems.  

The insights gathered in our conversations about neighbourhood health, alongside what we are learning from the development of our Neighbourhood Transformation Funds, have surfaced some key themes about what enabling conditions might be needed to support this new way of working. These enablers cover both practical foundations, such as funding and physical infrastructure, but also more relational aspects, such as having strong relationships and trust. These enablers are the essential underpinnings that can support turning the vision of neighbourhood health into reality.   

“There's different dimensions to this around systems, processes, but a lot of it is about cultural relationships and learning to work in different ways”.  

In the context of stretched budgets across not only NHS organisations but also for partners in local authorities and the VCSE sector, there are questions about what funding might be available to deliver neighbourhood health but also the wider financial underpinnings needed. 

While we heard that a degree of additional funding would be helpful, this was not necessarily just about having more resource available but also reflected the difficulty in moving money around the system to invest in transformation.  

“It would be good if we had enabling funding or double running costs to it to allow us to make some of these changes. We don't”. 

We heard that without additional resource to enable a certain degree of ‘double running’, there is a need to use the resource available across a system more flexibly and with a willingness to be innovative. For some that we spoke to this meant expanding the use of existing financial levers, for example the Better Care Fund, and using this as a way of directing funding from both health and social care to drive neighbourhood ways of working. For others it was about seeking new mechanisms to draw in third party investment, such as community interest companies, which provide funding to enable different approaches to neighbourhood health. For example, as explored above, a key enabling element that is supporting West Hertfordshire Teaching Hospitals Trust in achieving their neighbourhood health vision is the ‘de-risking’ of transformation through the repayable funding mechanisms that Macmillan and non-profit enterprise Social Finance have provided.  

“And in a system with like zero spare revenue it provides that opportunity to start to move money around the system in a way that reduces risk for the NHS”. 

While these mechanisms were being used locally in different areas, those we spoke to felt that significant changes in the financial architecture would be needed at a national level to make neighbourhood health models truly sustainable. For example, thinking about how to enable greater use of single pooled budgets would need to be done at a national level given the different funding streams that exist for health and social care. Similarly, if a neighbourhood health system successfully reduces reliance on hospital services, through admission prevention or reduction of outpatient appointments, then the financial flows need to recognise this and be able to redeploy previously fixed costs to benefit the system.  

“We're not driving efficiency because we're still operating in silos that, you know, if we can remove some of those silos and some of those fixed costs or redeploy the fixed costs into different spaces, I think we'd see a very different outcome in our health and care system”. 

We also heard that while there seems to be an expectation that moving resources to a neighbourhood health service would deliver financial efficiencies, our interviewees were sceptical about this resulting in cost savings, particularly in the short term. Many talked about the high fixed costs associated with hospital care, for example capital costs associated with buildings, which would not be immediately released by delivering more care in the community. However, in the long term a continuation of the current model of reactive care is likely to be more expensive and so shifting the balance of resources would be more financially sustainable. 

“I think focusing on [whether] this will save us money is A) not the right measurement because it doesn't really improve care, but B) won't happen and we'll still be here in another 25/30 years saying why haven't we moved care out of hospital?”. 

Tied into the question of how neighbourhood health will be funded is also the question of who should be involved in its development and delivery and what mechanisms are needed to make it work. The 10-year plan indicated that neighbourhood health will be underpinned by a number of new contractual vehicles, including the new integrated health organisation (IHO) and the single and multi-neighbourhood health contracts. However, we heard that this risks driving the question of accountability in the wrong direction with different providers competing to hold these contracts rather than focusing on the work to collaborate more effectively across different organisational boundaries. There was also the sense that this focus could prevent consideration of accountability beyond NHS organisational boundaries, for example what role local government should play or how the neighbourhood health service will be accountable to local communities. 

“I just think that creates a conversation that's very system focused and moves away from what we're trying to achieve…because you're then focusing down on contracts and where the money sits”.

For some of those we spoke to, the focus on contracts risks excluding key partners in the development and organisation of neighbourhood health, such as general practice, who often do not have the capacity to engage beyond their existing workload. This was despite many interviewees feeling that general practices, as holders of hyper local relationships with people, need to be the cornerstone of neighbourhood health. 

“I mean general practice is neighbourhood health, in that they hold a registered list of patients in the neighbourhood…GP practices are the anchor point of a lot of this stuff”. There was also a sense that existing mechanisms for accountability and delegation could be put to use to enable neighbourhood health, rather than needing complex new contractual forms which have had mixed success in the past. One interviewee we spoke to described how in their area they were using existing provisions in the regulations to delegate responsibility from one NHS entity to another, in this case from the Integrated Care Board (ICB) to the acute trust, so it could act as the host provider for the neighbourhood health partnership. This was described as a way of bringing together “all of the formal levers that we need in both the provider and the commissioner side in order to make decisions once”. For example, as a host provider the trust was able to hold formal accountability for certain delegated functions, such as some commissioning responsibility, and employ staff.  

Neighbourhood health ultimately relies on a workforce equipped and supported to work in multidisciplinary, community-based environments. Interviewees described the shift to neighbourhood health as reshaping how people train, work, and collaborate across organisational boundaries.  

This raised questions about how staff are prepared for this environment. We heard that as much of the workforce is still developed within acute hospital settings, they have limited exposure to the different approaches needed to work in community-based, multidisciplinary teams. For many, working in neighbourhood teams would require a different set of skills, mindsets and support structures. 
“The way we train our workforce is very much focused on acute hospital. We don't train people in the community. We don't support them”. 
Our interviewees also highlighted the importance of aligning staffing across primary care, community services, secondary care, mental health, social care and VCSE organisations, so that teams can flex around local needs rather than organisational lines. 

Another insight was the need to think differently about specialist staff. Even as neighbourhood health looks to deliver more care locally, people living with cancer will still need complex care including highly specialist staff in areas. For this workforce, part of their role will need to rethink how they work and dedicate time to neighbourhood-level practice, contributing expertise in ways that support broader population health goals, and engaging in cross-sector collaboration. 

“If you're not very careful, splitting up everything into tasks that are done by people who do tasks means you lose continuity, you increase handoffs and the opportunity for error… and you lose the full picture of what's happening to the patient”. 

These elements should be picked up in the new 10 Year Workforce Plan, which will be a key enabler for ensuring that the health service has the workforce it needs, now and into the future, to deliver these different models of care.  

The ability to collaborate across organisations, share information, and deliver more care closer to where people live depends as much on the spaces, systems and tools available as on the skills of the workforce.  

We heard that estates and physical infrastructure matter as part of enabling effective neighbourhood working. Neighbourhood teams will need places to meet, talk, and coordinate and the sense from our interviews was that while virtual tools can help, they cannot fully replace the need for shared spaces that make collaboration real and relational. In other words, collaboration needs both the right people and the right places, to understand each other’s pressures, align goals and make working relationships stick. 
“If you want people to work as teams, they need to meet and talk together. Yes, absolutely we've got virtual tools and we can do some of that. But we also need to think about how we pull people together’”. 

People and communities also need access to spaces that accommodate the different services they use to ensure that they don’t have to travel to multiple places to receive the care they need. This has been recognised by the government, who have made a commitment to developing Neighbourhood Health Centres intended to be "one-stop shops" for care, bringing multidisciplinary teams together under one roof. 

Digital and data infrastructure will be an important enabler that supports neighbourhood health. Too often, basic infrastructure is missing, with one interviewee reflecting that “we’ve got district nurses who haven’t got a laptop that works”. Another stakeholder described GPs spending 20 minutes each morning just trying to boot up a computer. These are daily realities that slow care and make neighbourhood working difficult.  

We heard about the importance of interoperable systems that allow all partners, from hospitals to GPs and district nurses and VCSE organisations, to access and update shared records in real time. Without this, teams are working on partial information and potentially duplicating assessments which leads to frustrating experiences for both staff and patients.  

“Proper interoperable digital systems - the ability to read, write and have access to records in formats that are useful both to the hospital clinician or district nurse or the GP”. 

Interviewees repeatedly emphasised that neighbourhood working depends just as much on the relationships, behaviours and shared purpose that bind organisations together. Without this relational groundwork, even the best-designed structures risk operating in parallel rather than in partnership.  

Many of the stakeholders we spoke to reflected that one of the most persistent challenges for neighbourhood health is the absence of a shared understanding - both of what it is and what it is for. 

“No one’s really clear what it’s there to do”. 

They reflected that often neighbourhood health is described mainly in terms of reducing A&E attendances or unplanned admissions, which risks it becoming narrowly framed as an NHS-led initiative focused on relieving hospital pressure.  

We heard that developing a shared vision locally is essential and that it cannot be imposed centrally. For many we spoke to, neighbourhood working only gains momentum when partners across the NHS, local government, and the VCSE sector recognise themselves in the purpose and approach. But crucially, involvement in setting the vision also has to extend to the local communities themselves so the shift in services works for them and their needs. 

"You can't dictate neighbourhood from the centre… You can certainly set standards… but how that's delivered has to be locally determined and will look different [from place to place]”. 

Interviewees described that the practical reality of reaching a shared view requiring conversations about priorities, pressures and expectations that can’t be shortcut and that requires building strong relationships.  

“You can have all the nicest relationships in the world, but if you don’t actually know what you’re trying to aim for… or if everyone’s aiming for something different, that ain’t going to fly either”. 

Strong relationships and trust were described as foundational building blocks that create the conditions to collaborate effectively. Building these trusted relationships should be accompanied with a willingness to change how power, authority, and accountability are exercised across all levels of the system. As one stakeholder put it, neighbourhood health requires participants to have a ‘working relationship that supports collaboration and that is trusting, open, honest, willing to perhaps give something of yourselves to benefit the totality’. 

“I think lots of neighbourhood health requires setting individual organisational priority and ego aside, especially when you start to work around community and community priorities”.

Achieving equity of voice, particularly for the VCSE sector, is central to this shift. We know that these organisations may not match NHS or local authority budgets, but contribute deep trust, lived knowledge of communities, and the ability to co-produce with citizens - capabilities critical for neighbourhood health success. Alongside a better recognition of the VCSE sector is also a shift in power which means that communities are considered as their own health resource with their own agency. 

“You do need time. You need the people with the skills to bring people together to do that brokerage, to really help drive this forward”. 

We also heard while coterminous boundaries are often seen as a prerequisite for neighbourhood health. However, even in less-aligned areas, neighbourhood teams can thrive by prioritising meaningful engagement, trust-building, and collaboration. Ultimately, it is likely the relationships, not the neatness of maps or boundaries, that will determine effective neighbourhood health. 

In our conversations, interviewees repeatedly emphasised the related issues of time and bandwidth as barriers to realising the vision of neighbourhood health. As one participant put it bluntly: “This takes time and energy and desire and all of those things are difficult when you're being pushed and pulled in multiple directions”.  

There appeared to be a tension in the need to focus and deliver on multiple priorities, from elective waiting lists to financial sustainability to developing neighbourhood health services. 
“The thing we're looking for really is clarity about what needs to come first, especially in a system that's so tight on finances and tight on capacity and really focused on elective recovery”.  
In this context, we heard strongly about the need for protected capacity and headspace to be able to build the much-needed relationships as described above that would support neighbourhood health. Our interviewees acknowledged that this takes time, particularly when working with and alongside communities.  

“A lot of those connections [with communities] didn't really exist that much if you go back like 2-3 years locally and it's taken a bit of time to kind of build up those connections, those relationships”.