Structural reorganisation will only create the conditions for change. Changed behaviours and mindsets are needed to shift cultures. Here we explore why hyper-local change is best placed to make the most tangible difference to exclusion, inequality, and the inverse care law: levelling up in health. This challenges the emerging "big footprint" structures within the NHS to put neighbourhoods at the centre of planning and investment. What is needed to make this moment a time for neighbourhood action in health?
Not just projects: a neighbourhood mindset
While neighbourhood could be viewed as a statutory unit smaller than place, in health terms it makes sense to think of natural communities – an estate, ward, or village. There is no shortage of examples of brilliant neighbourhood working. From community health workers in Fleetwood to partnerships to reduce sugar consumption and tackle obesity in Sheffield. NHS England and NHS Improvement chief executive Amanda Pritchard voiced the potential to intervene upstream with home adaptation and tackling fuel poverty to prevent admission and improve exit block. Deep inside the NHS Long Term Plan was a commitment to community-centred approaches. From the US we see examples now being trialled in Hampshire. Proponents of the Canterbury model in NHS South-East make a similar case.
But good practice and good intentions are not enough. Drift is too gentle a word for what happens as supply-led demand consumes workforce, funds and attention. Neighbourhood health has to now become not projects but the foundational mindset. This is the beating heart of population health. Making upstream innovations mainstream; just as GPs in the black country are doing through social prescribers leading their home visiting teams. That radicalism has to be matched by deep end working that seeks to blend local understanding of need with upstream interventions.
Connection is why neighbourhoods matter
The neighbourhood approach can seem remote from the day-to-day work of many NHS providers. But as we reflect on an ongoing pandemic, on reaching new communities and on building social capital, it is this hyper-local level which has brought together populations and created new services addressing unmet need. The Red Cross have published findings suggesting that a small number of patients, drawn from specific communities, account for huge swathes of traditional service demand – the urgent issue which dominates leaders' work.
Leaning into neighbourhood working offers a threefold benefit: reducing demand on the health and care system, developing community resilience and enabling retention through delivering new models of care. Focusing on underlying determinants motivates staff, albeit pushing health employees into territory that feels less clinical and more relational.
This is not a new agenda to local government. It builds on councillors' kerbside insights and wider understanding of inclusive growth and housing. A neighbourhood scale makes sense to key partners even if it is not in the NHS lexicon. The People's Trust are sponsoring work to change that orientation in Lozells in Birmingham. In January a major review into how health wraps itself around a specific neighbourhood will be published, built from local voices. The renewal of NHS England's interest in primary care networks signalled by the Fuller Review, suggests that the need is understood nationally too.
Inhibitors and enablers
Why is this approach not systematic? One reason is that it does not fit easily into a role culture. Policy sometimes proceeds as if this is what primary care does. But general practice care is not geographic, it is list based. Primary care cannot do this alone anyway. Before the pandemic the IPPR argued that a 'neighbourhood health' model could be the jewel in the crown of the NHS, set in stone in primary care, but that changes were needed to support infrastructure and create at-scale support for a local front-end. The experience of the vaccine rollout surely supports this contradistinction: local knowledge and trust, with economies of scale for implementation and development.
In sporting parlance, neighbourhoods need a squad not a team. Too often community services are still 'purchased' as contact-based interventions and local authority work is tied to the most acute end of presenting threshold. The third sector plays the essential part, sometimes acknowledged, often unseen. In truth, the neighbourhood health model needs all contributors to use this lens. Hospitals should be deeply interested in why a given geography is seeing presentations in urgent care and equally interested in why another surprisingly is not. Trusts hold vast data lakes on long-term condition care and can deploy them, as some, like Sandwell, have begun to do to spot people falling through gaps.
The to-do list is overflowing, but there are some steps which should unlock possibilities:
- Analysis: Within a thought-through framework like Core20Plus5, identify those patients in need of support who are not captured by screening, vaccination, and health-check services. Systems must go and look, not wait and treat.
- Immersion: Leaders have to have best insight about how local people live their lives and how they interact with public services. Induct into the local community – for leaders and for staff.
- Promotion: Work at neighbourhood level exists in every system. But what is less visible is the work of all agencies in a neighbourhood. Now is the time for an integrated care board (ICB) to use its soft power to give visibility to others' work before new commissions happen exclusively within the NHS 'family'.
The integrated care partnership, which will set strategy for the ICB, must insist that no approvable integrated care system strategy can lack this neighbourhood lens, delivering through place. It will be through making sense of hyper-localism that reform as well as recovery can take root: no roots, no growth. Miss this and a key lesson from COVID-19 could be left on the history shelf.
This blog was first published by HSJ.