Scale-up and join-up: what neighbourhoods need to achieve the left shift

The energy on display at the recent National Neighbourhood Health Implementation Programme (NNHIP) collaborative design event was palpable. With over 200 leaders and patients gathered, it’s clear that many are passionate about the potential for neighbourhood health care to be transformative.

However, in today’s reality of tight budgets, and without the option of double running, for neighbourhood health to deliver the ‘left shift’, it must go further than relationship building and improving staff and patient satisfaction. It must deliver reductions in both planned care referrals and non-elective hospital admissions.

This is how we’ll know neighbourhood working is delivering the care that people and communities want from the health service . An enhanced neighbourhood offer must also pay for itself by reducing costs elsewhere in the system, which is likely to mean taking costs out of hospitals. Done well, this benefits everyone.

The good news is we know it can be done. Evidence from across the NHS shows the potential of delivering care differently to benefit all parts of the system. For example, GP practices with the capacity to meet patients’ urgent care needs lead to lower rates of 999/111 calls and emergency department attendances.

Primary care networks that make best use of technology and consultant input show reductions in planned care referrals. While integrated models for managing and preventing frailty are significantly improving outcomes for patients and reducing hospital admissions.

Scale is key here. For neighbourhood working to successfully shift care out of hospitals and into the community, both activity and costs need to move too. The only way to truly take costs of out of hospital settings is by closing wards - reducing bed demand, redeploying staff, and supporting patients in the most cost-effective and appropriate setting.

Small-scale interventions may be too expensive to replicate everywhere, and could fail to take into account how care is being delivered across a wider geography, therefore limiting their impact. We need large-scale changes across community and primary care to make it work.

A single neighbourhood, no matter how joined up, simply will not deliver care at the required scale to achieve a significant enough reduction in hospital admissions. That’s the challenge. We have examples of neighbourhood health that work – but they must operate at sufficient scale to drive the left shift. This is why the pilots currently being selected by NHS England must include services being delivered at a multi-neighbourhood level.

The pilots offer an opportunity to refine the concept and design of new neighbourhood and multi-neighbourhood contracts set out in the 10-Year Plan for England. Realising the benefits of the multi-neighbourhood tier will require clarity on which services are included in the single neighbourhood, which sit at the multi-neighbourhood contract, and how the two relate.

The GP-led single neighbourhood contract must provide the resource to ensure the delivery of high-quality general practice. This means providing sufficient capacity to meet patient demand, from telephony and appointments, to managing patients with long term chronic conditions, providing effective local care for mothers, children and those with lower acuity mental health needs, and using risk stratification to avoid unplanned hospital admissions.

It must also support collaboration across neighbourhoods and places, bringing together system partners - from NHS trusts, to voluntary, community and social enterprise organisations, social care and local government - as delivery partners for the multi-neighbourhood contract. Doing this consistently across neighbourhoods is not an easy task, but the investment required offers both immediate and long-term returns.

The multi-neighbourhood contract is where the heavy lifting happens. It should provide the framework for delivering integrated neighbourhood care. This contract could be held by any local care provider selected to act as the 'integrator', responsible for ensuring successful implementation.

Some services will be delivered across a whole place, such as urgent community response or virtual wards. But much of the work, whether it’s frailty consultants running multi-disciplinary teams, specialist consultants reducing planned care referrals, or aligning community nursing and therapy staff, will be delivered at the neighbourhood level.

One important message is that much of the care we need delivered in neighbourhoods, will not be covered by the neighbourhood contract alone. The neighbourhood is the delivery vehicle for the multi-neighbourhood contract.

They must be designed and implemented together, not treated as either/or. In most cases, they will be both necessary and complementary. This is an opportunity to move to a more joined-up model where commissioning and delivery of primary care, urgent and emergency care, and planned care are not considered in isolation.

Finally, each place must have the financial incentives to manage budgets, deliver the new care model, and establish governance and operating models to make it work. Without this, all risk will continue to sit in one part of the system. But that’s a topic for another piece of the new operating model jigsaw.

For now, we call on national leaders to move quickly on neighbourhood and multi-neighbourhood arrangements in a coherent and joined up way and to be clear from the outset on what the markers of success will be.

This article first appeared in Health Service Journal