Working better together in neighbourhoods

The steps that can be taken to create new, more effective and sustainable solutions for neighbourhood health.

Background

Most of us can describe the neighbourhood where we live, but few of us would want to try to define someone else’s or what this might look like nationally. 

When statutory services define neighbourhoods, they will generally describe areas which are just smaller sub-divisions of other geographies to which they relate, such as regions, counties and cities. 

Within the NHS structure, integrated care systems (ICSs) can range from 500,000 to 3 million people, while ‘places’ are typically described as being at the 250,000 population level. 

The next level down in current NHS structures is often the primary care network (PCN), including groups of GP practices designed to cover around 50,000 people, and now strongly linked to the concept of integrated neighbourhood teams (INTs), which are due to be rolled out across England.

However, even 50,000 people is much larger than many of us would associate with a neighbourhood.  The reality is neighbourhoods are different everywhere, defined by a combination of political, socio-economic, historical and cultural factors that are as diverse as our local communities and which often defy geography. 

Within and across neighbourhoods live those communities, whose identity is often even harder to define, with an individual or family potentially having more than one identity that can change and evolve over time.

The fact that neighbourhoods and communities are difficult to define does not mean that they are not critical to the future of our health and wellbeing.

About this report

Our case for change makes the argument that only by changing the nature of the relationship between statutory services, neighbourhoods and communities will we have any chance of sustaining our health and care systems, closing the gap on growing population inequalities, and achieving our bigger aspirations for a better society.

As part of this work, we have looked at the evidence for neighbourhood and community-based efforts to improve health and wellbeing. We have found a spectrum of different types of interventions, from those developed within and by statutory bodies, to those that have arisen entirely within communities themselves, often in a conscious response to gaps within, or perceived failings of, the local services upon which all communities rely.

This report shows how we can learn from these experiences to build a better set of co-ordinated, neighbourhood-based responses to improving health and care, working together.

Statutory services have access to resources, infrastructure, people and scale that community groups often lack. This includes in and around the most deprived communities where there is the greatest need, but which have also often experienced the greatest degradation of community assets in local years.

Communities in turn bring their own assets, insights, understanding and lived experience; a sense of ownership, continuity and a rootedness which, for reasons including the need for efficiency, consistency and scale, have long since been lost in many of our public service delivery models.

Bringing together these two powerful forces for good to advance the health and wellbeing of a neighbourhood is not easy. 

Our report supports the Darzi review findings that INTs, in a statutory context. are essential to health and care services being more proactive, preventative and person-centred. This requires organisations within neighbourhoods to be able to integrate their structures and relationships.

However, a commitment to integration with community-led organisations and assets needs to be carefully considered. 

Part of the power of communities is that they have freedom to shape how they respond to local need in a way statutory services do not. For people in communities, they often have a unique relationship with their community that would be very difficult for statutory organisations to replicate. We must not lose the identity and role of community-led initiatives by creating one homogenous whole, but instead find opportunities to work together for a shared purpose, unlocking skills, insight, experience and resources across a neighbourhood.

Approaches that are genuinely community-led, but supported and enabled by co-ordinated public sector action, can successfully mobilise individual and shared assets and deliver better outcomes that could not be achieved by either partner alone. 

This report speaks to how professionals from within the NHS, local government and wider public services can step jointly into the neighbourhood space.

The failure to collaborate effectively around neighbourhood needs drives demand across the whole health and care system, not only in acute hospitals but in primary, community and mental health services and in adults’ and children’s social care. It results in people with serious health conditions presenting later, with more severe needs and worse outcomes, as well as being unable to gain meaningful employment or live independent and fulfilled lives.

The neighbourhood is uniquely placed to support health creation once the required enablers are in place because it is the nodal point where our efforts as statutory services come together with the communities we serve.

We’ve seen through our research the transformative power of working together at a neighbourhood level and the many varied forms this can take. At the heart of any effective and sustainable neighbourhood effort are relationships between statutory and non-statutory partners that unite to drive towards a shared objective, with mutual respect and acknowledgement of the role and impact each has. Where successful, this alignment is often transformational. Improving health outcomes and reducing pressure on health and care services. .

The UK Government has set an objective of transforming the NHS into a ‘Neighbourhood Health Service’ where better coordinated action on preventing ill-health and proactively caring for those who need help is delivered closer to home. It supports the wider fourth purpose of ICSs in underpinning not just the health of our whole population but through this supporting the growth needed to invest sustainably in better public services.

The first step is to understand that this is not just about where and how primary, community, mental health and specialist clinicians collaborate with each other and other statutory partners, but how we take this opportunity to reframe relationships with neighbourhoods and communities as a whole.

This report follows from and complements The Case for Neighbourhood Health and Care, which describes the overall case for change.

It makes recommendations, informed by our literature review and case studies for stakeholders working at all spatial levels, from national policy to local delivery.

We have found that a different change model is required to many of those we are used to applying to health and care. This is an approach that can catalyse, nurture and sustain neighbourhood working, through being adaptive and willing to cede leadership.   Without a new approach at a national and local level, isolated pockets of good work and practice are unlikely to be sustained, to scale or spread. 

While people do not want to be ill, incapacitated or hospitalised, we will always need high-quality specialist services, institutions and professionals to respond to their needs. However, the consequence of a failure to build on existing community initiatives that support people to stay healthy and well, living safely and independently in their own neighbourhoods and homes, is that no amount of investment in public services and institutions will ever meet projected demand.

The approaches highlighted in this report speak to simple and non-medical interventions at a local or hyper-local level, but have a direct impact in future on the performance and sustainability of urgent and emergency care, planned care and social care, as well as the experience and outcomes of the individuals involved.

The following sections include descriptions of the experiences of communities and their partners, common barriers to and enablers of better neighbourhood working, six principles to support this, and practical recommendations for those working at all spatial levels on scaling the impact and benefits of neighbourhood based, community-led approaches. 

Our recommendations link to six key principles of effective neighbourhood working as identified from our research:

• Listen to understand.
• Build relationships.
• Empower neighbourhoods.
• Create common purpose.
• Embrace diversity of approach.
• Think and act sustainably.