The case for neighbourhood health and care

Background

The NHS is one of the closest things we have left in England to an institution that is revered, and yet it is in serious trouble. 

Since 1948, the NHS has made huge contributions to the health and wellbeing of the population. That work continues in communities across England every single day.   However, as the independent investigation of the NHS in England by Lord Darzi highlighted, public satisfaction with the NHS is at record lows and there are serious issues affecting almost every aspect of health and care service delivery.

This report makes the case that we will not succeed in addressing growing demands on health and care services, improving health and wellbeing, reducing health inequalities, or delivering on our wider socio-economic priorities, without a fundamental change in how health and care services in England engage with neighbourhoods and communities.

In many ways, this argument is not new. 

Policymakers and practitioners have long talked about the need for more joined-up, proactive care with flexibility to respond to local needs.  This includes a recognition that much of what drives service demand and health inequalities sits outside of the power of our current health services to influence. 

The role of communities in working with statutory partners as part of the COVID-19 pandemic response has been widely acknowledged.  Our recently developed case studies show the enduring power and importance of communities, before the pandemic and since.  Within the NHS, there is an increasing focus on the role of places and neighbourhoods, as articulated in the 2022 Fuller stocktake, which was signed by the chief executives of NHS England and all 42 of England’s integrated care systems (ICSs).  The new Labour government has emphasised the importance of this shift in its manifesto commitment to a ‘neighbourhood health service’. Two of the Secretary of State’s three big shifts, hospital to community and sickness to prevention, rest on a better relationship with our communities, going beyond the medical model and building a stronger understanding of the NHS's role in wider determinants of health.  These developments align with strong international evidence and experience elsewhere in the world. 

Yet in many areas, and especially in many of the most deprived, this is not how our health and care systems operate or are experienced by communities today.

This report reflects the most recent research and evidence compiled by social enterprise PPL, working with the NHS Confederation, representing the healthcare system in England, and Local Trust, experts in place-based regeneration and neighbourhood capacity building in the UK. 

It confirms that any transformation of public services will not be successful unless it is accompanied by a more fundamental transformation of relationships between our statutory services and our communities, building on the best of what is happening on our neighbourhoods today. 

This can be understood on two, related levels:

1. How communities can be enabled to take back power over their own health and wellbeing, particularly in areas with the greatest levels of deprivation and a lack of social infrastructure.
2. How the NHS needs to be an effective partner in this change, including a partner in broader community development and in addressing the social determinants of health and wellbeing, working with local government and VCSE (voluntary, community and social enterprise) partners.

Partnership sits at the heart of this.

Our research shows how combining community leadership and empowerment with the work of the statutory sector improves health and wellbeing across multiple different dimensions, while supporting local and national strategic goals. In enabling these developments, the NHS is potentially our biggest resource. 

The NHS employs over 1.5 million people and will receive around £180 billion in government funding this year.  NHS staff are a core part of our communities and neighbourhoods, and expenditure on health is a huge and ever-growing part of our annual public sector spend.  And yet, too often this resource is bound up in operating models and conflicting priorities that prevent meaningful relationships with communities experiencing ever-worsening health inequalities.

We believe a failure to work with communities and neighbourhoods will only lead to further productivity challenges within the health service and a worsening of inequalities across the country as a whole.  Without communities and neighbourhoods, a neighbourhood health service risks being – at best – no more than a re-branding of existing, stretched resources.  There is still much to do to create really integrated approaches to health and wellbeing, in ways that are sustainable and capable of scaling.  Much of what community-led initiatives achieve is through applying an agility and hyper-local focus which is enabled by not being part of formal systems and we know there will never be a one-size-fits-all approach that works everywhere.   

Reconciling all of this is hard. It involves a degree of risk that most statutory services, the people who fund them and many professionals within them are not used to. This is a core reason why, despite the evidence summarised in this report and the accompanying literature review, we have not yet achieved the scale of change needed.  It is equally important that we do not allow definitional arguments – for example, how we choose to define ‘integration’ and ‘neighbourhoods’ – or the broader desire for perfection, to stand in the way of immediate opportunities to work differently, and better, with people where they live.

There are a growing number of examples of inspiring community-led work across the country that highlight both ongoing barriers to change and the conditions for success.  This will require significant shifts at governmental / national level, but there are practical steps we can be taking as neighbourhoods, places and systems now, with local government and the voluntary and community sector as partners in this journey.

The bigger risk is trying to continue as we are.

This report calls for an urgent acceleration of progress, nationally and locally, building pragmatically on the best of how our statutory services and communities are working together at a neighbourhood level today. But to move from pockets of excellence to widespread shifts there needs to be clarity on the role the NHS should and should not play, a strategy to reform the NHS to play this role and a commitment to delivering this strategy.

Our approach

The findings of this report are based on our review of the growing literature relating to neighbourhood and community-based working, nationally and internationally, together with direct engagement across England with those who are already working differently, to identify those defining factors in effective, community-led health and wellbeing at the neighbourhood level.

The case for change

The case studies we have developed provide a compelling argument for working with communities and neighbourhoods differently. Some involve successful examples of neighbourhood approaches within the NHS, while others involve local community-activated services with a broader scope beyond health.  

Each highlights a clear need for local residents to be a leading partner in neighbourhood working: a role communities are well-placed to take on. 

This kind of community involvement can meet a range of health and wellbeing goals. These range from improving the lives of children and young people to helping older people living with increasingly complex needs, and supporting working-age adults who find themselves in a cycle of socioeconomic exclusion linked to compounding mental and physical health challenges. 

Such issues are rarely capable of being resolved through episodic, medically based interventions.  The latest review of the NHS by Lord Darzi has highlighted the need for:

• simplifying and innovating care delivery for a neighbourhood NHS, embracing multidisciplinary models that bring together a range of primary, community, mental health and wider services
• NHS organisations focusing on the patients and communities they serve, with national organisations enabling and not distracting from this process
• recognising that, as one example, people in the most deprived communities are far more likely to have multiple emergency admissions to hospital in the last year of their lives, but that the health service has a potentially huge role to play in tackling wider socio-economic inequalities, improving the quality of people’s lives and economic prospects, at all stages of their lives.

Our work suggests that the support to change lives effectively exists in our neighbourhoods, but only if public sector resources and community assets can be brought together in the right way.

There are several compelling reasons to make this a priority now. Neighbourhood healthcare is already a top concern for the new government. It is also an increasing issue for frontline workers, recognising that statutory services alone cannot provide all the support people need.   There is a growing recognition that without the help of local people we will never be able to unleash the potential of our neighbourhoods, with the new perspectives, energy, creativity and understanding of community assets.  And crucially, there is a growing body of evidence that, just as conventional top-down approaches to health have failed, approaches based on working in active partnership with communities are much more likely to succeed. With the NHS under more strain than ever, this mounting evidence cannot be ignored. 

National policy

The commitment of the government to this agenda does not, on its own, determine whether or not this is the right thing to do. But political will is significant. It would be a mistake to ignore the clear priorities being set out by the new Secretary of State for Health and Social Care, and to miss the opportunity to shape emerging government policy to benefit both communities and the statutory services upon which they rely.

The new government already has a clear aspiration to develop neighbourhood health and care services in England, transforming the focus of the NHS away from high-acuity settings and towards community and neighbourhood-based approaches to improving care. This is set within the context of a broader mission to improve population health, and a commitment to devolution. 

There is also a clear starting point for this work within the NHS. The Fuller stocktake – a comprehensive review carried out in 2022, by Dr Claire Fuller – articulated a position on the future of neighbourhood care based on three related areas: 

• Helping people to stay healthy for longer through a more joined-up approach to prevention.
• Providing more proactive, personalised and multi-disciplinary care for people with more complex needs.
• Streamlining access to care and advice to meet the needs of infrequent users of healthcare services. 

“Throughout the stocktake, we heard that the primary care networks that were most effective in improving population health and tackling health inequalities, were those that worked in partnership with their people and communities and local authority colleagues.” 
Dr Claire Fuller, the Fuller Stocktake Report, May 2022

At the heart of this approach was the concept of the integrated neighbourhood team (INT) that ‘brings together previously siloed teams and professionals to do things differently to improve patient care for whole populations.’

The future of primary care is intrinsically linked to the neighbourhood agenda.  In some areas, the GP practice or local pharmacy may be the only community asset left. 

There is significant variation in the capacity of individual practices, social prescribers and the primary care networks (PCNs) that support them to move beyond traditional patient engagement to partnership working with communities.  Some PCNs report they are doing this already, and our case studies highlight examples where this is happening.  However, enabling GPs and wider professionals to engage and work more proactively with their communities will require changes to how primary care services are contracted, funded and assured, to unlock capacity and optimise at-scale provision/expertise in primary care.

This is an important next step to improving both population health and the sustainability of primary care in England and has implications for wider health and care services, including our community providers and large hospital trusts. 

INTs provide a potential pivot within the NHS for professionals working towards this vision of a more neighbourhood-centric health system, but this report is about more than just integrating health and care professionals.  There are clear lessons to be applied from wider community health efforts, drawing from a strong international evidence base. 

A singular focus on developing INTs should also not obscure the very real work going on today within communities themselves, or the benefits of going beyond integration as a way of joining up statutory services.

The best models will go further:  exploring the potential for health and care systems to co-design and co-produce better outcomes with local residents and communities themselves, without undermining the existing rich tapestry of successful community-based and community-led initiatives that are already contributing to improved health and wellbeing at a local and hyper-local level.

Lessons from the front line

Most of the issues facing public services will never be solved by central government or national institutions acting alone.  Currently, the pace of UK life expectancy improvement is slowing. Health inequalities and socio-economic inequalities are widening. These are problems that demand joint action, involving both individuals and communities. 

We now have a far better understanding of the social determinants of poor health. These include income, education, diet, access to green spaces, employment and housing. Each is rooted at the neighbourhood level, and are exacerbated by high levels of social isolation, with implications for mortality made worse by deprivation and a lack of access to social resources and networks.   

The factors that are driving poor health, and the most successful responses, sit outside of the conventional reach of the NHS and other statutory services not least because of the cuts to local authority spending which have often disproportionately affected the most deprived areas. A core part of the case for change is the need for a much stronger diagnosis of the impact of declining assets and infrastructure within communities, and of working with local statutory partners to reverse that decline.

The impact of healthcare interventions in this context has proven limited, with a significant productivity challenge in relation to ever-increasing expenditure on traditional healthcare services, and their effectiveness reduced by the many underlying issues affecting people’s lives.  Not only are medical solutions to social problems unlikely to work, but there is an increasing risk of ‘moral injury’ to healthcare staff when they are asked to solve problems for which they can’t provide the answer. This is reflected in growing issues of both recruitment and retention of highly qualified and committed staff, across the health and care sectors.

No one agency, service or group holds the answer to these problems. What is needed is coordinated, system-wide action that spans communities, health, criminal justice, employment services, education and local government. 

As one ICB chief executive told us, this is about thinking less about working ‘in’ the NHS and more about working ‘for’ the NHS and the communities it serves: changing culture and behaviours in this context is not something separate from the day job.

The examples in our research and elsewhere demonstrate that solutions need to be developed and delivered by and with the people who are most affected. This means a higher level of engagement between statutory services and communities than has been the norm in many neighbourhoods and requires a much more local focus. 

Building on asset-based approaches

Our work shows how working with communities has the potential to unlock new ideas, insight and resources.

A focus on the community’s assets and strengths, rather than its deficits, reframes how people think about the opportunities available to them.  Communities contribute skills, knowledge and individual commitment to build on existing social capital of networks and friendships. Other assets include local business, community centres, green spaces, as well as the resources of the voluntary sector and public services. 

Communities in many neighbourhoods are taking the lead in promoting health and wellbeing, creating healthy environments (including green spaces and employment opportunities) and developing social capital (the network of relationships and interactions that provide mutual support). Social capital makes a difference because it can buffer and protect communities from ill-health and reduce the impact of inequality and deprivation as well as being an important good in itself.

People understand their neighbourhood.  It is the scale at which people can organise – fostering participation, cohesion, and joint problem solving.  

However, while social capital is present in all communities, the most deprived require foundational investment to build and sustain social infrastructure. Without such investment, disadvantaged communities are likely to continue to experience significantly worse health and wellbeing outcomes than more affluent areas.

Delivering better outcomes together

This report argues that working at the neighbourhood level can improve people’s health and wellbeing. But it can also catalyse other positive outcomes:

• Local and national economic growth
    Impact studies have found that for every £1 spent on prevention of future ill-health, a £14 benefit is realised across society. Precise figures will vary, but we know this benefit is real and accrues in many different areas, including individuals, the local economy and in reduced demand for public services.  This is facilitated by support and investment nationally, but can only be realised by engaging with people where they live, work and play: in our neighbourhoods and communities.
• Employment
  Neighbourhood working can boost the local workforce by supporting individuals into employment and catalysing local economic regeneration. More than one-in-five working age adults in the UK are not looking for work for a range of reasons, a number related to rising waiting lists for acute care or long-term conditions. Public Health England estimates that returning people to work creates a £3,500 average financial gain to the individual, £500 to the local authority and £11,700 in savings to the national government. The overall gain to society (based on a local economy multiplier of 1.6 and 1.66 health-specific multiplier) is £23,400 per person returning to work.
• Reduced pressure on statutory services
  Improved health and wellbeing helps to avoid preventable use of health and other statutory services, meaning these valuable resources can be used by those who need them most.  We found multiple examples of this in our case studies and literature review, including some highlighted in this report.

As a result, there is a huge opportunity to harness existing health and care resources to better co-ordinate across the population, from working with communities to give individuals and families a better start in life, to helping working-age adults back into sustainable employment.

A system that works for communities themselves

Giving a voice and power to communities that have previously felt powerless creates more resilient and stronger communities that are more able to tackle the issues they face. This is particularly important in times of crisis. A strong neighbourhood with high levels of social capital can respond more quickly to stressors such as the COVID-19 pandemic or the cost-of-living crisis. 

The economic case and the impact on health services are important for decision-makers being asked to invest in supporting communities and neighbourhoods.  But benefits also come from helping communities leverage improved agency and control, which fosters increased pride in and sense of place. While these may appear less tangible, for people in communities these outcomes are just as important and meaningful. Research suggests that these benefits can become tangible and have a significant impact on the local economy and wellbeing of the population. 

A strong feeling that emerged from the case studies is that such developments help create a sense of engagement, energy and of being engaged in something different, something important and something which is ‘ours’. This all supports systems to create momentum, reach into new areas, and co-develop outcomes that are sustainable and last.

Conclusion

The case for alignment of statutory services and support to community-led initiatives, at a neighbourhood level, is stronger now than it has ever been.

There is widespread acknowledgement of the limits to what the statutory sector can do on its own to make change and of the health and wellbeing benefits from partnership.  At the core of the case for developing and nurturing neighbourhood-based work of the type we have examined is the energy that it releases; energy that creates opportunities for people to establish connections, address problems that they have often felt unable to influence and to enjoy the experience of doing so.  

The strongest examples demonstrate that it is possible for statutory partners and community sector partners to work effectively together at the neighbourhood level. This often means that a change is needed in the approach taken by statutory organisations, with a willingness to: 

• let go of elements of performance management and control 
• enter into longer-term contracts and funding arrangements
• tolerate work that is less ordered and consistent than their own
• balance tensions between standardisation and economies of scale, and the need for local adaptation and ownership.  

Such change at scale will require bold approaches to resource allocation, reflecting the need to ensure that areas experiencing higher levels of deprivation and lower levels of social capital receive targeted resources.

Companion publications alongside this report examine the steps required to make this approach work, provide case studies with examples of the existing impact of this approach and the literature review. 

The conclusion of this report, for both professionals and the many communities desperate to make a difference, is simple: if we do not approach the current challenges facing health, care and wider society through the lens of community-led, neighbourhood responses, then we are destined to repeat failures of the past. 

Conversely, if we can build on the power of neighbourhoods and communities, there is a real potential to make a significant and lasting impact across England – right now. 

Next steps

In September 2024, the NHS Confederation, New Local and PPL convened with a range of system partners in a roundtable discussion of the outputs of this work, chaired by NHS Confederation chief executive Matthew Taylor.

Our evidence shows local models are more effective in tackling health inequalities and responding to population health. However, as we consider the shifts the NHS needs to take, the role of the government and the role of local leaders, there is more work to be done. In our second report we have described this role in broad terms, but more work is required to determine the balance between a national offer, economies of scale/system offers and the community offer.  We know that this is something that systems across the country are tackling right now and as part of the ten-year plan we aim to support the government in describing what should be part of a neighbourhood health offer for every citizen and what needs to be locally determined. we will be working with neighbourhoods, places and system leaders to inform this work.

The roundtable highlighted key areas that would need to be part of this future focus: 

• Developing neighbourhood working across England will require a clear understanding of what needs to be delegated and what is the national role.
• The role of general practice and primary care in enabling our neighbourhoods and communities.
• The breadth, depth and forms of leadership and management (including within our neighbourhoods and the services that work with them).

Responding to these areas will involve engaging with wider national debates and priorities. 

Effective neighbourhood working will require both positive devolution of powers to communities and ‘negative’ devolution, by which we mean a readiness of government to create the space for community-led innovation and growth.   Existing place-based health and care partnerships, operating typically at the 250,000 population level and co-terminus with local authority boundaries, will have an important role to play within this but not all are yet ready to do so.

In advocating for a ‘neighbourhood health service’, the government will need to engage with citizens around both what they can expect, balancing consistency of access to and quality of services with local determination of priorities and needs.

And embedding this change in culture and behaviours at all levels of our statutory services, not least the NHS, will have profound implications for how acute, community, mental health and primary care services are planned, delivered, funded and assured. 

There was nonetheless a strong feeling that the size of the change and challenges involved should not obscure the potential rewards.  There is more than sufficient evidence that how we operate now, across health, care and wider public service, is not sustainable, and is working neither for patients and service users nor professionals. 

There was consensus that fundamental change is both possible and needed, and if it is to be successful, there is no better place to start than in building on the assets of our neighbourhoods and communities.

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