Communication materials

Neighbourhood health - improving care for our communities 

Neighbourhood health is a new way of organising and delivering health and social care.  

It focuses on prevention and early intervention, reduces duplication and improved communication between teams.  

Most importantly, it supports people to live well in their own communities for longer. 

What's happening now?  

At the moment, care can feel fragmented. People may see a GP, attend hospital, speak to social care and connect with community services - yet these teams do not always share information or coordinate support.  

This can mean repeating the same story, waiting for referrals and travelling between appointments, which can be frustrating for patients and carers.  

Care is often reactive, stepping in when problems escalate rather than preventing them earlier.  

This can lead to an increase in hospital admissions, resulting in waiting lists going up and a rise in 'corridor care'.  

What will be different under neighbourhood health?  

Neighbourhood health changes this, by creating NHS and social care teams built around local communities. 

Instead of services working separately, it will bring together GP practices, community health teams, mental health services, social care and voluntary organisations to work as one local team, working together.  

Care is more joined-up, easier to access and centred around what matters to people, not organisational boundaries. 

More care will be delivered in GP practices, community clinics, neighbourhood settings or in people's own homes, with hospitals used for specialist or urgent care. 

It will support people to stay at home and retain their independence rather than go to hospital.  

Each team supports a population of about 30,000 to 50,000 people and brings together GPs, community nurses, social workers, mental health colleagues and voluntary sector partners.  

These professionals will work as one team, sharing responsibility for people's care and focusing on what matters most to them. 

What does this mean for patients? 

For patients and their carers and families, this means having one local team that understands their situation. There is a single point of contact, so people do not need to repeat their story. Care is more personal, proactive and delivered closer to home.  

When someone's needs change, the team can respond quickly to provide the right support and help avoid unnecessary hospital visits. 

Example: Mary, 84. 

Mary, 84, is frail and has some conditions affecting her physical and mental health.  

In a neighbourhood model, her GP practice would have already identified her as someone who may be in need of more complex and proactive care.  

The practice will work with other colleagues such as a community nurse, a social worker and local voluntary sector services such as Age UK, to share updates, agree a single plan and focus on helping Mary stay independent and safe at home.  

If her health deteriorates or she has an unexpected crisis, such as a fall, the team will act quickly - arranging home-based support including diagnostics, physiotherapy or home adaptations to prevent hospital admission. They can also provide a wide range of hospital-level treatment at home. 

The team will also work closely with Mary's family and carers, so they feel more connected, involved and better able to support Mary's needs when they can. 

This approach also supports people with more complex needs. For example, people experiencing mental health challenges or substance misuse will have one team agreeing a joined-up plan, bringing in specialist support where needed and offering care in the community. 

What does this mean for colleagues in health and social care? 

Daily team discussions will help colleagues make decisions quickly and confidently. Instead of sending referrals and waiting for responses, colleagues can act straight away because they are part of the same team.  

Shared records will mean less duplication, fewer hand-offs and fewer forms. 

This gives colleagues more time to focus on care, build relationships with patients and use their expertise proactively. It also strengthens collaboration, as everyone works towards shared goals rather than organisational priorities. 

They don't care about what's on their badge, or what organisation or trust they work for. They are a genuine team.  

Colleagues will focus more on proactive support for patients in their neighbourhood, which will prevent people from getting into crisis. Less fire-fighting and more planned support means less stress for colleagues, patients and carers.  

Specialist services are an important part of neighbourhood health. Rather than sitting outside the system, specialists will work alongside neighbourhood teams. They can join discussions virtually or visit patients at home, helping to provide expert advice early and avoid hospital admissions where possible. 

Neighbourhoods also work together across larger areas, sharing resources, learning and specialist expertise. This helps spread good practice and makes sure people can access the right support when they need it. 

Neighbourhood health is a long‑term change, not a single new service. It will develop step‑by‑step, learning from local experience and shaped by feedback from colleagues. 

Neighbourhood health aims to create a more connected and compassionate system.  

This is a significant change, and it relies on collaboration, trust and a shared commitment to doing things differently. Whether you are a patient, carer or colleague, everyone has a role to play in shaping neighbourhood health. 

Together, we can build healthier communities and a system that works better for everyone.