With a big push towards neighbourhood health recently, deputy editor Beth Gault looks at urgent neighbourhood services – one of the core components NHS England has suggested should feature in this model
Neighbourhood health is increasingly seen as the direction of travel for the health service in England. From the 2022 Fuller Stocktake, to the Labour manifesto for the 2024 general election and Lord Darzi’s report in the same year, each had heralded this as the way to fix the NHS.
The 10-year health plan, which is due in this month, is expected to set out what these neighbourhoods will look like over the next decade. But in the meantime, NHS England provided guidance for system leaders in January, setting out the first steps towards this model.
These guidelines outlined six core components of neighbourhood health that systems need to work on (see box).
Core components
- Population health management,
- Modern general practice,
- Standardising community health services,
- Neighbourhood disciplinary teams,
- Integrated intermediate care with a ‘Home First’ approach,
- Urgent neighbourhood services.
Last on this list was urgent neighbourhood health. The guidance said systems would need to standardise and scale these services for those with an escalating or acute health need.
It suggested these services include urgent community response and hospital at home/virtual ward services, and that they must be ‘aligned to local demand’, as well as working together with other urgent services.
‘These urgent neighbourhood services should align with services at the front door of the hospital, such as urgent treatment centres and same day emergency care, which are also increasingly accessed through a single point of access,’ said the guidance.
The aim for these services feed into the fifth core component, which is a ‘home first’ approach, to reduce unnecessary time in hospital and enable more people to be supported at home, which is typically cheaper and can improve patient experience.
The guidance added there needs to be ‘step up’ pathways to prevent avoidable admissions, and ‘step down’ pathways to support discharge.
However, it said that service footprints would be determined locally and could potentially span multiple neighbourhoods.
It comes as last week the DHSC unveiled a new urgent and emergency care (UEC) plan, with £370m in capital investment that will deliver 40 new same day emergency care and urgent treatment centres and 15 mental health crisis assessment centres.
It is focused on shifting more patient care from the hospital into the community, the DHSC says, and includes measures to increase patients seen by urgent community response teams, have more paramedic-led care in the community, and better use of virtual wards.
However, NHS national director for urgent and emergency care, Sarah-Jane Marsh, hinted that there is more to come for urgent care in the 10 year plan, saying it would ‘set out a longer-term vision to transform urgent and emergency services for the 21st century’. But that there was also ‘so much more we could all be doing now’.
NHS Confederation senior policy and delivery manager, Charlotte Ruthven, says that this urgent neighbourhood service would need to feed into what was already in place in local areas.
‘In reviewing the needs of the communities and given current activity data, neighbourhood providers will be able to determine what level and type of urgent care is needed and review their current commissioning and delivery arrangements,’ she says.
‘This will involve looking at what currently exists – such as urgent community response, same day emergency care and GP out-of-hours – to understand how these services will work together to deliver a joined-up approach to meet the specific needs of individuals. It is also about identifying gaps to determine what more, if anything, is needed.
‘Given the current financial climate, we need to streamline services, avoid duplication, and ensure that the right services are set up effectively to deliver a consistent response to meet demand. Through good pathway redesign, providers working in partnership can determine the level of care needed at different points and who is best placed to provide that care.’
How are they working already?
In March, NHS England gave an example of an urgent neighbourhood service in East Kent, where they merged a virtual ward focusing on frailty, based on population need and demographics, and an urgent community response which caters to all population cohorts, to provide a coordinated care service.
It is coordinated by a single point of access multidisciplinary team (MDT), including frailty clinicians, emergency department consultants, and paramedics, with plans to include GPs in the future. It is also co-located with ambulance services and acute providers.
The case study said the goal was to ‘ensure people receive appropriate and timely care, enabled by the combined skill set of the MDT and co-location of staff’.
Over a five-month period, the average acute admissions reduced by 27.3 and bed days were reduced by 179.2 per week.
In Cornwall, the ICB say their ‘entire strategy’ is based on its ‘key reforms’, which are integrated neighbourhood teams, a community end of life offer, frailty in the community offer and a definitive discharge to assess model.
The ICB chief medical officer and GP, Dr Chris Reid, says the plan was to take strain of urgent and emergency care flow by having a targeted approach to the frail population and having ‘upstream work’ such as risk stratification.
As part of this model, the ICB has three community assessment treatment units (CATU), which are also linked to community diagnostic centres. These can admit directly those who might need diagnostics, or short treatment.
‘Ideally the patient is going to stay at home with our virtual ward offer,’ says Dr Reid. ‘If you need the crisis [support], we’ve got urgent care response, we’ve got an x-ray car that can come and see people, but if you still need to go somewhere, and especially for the frail, the next step would be our CATUs.
‘It’s all about just trying to keep people away from the front door of the acute provider,’ says Dr Reid.
The ICB has also funded same-day care through primary care hubs to increase the capacity for general practice to do preventative work for their frail and complex patients. These are based around the PCN footprint and run by the GP collaborative.
‘It’s become an asset that primary care teams can use wisely for that crisis management, so they can do more preventative work with their teams,’ says Dr Reid.
Though they started as additional capacity hubs for on the day minor illnesses for the winter in December 2023, they never closed, with 15 now operating across the ICB.
The hubs were given £1.7m of investment from ICB core funding and currently see around 4,000 patients a month, with capacity to go up to 6,000. An evaluation is currently being done to see if it has met its aims.
Dr Reid adds that the hubs will probably ‘iterate’ over time as the integrated neighbourhood teams mature and as the population health is understood in more detail.
Greater Manchester meanwhile has also set up urgent primary care hubs as part of managing same-day demand, which are primarily nurse-led and open seven days a week.
Dr Manisha Kumar, chief medical officer, at NHS Greater Manchester, explains: ‘They’re commissioned in line with local urgent care strategies and reviewed regularly to ensure they’re delivering value. In urban centres, we’ve seen strong evidence that walk-in models can help absorb demand that would otherwise fall on general practice or emergency departments.’
The centres manage around 64,000 same-day attendances each year, with patients either self-presenting or being directed by NHS 111.
‘The extended hours and central locations make them a vital component of the wider urgent care system,’ says Dr Kumar.
In the Midlands, Team Up Derbyshire has created one team across health and social care to support people with high complexity needs in their homes, rather than going to hospital.
It includes an urgent community response, which provides crisis response care within two hours of referral. The components of this include home visiting, rapid response nursing, adult social care rapid response and falls prevention and recovery service.
Dr Ian Lawrence, clinical director for integration for Derbyshire Community Health Services NHS Foundation Trust, and clinical lead for Team Up Derbyshire, recently told our sister title Healthcare Leader that the service had been delivering 600 fewer attendances than would have been expected at A&E, and 350 fewer unplanned emergency admissions to hospital.
The primary care role
Despite the lack of prominence of PCNs in the neighbourhood guidance, Dr Reid, who works sessions in Cornwall’s primary care hubs, says general practice should be ‘at the core’ of neighbourhood development across all the core components.
He says the vision for neighbourhoods is for integrated neighbourhood teams to really understand what facilities and clinics they have at their disposal and to use them in a much more coordinated way.
‘I think general practice is at the core, and I might have a bit of bias there, but it’s at the core of coordinating services, including voluntary, adult social care, to take that real understanding of our population, using risk stratification AI tools,’ he says.
NHS England has previously said it will ‘build on’ PCNs and other cross-team working to create neighbourhood health, and that it can be delivered by PCNs. Though the blueprint for the future model of ICBs explicitly said it did not have the picture of what neighbourhood health will look like yet and deferred to the upcoming 10-year plan for this.
NHS Confederation says there are a good proportion of ICBs using PCNs as a neighbourhood health footprint, but that it was not necessarily the PCN taking the leadership role, instead delivering the services with the provider collaborative or the place-based partnership leading.
However, there are others where the PCNs will not match up to the neighbourhoods, such as in London where the five ICBs recently released their neighbourhood plan, saying that PCN boundaries may have to change to align with neighbourhoods.
‘Many of the enabling functions for neighbourhood health are difficult to achieve at the 30-50k footprint such as workforce pooling, data sharing and utilising BI. This is better led at a larger scale such as a large PCN, alliance of PCNs or other primary care at scale provider such as a GP Federation or primary care provider collaborative,’ says Ms Ruthven.
However, she adds: ‘Where PCNs are working well and the footprint they are on makes sense to citizens and other providers (including local government), they often drive the local delivery of the ‘teams of teams’ approach. This is particularly helpful in more rural communities where working over too big a footprint makes it difficult for service planning.’
She says that it also depends on the maturity of the PCNs as to how involved they might be in neighbourhoods in general.
‘There are PCNs leading from the front on neighbourhood health. They see their role as a leading partner, working with others to improve health outcomes for their footprint. Where they are working well, they often have the maturity of well-established relationships built before the 2019 contract,’ she says.
‘Many were part of the original Vanguard or Primary Care Home programmes, supported by a larger infrastructure for back office support and have leadership committed to a more social model of care beyond the medical model,’ says Ms Ruthven.
PCN involvement is not necessarily dependent on the needs of the population therefore, but often the ability of the PCN to take on that leadership role. But Ms Ruthven adds that PCNs should be stepping up where they can.
‘We know primary care is vital to the success of neighbourhood health,’ says Ms Ruthven. ‘They are central to continuity of care, providing generalist expertise and acting as a front door that citizens are familiar with. Their agility, creativity and community roots mean they can be responsive to local needs while connected to the bigger NHS infrastructure.
‘Primary care working together through at-scale collaboration must be here to stay.’
A version of this story was first published on our sister title Pulse PCN.
