For some decades now the policy rhetoric for the NHS has described variations on a theme of ‘moving care out of hospitals’, whilst in practice the distribution of resources has gone in the opposite direction.
The current Secretary of State Wes Streeting describes this in terms of ‘three shifts’ – from treatment to prevention, analogue to digital, hospital to community. These shifts are critical in addressing the perfect storm facing the NHS, with deep-seated economic and health inequalities driving ill-health, resulting in increasing pressures on the NHS, local authorities and local partners. Without a greater focus on prevention, without making better use of the technology available to us, and above all, without a serious shift to place the community at the heart of the NHS, rather than the hospital, we will continue to see pressures on all parts of the health and care system grow.
But if this was easy to achieve, we would have done it years ago. So what gets in the way, and what might be different this time? PPL has worked in partnership with the NHS Confederation and Local Trust to look at these questions. Our work identified several barriers to change. These include:
- Funding. An overreliance on multiple short term and inflexible funding streams, with benefits taking time to be realised.
- The definition of a neighbourhood. Local people will often define neighbourhoods in ways that do not align with statutory services and vice versa.
- Reliance on a few leaders. Success is often the result of efforts of locally influential leaders.
- Balancing immediate needs with longer term solutions. The temptation to address symptoms rather than causes of issues.
- Data and information sharing. It can be difficult to share data across different teams, organisations and systems.
- Responding to diverse and conflicting views. Being mindful not to simply adopt the ‘loudest voices’ when making decisions.
- Reliance on volunteers. Striking a balance between ‘professionalising’ neighbourhood working and being overly reliant on people who want to support their community while at the same time balancing many other professional and personal needs.
- Performance management and targets. The centralised approach of the NHS to performance management of input and output measures does not lend itself to projects focused on wider determinants of health, health creation and prevention.
- Existing infrastructure. Community infrastructure is critical for neighbourhood working and this creates a challenge for neighbourhoods with low levels of existing infrastructure to build upon.
But there is hope! Alongside the NHS Planning Guidance for 2025/26, NHS England has published further guidance on the development of neighbourhood working. The intent is to accelerate the creation of a ‘neighbourhood health service’, one which addresses the multiple and complex factors required to enable people and communities to thrive.
The guidelines set out three aims for all neighbourhoods for the next 5 to 10 years. These are:
- for the NHS and social care to work together to prevent unnecessary time spent in hospital or care homes;
- strengthening primary and community based care;
- connecting people accessing health and care to wider public services and third sector support, including social care, public health and other local government services.
Systems are asked to focus initially on the first of these. However, to succeed it will be important to develop all three areas concurrently, as the broader aims are more likely to be effective in engaging staff who actually work in neighbourhoods, who will be critical to the success of this endeavour, than appeals to help reduce activity in high-acuity settings such as hospitals.
Much of the guidance is in line with the way in which places are already developing new ways of working, but there are elements that will require additional effort and shift in focus. These include:
- The development of population health management: especially the data and analytics component of this.
- Primary care development: continuing support to GPs and the delivery of the modern general practice model, Pharmacy First and self-service options via the NHS app. Without well-functioning and supported General Practice and wider Primary Care, the rest of the model will fail.
- Standardising community health services: This is likely to reveal major differences in the levels of community provision between areas within and between ICBs, bearing little or no relation to patterns of need.
- Creating Neighbourhood Multi-Disciplinary Teams (MDTs), in line with the Fuller Stocktake.
- Ensuring integrated intermediate care to deliver short term rehabilitation, reablement and recovery and step-up and step-down care.
- Putting in place urgent neighbourhood services: standardising and scaling services for people with an escalating acute need.
- Recognising the secondary care contribution to neighbourhood health: working with neighbourhood MDTs, supporting hospital at home and diagnostic hubs and creating frailty attuned services.
The scale of this task is huge in a context where there are substantial requirements both to make in year efficiency savings and to meet the other more immediate targets on access and finances set out in the broader planning guidance. In the medium term, the programme as set out here will help improve the capacity of the system to deal with demand and improve productivity, but there is a risk that the work to do this will be squeezed by short term pressures. How places and systems balance the two will be critical to both improving local health and wellbeing and the Government’s overall vision of a sustainable, neighbourhood health service.
