The co-location of services into a Neighbourhood Health Centre will be transformative for people who have faced systematic challenges around the coordination of their care. For example, we know that women have faced particular difficulty with NHS fragmentation in the past and we are committed to women’s health never again being ignored.  

In Tower Hamlets, women’s health hubs have proven effective by providing women referred by their GP with a single point of access, triage and direction to the right care, in the right place. 

The benefits have included:  

• a reduction in the number of gynaecology referrals that needed to be seen in secondary care. In its first 12 months, only 25% of referrals needed hospital care, representing a 60% reduction 

• a decrease in the average wait for a gynaecology appointment from 27 weeks to 11 weeks with waiting lists falling by 30% in a matter of months 

• 95% of patients receiving an initial response from their referral within 48 hours and 100% doing so within 5 days  

NHCs will need to consider how they build on this evidence and provide coherent, coordinated experiences of care for those who have otherwise not had one. 

Read the full case study on the NHS England website or find out more on the Barts Health NHS Trust website.

Inspired by Brazil’s successful family health strategy, community health workers visit residents in their homes on a monthly basis. They build personal relationships, rather than delivering transactional care – allowing the service to identify health and social needs early and personalise
support.

Their impact has been significant. For example, a one-year evaluation of Westminster’s CHWW programme – one of the country’s most established – showed a 47% increase in immunisation uptake and an 82% increase in cancer screening and NHS Health Check uptake in visited households (compared to unvisited households), while hospital admissions fell by 10% and emergency department visits by 7% among people living in postcodes covered by the service.

Find out more about Community Health and Wellbeing Workers (CHWWs) on the National Association of Primary Care website or read the articles below from the Healthcare Central London website: 

• Innovative Community Health and Wellbeing Worker (CHWW) initiative gains national attention
• A launch year well done: Westminster’s Community Health & Wellbeing Worker (CHWW) Programme – Healthcare Central London A launch year well done: Westminster’s Community Health & Wellbeing Worker (CHWW) Programme 

The London Ambulance Service (LAS) Hear and Treat initiative is already delivering the shift from hospital to community care, providing clinical assessment over the phone so crews can get to the most urgent cases, faster. 

The service has helped ambulance crews reach other patients faster and has helped the Service meet its target in March for responding to Cat 1 incidents – the most seriously ill patients. It has also helped reduce response time for Cat 2 incidents by over four minutes on average compared to March the previous year. 

By maximising the use of ‘hear and treat’, LAS is able to release a significant number of hours back to ambulance crews so they can respond to the sickest patients. On average this equates to around 9,200 hours for our double-crewed ambulances – ‭18,400 people hours per week 

Dr. Fenella Wrigley MBE, Chief Medical Officer at London Ambulance Service, said: “Thanks to the innovative work of our colleagues at the Hear and Treat service, we are driving down the time it takes to get to our most seriously ill patients and reduce A&E admissions when other forms of care would be more suitable.” 

Read more on the London Ambulance Service NHS Trust website. 

The Multi-Morbidity Model of Care (MMMoC) in South East London is a new way of supporting people who have several long-term health conditions. It focuses on treating the whole person, not just their illnesses, by bringing together all parts of the healthcare system to work more closely. 

This model of care supports patients at risk of developing or progressing chronic kidney disease and prioritises addressing their barriers to care. For example, if a patient has caring responsibilities or social needs that prevent them from prioritising their physical health needs, the team will support the patient priorities and then look towards optimising their care for their chronic kidney disease and other long term conditions. 

The innovation is in the collaborative approach between primary and secondary care staff, and between clinical and non-clinical staff (e.g. social prescribers, care coordinators). This makes this a truly holistic pathway, where colleagues have built relationships and come together to treat our patients as a whole person, led by patients to provide them with the best quality care. 

Francine’s story follows a patient through her care journey, including what a point-of-care clinic looks like. 

 Find out more on the South East London ICS website. 

In January 2025, London Ambulance Service (LAS) formed a collaborative approach in North Central London (NCL) to form a Single Point of Access (SPOA) / Integrated Coordination Hub.

The SPOA has supported ambulance decision making both at the point of the 999 call and when an ambulance is on scene with the patient. This has been achieved by bringing together ambulance clinicians and nurses with locally based Senior Doctors such as GPs and A&E consultants who are available to ambulance crews to discuss the best pathway for individual patients which the patient is happy with.

This new process, which sees health and social care partners working collaboratively, has enabled more patients to be referred to pathways closer to home either after a telephone assessment or face to face assessment and avoided going to the Emergency Department of a busy hospital when it is not needed. The telephone assessment rate, known as Hear and Treat, in NCL has remained as one of the best in the country, consistently treating 20% of 999 patients over the phone in March 2025 – this is compared to a national average of 16%

In addition, they have reduced the number of patients taken to hospitals and this has helped to contribute to fewer delays for ambulance handover helping to reduce the time it takes to get an ambulance to sick and injured patients in this area.

The SPOA is now looking to expand this service with a view to support some of the most vulnerable patients, frailty and mental health, needing urgent or emergency care.

Croydon has been working in this way for some time, first as integrated community networks and more recently in neighbourhoods. By working closely both the council and the local voluntary sector, local people can keep well.