The neighbourhood health service will balance the provision of consistent, high quality and accessible local care with the flexibility required to improve population health and address inequalities across London.

Without this shift, any improvements in the funding or delivery of individual services across health, local government and wider partners will continue to be overwhelmed by inexorable growth in activity and demand.

To achieve this shift, we need to improve outcomes for babies, children and young people, for families, working age adults, and for older people – a whole population approach.

We will need to respond to public concerns and current challenges around accessing everyday care, in the way which both patients and professionals tell us they want to see. At the same time, we need to improve support to prevent ill-health, and to improve co-ordination for those living with complex needs. We need to do all of this for all of our communities, including the most underserved and those currently suffering the worst inequalities. And we have an opportunity to build on existing models which are already bringing to life the concept of integrated neighbourhood working beyond the traditional medical model.

Within the Target Operating Model, the neighbourhood health service extends beyond the concept of INTs, but INTs are one of the main delivery vehicles for improving coordination and outcomes of care within each place and neighbourhood.

In London, INTs will be based on a “team of teams” approach. This will enable meaningful, coordinated working on a human scale, whilst affording the flexibility and authority to adapt and integrate specialist input wherever required.

Within this model, there will be a core of professionals who we anticipate will be engaged in a number of different integrated team settings, across all age groups, levels and complexity of need.

This core group includes general practice and wider primary care, community services, mental health, and acute specialists; public health; adults’ and children’s social services; and housing teams. We are experiencing rising demand for social care across all age groups, and domiciliary and residential care providers, (who are not part of current integrated arrangements in most places), will need to be a core part of teams working with those with complex needs, be those short or long-term.

Voluntary, community and faith groups already play an important role in communities – including as advocates, and as providers of support, services, and as hubs for engagement and delivery – but have been severely impacted by the funding pressures affecting all local services. They need support to be able to operate effectively alongside statutory services.

Addressing economic inequality and inactivity will also require increased joint working with employment services, enabled by changes locally and nationally, and alignment with plans for economic development and growth across London.

All of this will require a combination of upskilling, cross-skilling and strengthened awareness of the roles and contributions that professionals and organisations play.

Critically, communities and community leadership will be a core enabler in identifying and addressing population health priorities, assets, and needs. This includes in the development of new models of care that are able to respond to legitimate concerns around the impact of adopting new technologies, information and data sharing in care delivery.

Below provides an indication of how health and care functions might wrap around individual residents and communities, but it is important to note that this is indicative only.

Alignment of functions in the real world will depend on a range of variables including the population, geography, workforce, local assets, and needs. Nor does this approach necessarily imply wholescale organisational or structural change. It is much easier to begin by enabling people to work together differently, rather than to start with trying to reconfigure organisations. The opportunity in all places is how to apply the principle of having individuals, residents and communities at the heart of our health and care system to questions around how best to organise available resources to meet local needs.

The below is indicative of functions and services we anticipate will be required within a “team of teams” model of integrated neighbourhood delivery.

Aligned Functions

• The INTs will be augmented by additional specialist input, generalist roles (e.g., geriatricians) and resources
  tailored to local needs.
• While they may not sit directly in the INTs (e.g. because it doesn’t make sense to dedicate their time to a specific INT all the time), clear communication lines and clarity on how they input will need to be established.
• They will reach in and out of the other tiers to provide specialist input and care planning.

Tailored Functions

• This will vary between each INT depending on what is available and what helps the INT to meet the needs of the population that it is serving and achieve its specific aims and benefits (e.g. specialists).
• They will have consistent presence, dedicated resource and a role specific to the neighbourhood (e.g., integration hubs or specific VCFSE providers).

Consistent Functions

• There will be consistent membership from INT to INT, bringing together primary care, social care, community and mental health services, acute clinicians/specialties, key VCFSE organisations and population health dedicated/allocated to each INT (e.g. district nurses)
• They will manage and deliver integrated clinical and operational services, and provide continuity of care and work together to shared outcomes.
• They will reach in and out of the other tiers for specialist input and care planning.

Hyper-Local Functions

• Services (e.g., community pharmacy, general practices, VCFSEs) that often serve as the first point of contact for residents need to be reached into by/strongly linked with INTs.
• They hold deep community knowledge and connection, and play a proactive role In population health
  management, identifying needs early and escalating complex cases.
• Clear shared care protocols will enable seamless coordination with INTs.

Resident

• The resident is at the centre of all neighbourhood working.
• INTs need to be strengths-based building on local knowledge, community assets and local needs.

Our existing place partnerships and leaders will be responsible for leading the shift from planning and commissioning to operationalising neighbourhood delivery, building on existing local models, best practice and shared design principles.

This will commence, where not already agreed, with defining clear membership, sub-structures, and shared roles and responsibilities within each concentric “tier” of the local INT model. The aim is to ensure that professionals can operate within and across the right spatial levels, with geographic coherence, and with respect to capacity and demand in each place. This includes:

1. Residents: Starting with the premise that for the resident, care provision across the different teams, (from those operating hyper-locally to those at place, system and regional levels), should feel seamless and that they, their carers and loved ones are a part of this team in creating better health outcomes.
2. Hyper-local functions: Services that often serve as the first point of contact for residents and that have deep knowledge and understanding of the communities in which they are based. This includes general practice, community pharmacy, community nursing, domiciliary and residential care providers, and local VCFSE partners, amongst others.
3. Consistent functions: Bringing together dedicated, multidisciplinary health and care staff across an INT who can meet the majority of the demand from the local population; provide coordinated and personalised care; and continuity of care (both relational and informational) to those who value and would benefit from it. These will be consistent functions offered across all INTs within a place, and will be able to deliver at a “minimum efficient” scale. They will reach in and out of other levels of delivery as needed to meet the needs of the resident.
4. Tailored functions: Tailored functions may vary from INT to INT according to the needs of the identified populations that each is serving locally. They should have consistent presence, dedicated resource and a role specific to the neighbourhood.
5. Aligned ‘specialist’ functions: INTs must be able to embed specialist professional input from acute trusts and other specialist providers to provide seamless care, conduct multi-disciplinary case reviews, and ensure effective ongoing management of care across care settings. The make-up of supporting specialist resources should flex around the needs of the local population that each INT serves, and needs to be part of formal consultant job plans.

To deliver this will require:

• Clear and shared understanding of the roles of different members and teams and a minimal level of bureaucracy regulating how people and patients move between them: This includes having streamlined approaches to communicating, discussing, and sharing responsibility for an individual’s care. It means that the design of the team should, where possible, allow for the development of stable professional relationships between INT members and key professionals in the wider system. For example, aligning a named consultant to work with one or more INTs to provide specialist advice and support, consultation services, and input to population health.

• Alignment between the size and composition of the INT and wider teams with the needs and the characteristics of the places they serve: This will require a phased plan for the redistribution of resources, and an understanding in the short term of what can be achieved within existing organisations and structures through a commitment to mutual aid and support. A neighbourhood health service will still need hospitals and care homes, but will require a workforce that can operate effectively across different care settings and from the population level to the level of individual needs. This shift is as much cultural and behavioural as it is structural, and will need to start with existing clinicians and professionals being empowered to work in a different way.

• Aligned and tailored services should be positioned to flexibly respond to changes in local demand: Including through released capacity which can be ramped up or down to ensure the right support is available in the right place at the right time. Whilst some changes will take time to translate into reduced demand, others (such as secondary prevention, or a transformation in how we provide outpatient services) have the potential to free up resources much more quickly. We need to ensure these resources support increased focus on proactive and preventative care, creating a “virtuous circle”, rather than just being re-absorbed back into existing service models.

• Shared purpose and aligned outcomes: Successful partnerships need to be anchored in a limited number of clear shared goals. Existing neighbourhood partnerships demonstrate the importance of a unified vision to align efforts across health and care. These partnerships focus on population health management, reducing health inequalities, and encouraging trust amongst providers. The Relationships and Managing the Transition modules of this operating model provide more detail on this.

• Mutual understanding of roles and responsibilities: Effective teams need a good understanding of others’ roles and scope of practice, cutting down bureaucracy and ensuring that solutions can be found for patients more easily. It requires high levels of trust, and permission to work differently when it is in the direct interests of patients, service users, and communities.

• Regular structured engagement: Time and processes are required to allow reflective practice, the ability to link as required, as well as in more formal multi-disciplinary planning and delivery sessions. Streamlined professional collaboration improves coordination, minimises duplication, supports timely interventions, and can also help to create psychological safety which is highly associated with team effectiveness. INTs will need to be enabled by tools and processes that facilitate seamless communication between professionals, patients, service users, and carers, ensuring alignment on care delivery and messaging both for individual patients and across a neighbourhood and community as a whole.

• Shared accountability frameworks: Developing metrics that evaluate the effectiveness of relationships between INTs and system-wide providers, focusing on outcomes such as reduced care fragmentation and improved patient satisfaction.

• Clear evaluation mechanisms: Regular reviews of specialist service alignment with INTs should be incorporated into borough level governance, ensuring continuous improvement.

• Policy and funding alignment: National and regional policies will need to support the pooling of resources and shared accountability, incentivising collaboration across organisational boundaries. Local flexibility is needed around contracting and resource flow at both system and place levels to enable cross-organisational working today, and longer-term investment in the new ways of working of the future.

• Interoperable IT systems: Establishing seamless data-sharing capabilities to support real-time decision making and coordinated care, including identification of specific patient cohorts and needs, and monitoring of the effectiveness of INTs.

• Leadership development: Equipping leaders across INTs and system-wide providers with the skills to foster trust, navigate organisational boundaries, and champion collaboration.

• Shared principles: Defining baseline expectations for relationships between INTs and system-wide providers, including shared governance and integration of specialist services.

• Organisational development: Support for the significant cultural change required to enable more coordinated and empowered frontline teams across organisational and sectoral boundaries.

• Space for local adaptation: Allowing flexibility to address unique community needs, such as tailoring mental health services to specific demographic groups.