The Target Operating Model for the neighbourhood health service in London is designed to be read in conjunction with the accompanying Case for Change and proposed Next Steps for London.

The breadth of the model and the length of this document reflects feedback from across London around the necessary enablers and the barriers to overcome if we are to develop a true neighbourhood health service across 32 boroughs and the City of London.

Whilst the model captures and synthesises significant existing good practice and learning from across London and the rest of England, we recognise this is only a starting point and not an end point. To be successful, this model will need to continue to evolve in relation to national, regional and local findings and direction.

However, in identifying the things we can agree now, as a region; those which we can progress immediately, as systems and places; and those priorities for shared development, to improve care across the capital; we set out under Next Steps a concise roadmap to make positive change happen, for all those who live and work in London.

Since July 2024 London’s Integrated Care Boards and London Health and Care Partnership (including the Greater London Authority (GLA), London Councils, NHS England and the Office for Health Improvement and Disparities) have been working in partnership and with a range of wider national, regional and local partners on developing the concept of a neighbourhood health service for all Londoners.

In this context, a neighbourhood health service means a service that provides high quality, coordinated, accessible care in every neighbourhood; for all ages, from babies, children and young people to working age adults and older people; for all levels of need, from those at risk of ill-health but not yet unwell to those already in receipt of long-term, complex health and care; in a way which works sustainably for the wellbeing of all our communities and the professionals who support them.

Central to this model has been feedback from Londoners, including through deliberative engagement delivered by Ipsos Mori and Imperial College Health Partners.

This research has highlighted public support for the concept of rolling out integrated neighbourhood teams (INTs) in London, including the greater use of technology to improve access, coordination and outcomes of care; but also the need for a consistent “base level” of health and care services, so that patients understand the system and do not see a change in quality and accessibility of care based on where they live. How to balance a consistent set of services across London with the ability of frontline teams to respond to specific individual and local needs is a key challenge for all places and systems in making this shift.

A recurring question in the development of the Case for Change in London and the Target Operating Model has been what will be different, not least, for individuals and communities themselves?

London has a long history of working together to solve shared challenges and, (as with other regions of England), has existing examples of statutory services and communities collaborating at neighbourhood level to address health and wider socio-economic inequalities.

The challenge for London, as elsewhere, is that despite all these efforts, those inequalities continue to grow. This, in turn, has contributed to increasingly unsustainable pressures across all aspects of the health and care system, including the NHS, local authorities and Voluntary, Community, Faith and Social Enterprises (VCFSEs). Today, too many Londoners continue to experience challenges in accessing the care they need, when they need it; and too many of our limited resources are consumed responding to healthcare needs when it is already too late, at the point where people are experiencing physical and/or mental health crises.

The Target Operating Model for London recognises the opportunity to build from where we are today across the 32 boroughs and the City of London as well as to apply lessons of the past. Associated lessons include:

1. Challenges across health and social care cannot be solved by the NHS or local government continuing to work as we do today.

Specifically, working jointly to identify and co-design key enablers over the last six months, we have identified specific needs in relation to: geography; workforce; relationships and interfaces; participation, working with communities; population health management, and addressing inequalities; information sharing; access and technology; governance, including aligning clinical, professional and managerial frameworks; metrics, and evidencing success; ensuring resources – ensuring they are able to flow to where they are needed; and supporting people through the change.

We believe addressing the related challenges and improving overall health and wellbeing will require an organisation in each of our place partnerships to host required functions and infrastructure. Organisations taking on this integrator role will support and enable places and London as a whole to operate efficiently and effectively as a neighbourhood health service and draw down, as appropriate, system, regional and national resources.

Given time and resource constraints, integrators will need to come from within existing partners operating at place level. Their role will not be to lead or dictate the local neighbourhood model, but to enable successful delivery.

This is likely to involve working closely, and sometimes formally, with other local partners providing complementary functions. Combined, this set of support functions will also need to be able to respond if there is any risk to the sustainability of health and care or access to neighbourhood health services within or across neighbourhoods including support to individual teams and practices if required.

The intention of the Target Operating Model is not to mandate which organisation from our existing partnerships will provide this support; it is not about creating new or competing organisational forms or expending limited local resources on competitive processes.

Places will be asked to work as partnerships to determine which organisation is best placed to act as the core integrator within that place, supplemented by other partners as appropriate. To support this, a core set of requirements will be developed, building on the model for London and emerging national guidance.

This will ensure not just a core offer around health services across London but a parallel core offer capturing how Londoners can expect those services to be coordinated around them.

2. Communities are at the heart of this change.

Alongside the three shifts – (of hospital to community, analogue to digital, and treatment to prevention) – will be the fourth shift from national to neighbourhood.

Achieving this will mean empowering individual patients, service users and carers, and neighbourhoods and communities themselves, to be partners in improving health, wellbeing and the wider drivers of inequality across the capital.

Some of what is described in the Target Operating Model may feel quite far away from how our structures operate today.

We do not underestimate the challenge of transitioning from historic and current ways of working to new models of community-centred and – led care. This will involve cultural, structural, contractual and wider societal changes and, as with everything else detailed in the model, will take time. But it will take even longer if we do not start today, and support each other wherever possible to achieve progress across London as a whole. As a senior leader within our acute sector commented as part of the co-design process: “This may be hard, but we don’t have a Plan B”.

3. A neighbourhood health service will not be possible without ensuring all Londoners have access to high quality and sustainable primary care services.

These services include those provided by general practice, community pharmacy, dentistry and optometry services. We recognise the value of existing models of primary care, but also that in areas such as general practice, London as a region is facing specific challenges in relation to workforce, estates and demand – which have continued to grow even as we provide more appointments than ever before. This is reflected in a loss of 20% of practices in the last decade.

As in many areas, these challenges affect everyone, but disproportionately those who are already living in the most deprived communities in London.

An enhanced offer of support to primary care in the context of the neighbourhood health service, is not about attempting to take over contracts or services, mandating specific models of primary care ownership and delivery, or ignoring existing support structures where these are already working well. Nor is it to ignore the role the whole system plays in making each part sustainable, and a good place for health and care professionals to work.

However, acknowledging the core role that primary care plays in neighbourhood delivery is also to acknowledge that we cannot proceed with implementing a neighbourhood health service without ensuring that primary care colleagues have access to the right level of support and services, wherever they are based in London, to enable INTs to function and thrive.

4. A neighbourhood health service will not be possible without the active involvement of social care and wider local government services.

Work is ongoing at a national level around the future of social care, but the aspirations of the neighbourhood health service today cannot be achieved without a practical transformation in the way in which health and adults’ and children’s social services work together in London, including those services commissioned from domiciliary and residential care providers.

For Londoners with long-term and often complex needs, the majority of the workforce and the daily contacts with health and care services are through such care providers. We cannot create an integrated neighbourhood team, or even a set of team of teams, without understanding their role, supporting cross-skilling and upskilling, and more effective information sharing – including with VCFSE delivery partners.

Equally, in relation to the role of public health, housing, economic and community development, the environment and wider local service delivery, we need to acknowledge both the critical role of local government and the specific financial pressures affecting all local authorities in London.

At the heart of the Case for Change and the Target Operating Model is the recognition of the impact of current inequalities and challenges within the NHS on other public services, as well as the opportunities to work together to build a more sustainable future for all.

Within the Target Operating Model are shared principles and practices we can agree now; areas which will benefit from working together as a regional partnership; and areas which specifically will need to be planned, managed and delivered within each place and neighbourhood.

What unites them and what unites us is an unashamed focus on delivering improved outcomes for all of London’s communities. By working with our existing systems and place partnerships, providers and communities themselves to an aligned vision and set of enablers, we have an opportunity to ensure not only that the Government’s vision for a neighbourhood health service is realised in London, but that all Londoners will benefit from this.

This means a fundamental transformation of our health and care systems to a fairer, more equitable and more effective model of delivery – one which prevents as well as proactively responds to ill-health and which promotes wellbeing, building on the best of what we have today.