The neighbourhood health service in London

Next steps for implementing the Target Operating Model in London

What can we agree now across London?

Enabling integration

1. In London, place, co-terminus with the London boroughs, is the key enabling layer for developing a neighbourhood health service and the INTs at its core, working with system teams.
2. Place partnerships will provide the leadership and overall accountability for planning, delivering and evaluating improved population health and reduced inequalities with each place.
3. Each place partnership will nominate an organisation from within that place to host the functions required to enable primary, community, mental health, acute specialist, local authority, VCFSE and other partners to work together better at neighbourhood level, as described in the Target Operating Model for London.
4. Nominated integrators will also work with others locally to provide additional support to any part of the partnership, including within the health service at individual practice level, experiencing difficulties which threaten the sustainability of the INT and the local neighbourhood health service as a whole.

Geography

1. The footprints for integrated working in London will be defined by recognisable communities and neighbourhoods and population health needs, as determined jointly by place partnerships working with local communities themselves.
2. Where local statutory boundaries, including those of current PCNs, align with such natural communities, the boundaries may be co-terminus. Where boundaries do not align, re-alignment to these footprints or development of local arrangements capable of operating efficiently and effectively across them will be required.

Participation

1. We will establish consistent messaging to support the future of neighbourhood health and care across London, developed with direct input and support from communities and partners, providing clarity for all Londoners around what will be the same across London; what will vary by system, place and neighbourhood; and why.

Population health management

1. We will implement a core, standardised, London-wide, all-age approach to classifying the needs of local populations, enabling professionals and people themselves to easily identify and proactively respond to individuals in their community. We will build on learning from existing diagnosis-based, case-mix methodology to support consistent local population segmentation across all practices and neighbourhoods in London.

Access and technology

1. We will work jointly to implement a 24/7 “gateway” to neighbourhood teams harnessing digital and other channels to enable people to access care simply, in a way which works for them.
2. We will adopt a consistent approach to managing patient flow, which considers both clinical and social factors and aims to ensure seamless integration with primary, community, urgent and specialist care services. To enable this, we will require interoperability between systems in use across health and care in London.

Information sharing

1. We will develop OneLondon to provide a consistent, standardised, and accessible view of person’s healthcare history, essential for providing informational continuity and quality of care.

What are the suggested priorities for place/system development?

Enabling integration

1. Agreeing who will host integration functions locally including supporting INTs and future local resilience, together with the relationship to the place partnership.

Geography

1. Finalising the footprints of London’s neighbourhoods based on local evidence and data, including existing capacity and demand, local assets, and needs.
2. Developing an identified set of priority cohorts (covering babies, children and young people; working-age adults; and older people), with interventions within each neighbourhood which apply a core offer for all Londoners and tailor and supplement this to reflect the individuals and communities who live, work and receive care there.

Participation

1. Developing localised, contextualised messaging describing “what the neighbourhood health service means for you” within each borough.
2. Ensuring effective community representation and leadership in decision-making around neighbourhood care.

Relationships and interfaces

1. Developing options around co-location where it makes sense, including exploring opportunities within existing and recognisable neighbourhood “hubs” as venues for shared delivery.
2. Ensuring key partners including domiciliary and residential care providers are part of the process of co-designing and INTs.

Population health management

1. Bringing together population health management insights and asset and resource analysis to identify gaps and overlaps in current neighbourhood provision, to inform shared planning and
   resource allocation.
2. Developing mechanisms to incorporate lived experience and qualitative feedback into planning processes involving communities, staff and other stakeholders to help ensure that interventions and approaches reflect and respond to lived realities.

Governance

1. Developing consistent neighbourhood governance structures which support and empower local clinicians, professionals, and communities whilst ensuring alignment with broader goals.

Access and technology

1. Clear signposting systems, agreed and facilitated by cross-sector partners, will help to reduce confusion and improve access to services.

Metrics

1. Mapping data associated with each population segment at a granular geographical level (eg within individual lower super output areas (LSOAs), to build a picture of need across a locality as well as “what good looks like” in terms of outcomes for local communities.
2. Understanding geographic trends, variation, and drivers including measures of engagement/disengagement with health and care services.

Enabling integration

1. Working with primary care to articulate the support offer to ensure consistent, high quality and sustainable services across London, recognising the critical role general practice and wider primary care services will play in enabling the neighbourhood health service.
2. Working as five systems to co-develop a Strategic Commissioning Model for London, including the scope of services within the INT core offer, investment principles, and use of aligned incentives to enable all ICBs to move towards this for 2026/27.
3. Building the value case with local authorities, understanding the relationship between demand pressures across health and care in London both to improve individual outcomes and start to relieve activity, demand and financial pressures across health and care.
4. Developing aligned delivery plans across all five London systems enabling year one of the neighbourhood health service.

Workforce

1. Developing integrated workforce planning with a focus on shifting and expanding the workforce “upstream” into proactive care through recruitment, skills development, and making full use of the depth and breadth of health and care professionals and experts-by-experience within local areas.
2. Working with primary care colleagues to maximise the impact of existing resources including the Additional Roles Reimbursement Scheme (ARRS) funding; GPs with Extended Roles (GPwER); current and new community-based roles.
3. Developing the “team of teams” model for integrated neighbourhood working including how best to align relationships within and across different spatial levels, including through embedding specialists where appropriate and rapid access to specialist help whenever needed.

Geography

1. Developing shared understanding of how services are being used and how this, in turn, is reflected in any future integrated models of neighbourhood and community-based care. This includes the prevalence, impact and management of activity where patients and service users are currently receiving health and care services in different parts of London, as well as activity flowing into and out of London from surrounding regions.
2. Developing a common approach for working with primary care at scale. For example, where current PCN boundaries do not align with natural communities or population health needs.
3. Understanding how best to manage relationships with providers working on larger footprints across ICSs and regionally, including but not limited to the London Ambulance Service and larger acute trusts.

Relationships and interfaces

1. Modelling the impact of the shift to neighbourhood working across London’s current provider landscape. This includes key priorities such as reviewing the Outpatient model in London.
2. Working with voluntary, community and faith groups to understand common opportunities and barriers, and develop a shared approach to enable VCFSE organisations in London to play a full part in future neighbourhood teams.
3. Strengthening mechanisms for sharing best practice across neighbourhoods and places. This includes ensuring that learning and emerging evidence is used to support the scaling and spreading of “what works” in neighbourhood health and care.

Population health management

1. Selecting and rolling-out a suitable framework to enable consistent practice level management of population health needs, building on learning from existing diagnosis-based, case-mix methodology to support consistent local population segmentation across all practices and neighbourhoods in London.
2. Working with partners to develop a London-wide approach to understanding how best to engage housing, employment, education, local policing, and economic development functions and assets, building on existing local and system best practice.

Participation

1. Co-developing relatable and accessible materials to enable active participation, helping people understand their role in driving and realising the benefits of the change, working with existing networks and partners across our place partnerships, and building on the recent London-wide deliberative engagement.
2. Developing adaptable communications templates and engagement tools at national and regional levels, will help to ensure alignment in messaging and participation opportunities, whilst allowing for local customisation.

Resource allocation

1. Understanding funding in relation to existing pooled and wider health and care budgets, considering how best to deliver long-term sustainable support to communities within existing financial structures and arrangements, including use of delegation and subsidiarity.
2. Linking plans for public sector estate and capital as a catalyst for integrated neighbourhood working and improved outcomes.
3. Developing guidance around refreshing alliance and place roles to support this shift towards greater local autonomy in resourcing.

Information sharing

1. Developing a London-wide data sharing framework to enable integrated datasets to inform proactive health planning, encompassing wider determinants of health. A unified approach will include statutory and non-statutory organisations, such as VCFSE partners, and understanding how they can be included within data sharing agreements as appropriate.
2. Developing principles and practice to enable Londoners to “own” their own care record and data supporting a move toward greater levels of independence, strengths-based models, and patient activation.

Governance

1. Developing clinical governance, resource and risk management including protocols to oversee care quality and patient safety, mitigate clinical errors, and ensure patient safety across multi-organisation health and care delivery systems.

Access and technology

2. Developing our approach to accessing INTs via a streamlined 24/7 “gateway” including telephone and digital channels and support to those presenting in person, wherever they present (including at GP practices, pharmacies, and other community-based organisations) to be connected with the relevant neighbourhood teams and services.
3. Developing a consistent approach to managing patient flow which considers both clinical and social factors and provides as near as possible a seamless integration across primary, community, urgent and specialist care services.