INTs have the potential to be a pivotal force in addressing health inequalities and delivering more person and community-centred, proactive and preventative care across London. The ability to flex and adapt to the specific priorities and needs of the communities they serve will enable the delivery of tailored interventions that resonate at a local level, through:

Developing a detailed understanding of the demographic and public health landscape at a neighbourhood level in a way which will allow us to tailor interventions to meet the needs of individuals, families, and communities.

Population Health Management (PHM) insights drawn from robust data, supplemented by community and professional insights, will be an essential enabler of the neighbourhood health service in London, to ensure that interventions target and reach priority cohorts effectively, and we learn from our successes and failures.

To achieve this, we will implement a 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.

We will consistently operationalise population health insight in everyday practice, in regular interactions with patients as well as in planning proactive work and outreach for prevention. This includes ensuring access to accessible datasets and dashboards, showing an agreed set of measures and information that is tailored to ensuring that all of our systems, places and neighbourhood teams are delivering consistent, just, and flexible approaches that meet the needs of London’s diverse populations.

At place level, we will bring together PHM insights and asset and resource analysis supported by training and upskilling for all relevant staff working in our neighbourhoods. These staff will be equipped to apply PHM-derived insights effectively, cross-referencing them with system-wide workforce analysis and asset (including physical infrastructure and services) mapping. This will be delivered in a way that recognises quality as well as quantity and identifies both gaps and overlaps in service provision; and will inform integrated resource allocation and planning in order to better meet community need as a neighbourhood health system.

Places will continue to develop 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. Tools like participatory workshops or community surveys will be available to gather insights into local barriers to accessing care, such as transportation challenges or language barriers, which quantitative data alone may not capture. Closed-loop engagement structures, including existing public forums, will help to share decisions and explain how they were made, providing feedback that allows neighbourhood stakeholders to see how their contributions have shaped outcomes and an opportunity to engage around key decisions collaboratively. Utilising this will help to ensure that decisions meet the needs of the neighbourhood, and not just the loudest voices.

We will take coordinated action across place and neighbourhood teams to understand and address inequalities, their impact on population health and current service pressures. PHM insights will be critical to building this understanding by providing the evidence base for locally tailoring INT resourcing and design decisions, through monitoring priority groups (such as Core20PLUS). Our neighbourhood PHM analysis will adopt an equity focus and processes for the continuous input of PHM insights to steer learning and improvement, essential for ensuring INTs are guided by where the most impact can be made for communities.

We will actively engage marginalised and deprived communities in these findings through co-design and culturally sensitive outreach, fostering alignment between services and local needs. Involving communities, staff and other stakeholders in shaping service delivery will help ensure that interventions and approaches reflect and respond to lived realities. Implementing consistent approaches across London to measuring both participation and the impact of participatory interventions on addressing inequalities will help to ensure all Londoners benefit.

Actively engaging all of London’s statutory and VCFSE partners in this mission.

Whilst it is tempting – and simpler – to define INTs only around a “core” set of clinicians and professionals, we know that addressing wider determinants and inequalities will be key to making a success of the neighbourhood health service. INTs are fundamentally about collaboration and new ways of working – this can only succeed if all local partners are able to work together in alignment and understanding.

This will require concerted effort to strengthen partnerships not just within health and with social care, but also bringing in key resources around housing, employment, education, local policing, and economic development, including through dedicated resource to build partnership relationships, understand different processes and pathways operating within local neighbourhoods, undertake regular shared strategic and planning forums, and invest in shared organisational development to establish adaptive working practices with shared responsibility for outcomes.

Assets should be aligned with community priorities through structured mapping and governance frameworks, ensuring equitable access to services and opportunities. Overlaying this with PHM insights will ensure resources are configured to address inequalities. This includes the use of Indices of Multiple Deprivation and related national and regional datasets to target earlier intervention, including for babies, children and young people, families and working age adults at risk of socio-economic isolation and health deprivation.

We will implement mechanisms to track progress, measure outcomes, and incorporate stakeholder feedback to continually refine interventions. INTs should establish clear processes for PHM insights to feed into ongoing planning and resourcing decisions. Public forums should be used to share decisions and explain how they were made, providing feedback loops that allow stakeholders to see how their contributions have shaped outcomes and approaches.

We will capture impact on population health and on tackling inequalities across London through consistent metrics, tools, and processes encompassing national frameworks for measuring inequalities and mapping assets, enabling alignment and comparison across areas and mechanisms and reporting processes at a system and place level, to record data, track progress and assess the impact of interventions and services.