1.London is experiencing a “perfect storm” in which deep-seated economic and health inequalities are driving ill-health, resulting in increasing pressures on the NHS, local authorities and local partners. In turn, these pressures exacerbate those same inequalities, and limit the ability of our boroughs, health and care providers and systems to respond effectively. Whilst London’s strength lies in its diversity, our communities are too often afflicted by poverty, economic inactivity, and social exclusion, all resulting in unwarranted variation in access to and outcomes of healthcare, growing disparities in health and wellbeing, and inequalities in overall life expectancy.

2. Whilst no part of London’s health and care system is immune to these developments, general practice in London is experiencing particularly severe challenges even compared to other parts of England. This case for change considers the holistic impact of growing activity and financial pressures across the health and care system and the populations being served by each of London’s five integrated care systems and 32 place partnerships. However, unapologetically, there is also a particular focus on primary care, and within primary care the opportunities and challenges facing general practice, in the context of the Fuller Stocktake and the Government’s planned “three shifts”, along with the move to a neighbourhood health service.

3. London has already seen over a 20% reduction in GP practices in the last 10 years, with the most disadvantaged neighbourhoods and communities often the most disproportionately impacted. Whilst some of this has been planned consolidation of smaller practices, these changes reflect the growing pressures across primary, community, mental health, and acute services; across adult, and children and young people’s social care; and the voluntary and community sector in London. In turn, they contribute to, and are further affected by, increasing challenges in key areas such as access to high-quality care and the ability to attract and retain people into the workforce which provides it.

4. In parallel, senior executives in London’s hospital sector have highlighted that “we have no plan B” for acute care. London, as elsewhere in England, has experienced continuing pressures across both emergency and planned care, starkly evidenced by the rise of “corridor care” and growing waits in A&E. The message from acute colleagues is that they have opened up all the wards and filled all the corridors they can fill, in response to an inexorable rise in demand in London, with facilities already stretched to breaking point in traditionally quieter summer months. If we cannot use this opportunity to create a genuine shift of activity away from hospitals into the community, and into more proactive and preventative care (including secondary prevention for those already identified as being at imminent risk, and a better model for managing outpatient care for those in receipt of treatment), then no amount of additional investment in the health service is likely to be sufficient to meet future needs.

5. This document makes the case that our current structures, including acute, community, and mental health providers; integrated care systems (ICSs); primary care networks (PCNs); GP federations; local authorities, and wider place-based partnerships in London, will not be able to respond to these challenges without a clear, shared vision and the mechanisms to deliver this vision. This includes a consistent approach to developing Integrated Neighbourhood Teams (INTs) in London as part of the shift to neighbourhood working, encompassing the totality of population health priorities and needs; one which brings together partners across the public, private, and voluntary and community sectors; around health and wellbeing, public health, social care, and related areas such as housing, employment support, and criminal justice.

6. The Government has set out ambitious plans to transform the NHS into a neighbourhood health service which can respond better to individual needs, including through increasingly preventative and proactive care, building on three shifts – from hospital to community, analogue to digital, and treatment to prevention. These shifts will require change across all aspects of health and care in London, including how and where professionals work and interact, supported by systems and infrastructure designed to enable, and not inhibit, collaboration.

7. These shifts cannot be achieved by the NHS alone. It will require joint effort across London’s public sector providers and voluntary and community sector partners, if London is genuinely to improve population health outcomes and reduce “failure demand” across our systems. Whether that is building capacity and local leadership within communities, developing digital and data infrastructure to enable earlier and better support and care, or helping people to stay healthy and well at all stages of their lives. This effort will need to start now, and to be sustained over time.

8. Improving the quality and sustainability of social care for all will be critical to securing the future of both the NHS and local government in London. The relationship with social care is two-way – it is a core part of supporting people and communities, and is at risk if we cannot do that in a sustainable way. Just as for those Londoners who, due to a failure to provide access to health and care services at an earlier stage, find themselves in the urgent and emergency care system, experiencing prolonged hospital stays, and living with otherwise avoidable and life-limiting long-term conditions; so too many Londoners will find themselves needing long-term domiciliary and residential social care for want of effective community rehabilitative, mental health services, and wider support to stay healthy, independent and well.

9. The voluntary and community sector and communities themselves are already at the forefront of the neighbourhood agenda but their capacity to respond to the challenges being faced is equally affected by the pressures on statutory services, including around a lack of long-term sustainable funding. As recent work with the NHS Confederation and Local Trust has highlighted, often those communities which are the most in need are the ones which have seen the greatest degradation and disinvestment in community assets in recent years. There is a risk that without sustained support and investment in the voluntary and community sector, London’s public services will be unable to reach the people most in need, and will fail to harness wider community knowledge, relationships, and assets (sometimes described as “social capital”), which the experience of the pandemic and existing community-led work show are vital to address the inequalities driving growing demand.

10. The benefits of successfully and consistently navigating the shift to neighbourhood and community-based approaches go beyond health and wellbeing. Alongside benefits for the many children and young people, working-age adults and older people all living with complex needs, there is a requirement and an opportunity for teams to support those Londoners at risk of losing jobs due to unsupported physical and mental health conditions; and to enable people already classed as economically inactive back into meaningful employment. There are significant economic as well as health and wider social benefits to getting this right.

11. Most importantly, this change is what Londoners themselves tell us they want. Through a process of deliberative engagement led by Imperial College Health Partners (ICHP) and Ipsos-Mori, Londoners have expressed the desire for accessible, technology-enabled services which provide a consistent approach to care everywhere in London, whilst also being able to respond to the local population and individual health needs. Whilst this need for both consistency and adaptability often appears currently as a tension and potential barrier to change, if we cannot navigate this complexity, the neighbourhood health service will not be able to fulfil the aspirations of both better care for people and improved population health for all.

12. Practically, if we are to meet the needs of all Londoners in the most efficient and effective way possible, we need to work in a way which recognises the importance of providers who are already engaged in delivering services across regional, system and borough boundaries. Ensuring a balance between a health and care system which provides a core offer of high-quality, comprehensible, coordinated support wherever people live, whilst at the same time enabling frontline staff and local place partnerships to tailor that offer to meet individual requirements, is challenging – but is also fundamental to the success of the neighbourhood health service in London. Some of this may require national changes, including to NHS contracts and health and social care funding, but that does not mean it is not the right thing to do nor does it preclude making progress in the meantime.

13. This document argues that in London, as elsewhere, we need to both learn from the lessons of the last decade and build on the successes. No system or place is starting from scratch, but whether we are describing integration and the benefits of integration at a neighbourhood and community level or just better collaboration between professionals and communities, this will not materialise, scale or spread without specific support. This support will need to include the time and resources to develop the required relationships at a neighbourhood level; the ability to link progress and resources at place, our five ICSs and the London region; to develop clear strategies around key enablers including digital, data and estates.

14. We believe that having nominated public sector organisations able to support the operation of the neighbourhood health service in each place will be critical to realising the vision and achieving the Government’s three shifts. The accompanying Target Operating Model articulates how, within each place, an “Integrator” will need to coordinate and enable delivery of associated functions around geography; workforce; relationships and interfaces; participation and working with communities, population health management and addressing inequalities; information sharing; access and technology; governance (clinical, professional and managerial); metrics and evidencing success; ensuring resources can flow to where they are needed; and supporting people through the change. This integrator could come from a range of existing place-based organisations, but it is critical that whichever organisation takes on this role, it is able and committed to working in partnership with other local organisations and as the enabler, not the leader or owner, of the neighbourhood working agenda locally.

15. In the context of ongoing financial pressures across all sectors, and applying the principle of “building from where we are”, this is explicitly not about creating new structures and organisational forms but better harnessing what exists already. Specifically, this is not about asking organisations to take over, or in isolation take on the challenges of delivering a neighbourhood health service, but ensuring we are using the capacity and capabilities which exist in our larger community-based bodies to support explicitly the delivery by place partnerships as a whole of jointly agreed local priorities and plans.

16. There is no “do nothing” option, but we will need to address remaining “wicked issues” which threaten to act as barriers to change. These include how to resolve the patchwork of current services and offers across London, understand the role of existing structures such as PCNs in new models of neighbourhood health and care, and manage the transition without access to significant new resources. Currently, in London we spend billions each year on healthcare provision, and that cost continues to grow, even as health inequalities and public dissatisfaction increase. To succeed in this environment, change will need to be appropriately phased and prioritised, but cannot be avoided.

17. Effecting the required shift in existing resources, be those people, money or supporting infrastructure, will be complex (even with specific organisational support). We do not have an obvious alternative in any part of our health and care systems in the absence of significant increases in public sector funding and in the face of ongoing unsustainable growth in pressures across health, local government and the voluntary and community sector in London. Whatever solutions we come up with, we will need to ensure these also provide options for sustaining neighbourhood providers including those GP practices which are already in or at risk of falling into distress.

18. We have found an existing broad consensus on the need for change – the key question now is how that change will be enabled and delivered. This report concludes that this is about spread, as much as it is about scaling. We already have good examples across London of the impact of working differently, but these are inconsistent and often very dependent on local circumstances, leadership, local goodwill, and short term/non-recurrent funding. The opportunity is to spread good practice within and between all 32 boroughs and the City of London, enabled by effective support at place, system and regional levels; and to make best use of our existing resources, with regional partners including the Greater London Authority (GLA), at a system, place and neighbourhood level.

19. To achieve this will require clarity around what Londoners can expect, wherever they live in London; the role of clinicians, professionals, volunteers, and all those who support them at place and system level; what we could do once for London, in making the most effective use of available time and resources; and how we can both draw down to and build up from neighbourhood level, in creating better outcomes for all.

20. It will require shared leadership commitment – to take the opportunity of the Government’s commitment to a neighbourhood health service, and to the associated shifts, as a “green light” to convert existing ambitions and best practice into better outcomes for all Londoners.

This means moving from working with small cohorts of complex patients, and delivering targeted, time-limited action to support individuals and communities, to embedding these approaches as “the way we deliver health, care and wider improvements in outcomes” across London.