Working together to improve health in Fleetwood

An ambitious programme of integrated neighbourhood working is helping children and young people with their self-esteem, anxiety and stress at a local youth hub with specialist sessions that aim to improve their mental health and get them back into work and education. Building on their work over the last 10 years, Fleetwood wanted to develop a fully-fledged Integrated Neighbourhood Team including GP practices, community pharmacies, dental practices and more.


Fleetwood Primary Care Network (PCN) has a registered population of 28,595 patients across three GP practices. It is a significantly deprived seaside community that has poor health outcomes and poor mental health compared to the national average. In younger age groups they have twice the Lancashire average unemployment rate.

Services in Fleetwood have been working together in an integrated way for the last 10 years.  This has included GP practices, community pharmacies, dental practices, a specialist drug and alcohol service (commissioned by the local authority), a mental health trust and community services.

The need/aim

When residents talk about issues in the town they always start with mental health. The data says the same: the biggest adult disease prevalence is anxiety and depression, at 25% this is more than twice the England average. But what matters most to the community is the mental health of their children and young people. Hundreds of children are on waiting lists, some families find it difficult to access support, and community services are limited. Families do not know how to support their child’s physical, emotional and mental health.

The team wanted to create a healthier Fleetwood by improving education, employment and housing in the town as well as addressing illness.  They aim to prevent intergenerational cycles of poor health and inequalities by increasing young people’s choices and improving physical and mental health support.

The solution

Future Fleetwood is a multi-agency team that focuses on building relationships. The leadership team includes representatives from the local authority, the Primary Care Network, faith groups, local charities, Healthier Fleetwood, schools and a housing association.

They listened to healthcare professionals and collated data from schools, primary care, and secondary care to understand the local issues:

  • 147 children attended the paediatric A&E department due to significant risk around their mental health (April 21 to March 22)
  • 168 children attended their GP practice coded as a mental health presentation (April 21 to March 22)
  • 242 children were referred to Fylde & Wyre Children and Adolescents Mental Health Service (April 21 to March 22)
  • 27% of the students achieved a grade 5 or above in English or Maths at key stage 4 (2019)
  • high levels of unemployment contribute to mental health issues.

The team knew that they needed wellbeing services, safeguarding leads and schools to work together. Anxiety, low self-esteem, depression and self-harm are preventing young people from being in education or employment, but young people are not tending to engage with mainstream mental health services.

Fleetwood needed a different approach for these young people. They decided to work in partnership with a youth hub to make it easier for people to get the support they need. Thanks to the Primary Care Network’s Additional Roles Reimbursement Scheme (ARRS), multiagency funding, and partnership working, the PCN has employed a mental health Occupational Therapist, two Associate Psychological Therapists, two Adult Mental Health Professionals, a CAMHS professional and works with counsellors from a local charity. Clinical agencies work closely with the voluntary sector and the local Department for Work and Pensions (DWP) team.

The PCN runs sessions monthly at the youth hub, covering topics such as building up self-esteem, dealing with disappointment and managing anxiousness and stress. The young people can access one to one counselling from a local charity, Counselling in the Community, and a local college runs courses in English and Maths. This is helping them on the path to education and employment.

In addition, they noticed that children with significant mental health and/or problems often had at least one parent with a mental health issue too. Working as an Integrated Neighbourhood Team, they now have multidisciplinary meetings including CAHMS and Adult Mental Professions, GPs, Local Authority Statutory Childrens Services and School Safeguarding leads where these cases can be discussed.

They are breaking down barriers that prevent people from using existing services and thinking differently about how all those services work – better access, working differently, and filling the gaps.


It’s not a quick fix, this solution is built on 10 years of listening to the community (including residents, professionals that work in those communities, faith and community organisations, and other organisations that work in the locality) and relationship building. It’s built on co-production with residents and all the agencies that are working together as partners having residents at the heart of what they do.


In 10 months, 100 people have used the youth hub service, 20 have been helped back into education and 20 into employment.

The Integrated Neighbourhood Team now includes a CAHMS professional. GPs are delighted because young people previously had to travel to the Fylde coast for this service and were waiting for between six and nine months, they can now be seen in Fleetwood in two weeks. They also have a Social Prescribing link worker specifically focused on children.

They hope that longer term outcome data will show a reduced number of children self-harming, increased educational attainment, and better employment.

Beth is a medical assistant at a local pharmacy and has just passed her counter course. She tells us: “It’s nice to have someone there to help when I was literally at rock bottom. I didn’t even want to start a job until I got the kick start, I had no motivation, did not want to get up in the morning. It’s taken me four years to get where I am now and it’s amazing.”

Watch more about Fleetwood in this short film on YouTube.

Learning points

Always start by listening to the community about what matters to them and looking at the data. This might bring up different things but try to marry these up together. Bringing three strands together has been key:

  • Managing illness through the PCN as the lead agency for an integrated approach
  • Community empowerment through Healthier Fleetwood residents’ group
  • Narrowing inequalities through Future Fleetwood multi-agency team.

Next steps

To deliver more mental health support directly within our schools, especially primary schools, supporting children, parents and teachers.


Find out more about population health management, Integrated Neighbourhood Teams and Place-based working on the Population Health Academy