The Stockton National Neighbourhood Health Implementation Programme (NNHIP) site is pioneering a neighbourhood health approach that places families – not just individuals – at the centre of its model.

The programme has taken a distinctive and ambitious direction: identifying a younger cohort and designing interventions that positively influence whole households across generations.

Choosing  younger patients to maximise intergenerational impact

Instead of starting with frailty or older adults, Stockton’s pilot focuses on people aged 50–64 with three or more long‑term conditions.

Dr Lucy Falcus explains:
“We did that quite intentionally. We want to look at a person as part of their whole family. People aged 50 to 64 are likely to have parents, children and even grandchildren. If we improve their health now, the benefits can philtre down to younger generations.”

This rationale is rooted in the wider determinants of health. For example, helping someone remain in work – through condition management, wellbeing support or financial guidance- not only improves their own stability but influences the aspirations and outcomes of their children and grandchildren.

Flexible, multidisciplinary case finding

Stockton’s cohort identification combines digital case-finding tools with professional insight. Rather than limiting themselves to algorithm‑generated lists, the team encourages participants at regular cross sector meetings to bring forward cases they already know:

“We said, you probably know some of these people already – so bring your cases as well. We’re probably all working with similar patients, just not knowing it,” Dr Falcus notes. This openness has created a richer, more accurate understanding of patient need.

Shifting care from hospital to neighbourhood

Stockton’s model strongly supports the NHS “hospital to community” shift. Through long‑standing partnerships with the acute trust, the programme focuses on avoiding unnecessary waiting lists by finding lower‑level, neighbourhood‑based solutions.

“What could be done instead of a fairly lengthy hospital wait? Often a lower‑level intervention at home or in the community will prevent a small problem becoming a big one,” says Dr Falcus.

The team reports growing excitement as colleagues realise just how many conditions can be better managed locally when viewed through a neighbourhood lens.

Voluntary sector involvement and rapid problem‑solving

Citizens Advice has been a regular and invaluable contributor to Stockton’s multi-disciplinary team huddles. The breadth of support was unexpected.

Dr Falcus said:
“Almost every patient we discussed, Citizens Advice had something they could do—even when the person didn’t appear to be in financial difficulty.”

This joined‑up approach has led to significant practical wins, such as clearer communication with secondary care around hospital waiting times, helping reduce anxiety for people waiting for specialist input.

One early patient described the intervention as having “moved heaven and earth” simply because the team were able to explain what she was waiting for and when it was likely to happen.

Building GP leadership for long‑term transformation

Recognising the critical role of primary care, Stockton has invested in nine local GPs, each tasked with leading a specific neighbourhood health priority.

Dr Falcus explains:
“It’s so important that primary care is at the heart of this. Bring people with you- once colleagues catch the vision, they are more willing to make changes and adapt their ways of working.”

This leadership model is already being extended into Hartlepool.

Looking ahead

Stockton’s next phase involves expanding the model into new neighbourhoods, deepening GP leadership and embedding prevention across the life‑course. The site’s family‑centred design offers a useful example of how neighbourhood health can shape future generations and not just improve current care.