Rotherham’s involvement in the National Neighbourhood Health Implementation Programme (NNHIP) is characterised by an ambitious, multi‑cohort model designed to meet the borough’s diverse health needs. As described by Dr. Simon Langmead, clinical lead for the programme, the Rotherham site deliberately chose to work across three different population cohorts, each aligned to specific local priorities and gaps in care.

Prevention: Increasing uptake of NHS health checks

Rotherham’s first area of neighbourhood focus is prevention, particularly targeted efforts to improve uptake of the NHS Health Check for adults aged 40 and over. Using local population data, the team identified stark variation across the borough -some neighbourhoods were engaging well, while others had very low uptake.

Dr. Langmead explained that the team is now delivering targeted interventions to increase engagement and, crucially, thinking ahead to what happens after a Health Check. This ensures people do not simply undergo assessment but receive follow‑on support, advice, or referral that addresses the early signs of long‑term conditions.

This prevention‑first approach supports the NNHIP ambition to shift the system from treating sickness to preventing it.

Rising Risk: Supporting Younger Adults with complex needs early on

The second cohort is a younger rising‑risk population aged 18–39, who are living with at least one significant long‑term condition coupled with a mental health concern. Dr. Langmead emphasised that this group is growing and often accumulates long‑term conditions earlier in life.

Rotherham is addressing this by using a practice‑based proactive care model, bringing system partners together for multidisciplinary huddles focused on supporting each individual. The aim is to help people manage both their physical and mental health more effectively, intervening before issues escalate into crises or more intensive service use.

This reflects a deepening recognition that rising‑risk groups are not confined to older adults and that coordinated, neighbourhood‑level support can significantly change life‑course outcomes.

Complex Frailty: Improving wrap‑around support for older adults

The third patient group Rotherham is working with involves people experiencing complex frailty -those with four or more long‑term conditions and one or more unplanned hospital attendances in the last year.

Dr. Langmead highlighted that Rotherham is drawing on best practice from across local services to provide wrap‑around care, with strong involvement from primary care, community services, and the voluntary sector. This model ensures that individuals with complex needs receive coordinated, proactive support rather than reactive, episodic interventions.

Shared goals and strong relationships

A standout theme in Rotherham’s NNHIP work is the emphasis on shared purpose. Dr. Langmead noted he was “surprised how quickly we came to a shared understanding of why we need to do this”, with alignment across health, local authority and voluntary‑sector partners.

He stressed the importance of honest conversations, the right people around the table, and collaborative problem‑solving. This relational culture underpins the neighbourhood model’s success.

Beyond the wave one work

Rotherham is already shifting its focus toward scaling beyond the pioneer site work, ensuring that successful models become embedded and sustainable. The team is exploring how to build on current strengths-relationships, structures, and shared commitment – to ensure neighbourhood health becomes the default way of working.