A new innovative way of working is making a difference to patients in the North East.

Stockton-on-Tees is one of 43 areas across the UK selected by Government for the National Neighbourhood Health Implementation Programme (NNHIP) which aims to tackle health inequalities, move support closer to communities and prevent ill health, including those in areas with the poorest health outcomes.

Although Stockton has been chosen to participate in the programme, it is just one example of the innovative work emerging in the neighbourhood heath space within the North East. A new breed of integrated community hubs is now up and running in a number of locations delivering care to patients closer to home, helping people in a more holistic way and reducing hospital admissions.

Bringing care closer to home in Stockton-on-Tees

Stockton’s neighbourhood health model is uniting GPs, the Council, NHS partners, and the voluntary sector to deliver tailored support for residents at risk of long-term conditions such as diabetes and heart disease. By embedding services in local communities, patients can access care without long journeys and receive early interventions to prevent complications.

Councillor Pauline Beall said: “This is a pioneering approach that places more support at the heart of our communities, meaning people can access the right level of care in more convenient locations.”

Samantha Allen, Chief Executive of the North East and North Cumbria ICB, added: “There’s a lot of good work already in place, so we have a strong base to build on.

“With integrated teams working in neighbourhoods, we can bring services closer to communities and reduce inequalities in health. There’s been huge interest across our region, and over time we want to make sure every part of the North East and North Cumbria can benefit.”

 Patient story:
John, 62, from Portrack, was struggling to manage his diabetes. “Before, I had to wait weeks for appointments and travel across town. Now, the nurse visits me at the community centre, and I’ve joined a local walking group they recommended. I feel more in control of my health.”

Guiding You Home: Supporting Independence in Sunderland and South Tyneside

The Guiding You Home programme focuses on keeping people at home or returning them there quickly after hospital stays. Through a single Care Coordination Hub, patients, carers, and professionals can access community services 24/7 via one phone number. The initiative includes a respiratory monitoring hub, virtual wards, reablement at home, and admission avoidance schemes such as “call before convey.”

Programme Director Anna Hargrave explained: “We want people to think ‘Home First.’ Our hub means patients get the right help quickly without navigating multiple services.” Early results show a reduction in hospital length of stay, fewer people entering permanent care directly from hospital including after reablement and more patients returning to the most independent setting for them.

Patient story:
Margaret, 78, from Sunderland, shared: “After my hip operation, I thought I’d be stuck in hospital for weeks. Thanks to the Guiding You Home team, I was back in my own house within days, with carers popping in and a physio helping me regain independence.”

 A community health hub for Darlington

Darlington’s Forsyth House exemplifies integrated neighbourhood care. Serving 120,000 residents, the hub hosts NHS services, mental health practitioners, dentistry, and voluntary organisations under one roof. It offers evening and weekend GP appointments, social prescribing, and co-located pharmacy pilots, reducing pressure on A&E and improving access to mental health support.

Neil Bradbury, Managing Director of Primary Healthcare Darlington, said: “Forsyth House is a genuine community hub. We’re bringing together health, wellbeing, and even employability services to tackle the wider determinants of health. By working together on one site we are also increasing engagement and moving towards a more holistic approach to patient care.”

Patient story:
Sarah, 45, who struggled with anxiety, said: “I came for a GP appointment and was introduced to a mental health practitioner the same day. They also linked me to a local carers’ group. It’s all in one place – it’s changed my life.”

Meeting the aims of the 10 Year Plan for Health

These community projects all share a common goal: shifting care from hospitals to communities, improving outcomes, and tackling health inequalities. As NNHIP begins in earnest with the involvement of 43 sites including Stockton, these 3 North East initiatives are already setting the pace for a future where health and wellbeing are rooted in local neighbourhoods and delivered by truly multi-disciplinary teams.