The South West digital neighbourhoods programme aims to transform the experience of the citizens we serve and the workforce we support by empowering integrated neighbourhood teams with the best use of digital technology and data, thereby providing the capabilities required to enable proactive care and prevent unplanned healthcare events.

This work is part of a wider programme to make the South West, which has a very mixed geography including coastal, rural and older populations, the most digitally enabled region in England. This will pave the way for health and care professionals to work together as integrated neighbourhood teams to make health and care services more accessible, flexible and personalised.

A new AI-based digital tool, which has been successfully piloted in Somerset, will rapidly analyse routinely-collected GP-held data to identify those most at risk of an unscheduled hospital admission in the next 12 months.

People identified as at highest risk can then be contacted and invited to take part in a holistic assessment so that local, integrated neighbourhood teams of health and care professionals can work with those patients to develop a personalised care and support plan, based on what matters to them.

Integrated neighbourhood teams, made up of a range of professionals from health coaches and social prescribers to doctors, nurses and mental health professionals, alongside social care and the voluntary sector, can all work together with the individual to support them to stay well. Plans may include support in person, online and in the community, such as local classes and groups.

Watch this new animation outlining what this new approach and technology will mean for patients and the public.

More information about related programmes can be found here:

NHS England — South West » Transforming Community and Out of Hospital care

NHS England — South West » Virtual Wards in the South West

NHS England — South West » Integrated Personalised Care

If you work in the NHS or wider health and care system in the South West and would like to find out more or get involved, please email england.swdigital@nhs.net to join the NHS Digital Neighbourhoods Programme Future NHS space.