Kent Community Health NHS Foundation Trust has highlighted how it is testing new approaches to neighbourhood health, sharing progress and findings from pioneer sites, covering reactive, proactive and preventative care.
The first pilot approach for reactive care is taking place in Folkestone, Hythe and Rural PCN, where a new neighbourhood health team is reportedly testing a more joined-up approach for those with frailty and complex needs. According to the trust, it involves offering frail and housebound patients access to hospital-level care, with aims to reduce unnecessary admissions.
GP input is available five days per week, along with nursing, occupational therapy, therapy support, and care coordination. Patients identified within the highest-risk groups can be referred for same-day urgent support, as their need is flagged on their GP record, the trust explains, and referrals are also starting to come in from the clinical navigation hub, which reviews emergency calls to assess whether patients can be safely treated at home.
Total Health Excellence (West) PCN is piloting a proactive care approach, supporting 100 people identified as being at the highest risk of deteriorating health via risk stratification based on data and clinical insights. Multidisciplinary teams meet on a fortnightly basis to review patients at highest risk, the trust shares, with GPs, community health, pharmacy, and social prescribing input to agree joined-up care plans. KCH notes that a directory of services is being developed via the Joy app to help professionals connect patients to local voluntary and community support, and that work is underway to integrate this into GP clinical systems.
Key learnings from this proactive care approach are highlighted, with earlier intervention helping to prevent deterioration, joined-up teams reportedly improving patient confidence and independence, and relationships between services being observed to be “critical” to prevention.
A new approach to outpatient and preventative care is being tested in Romney Marsh, with more than 600 patients offering insight into barriers they face in accessing care and attending hospital appointments. It aims, the trust explores, are to improve early diagnosis and end-of-life care, increase community-based outpatient appointments, improve coordination between services, and expand advice and guidance between clinicians.
The programme is testing the use of remote pre-operative assessments, with follow-up checks delivered locally in GP practices where appropriate. “Although this introduces a small additional demand on primary care, the number of patients is relatively low and manageable,” the trust suggests. “In return, it significantly improves patient experience and allows specialist peri-operative teams to focus their time on higher-risk individuals.”
Work is also being completed to support patients with, or at risk of, diabetes, and to improve access to cancer care, with local clinical leaders looking to strengthen connections between oncology specialists and community teams.
Andy Cruickshank, CNO for the integrated neighbourhood health programme, said: “What we are building in Folkestone, Hythe and Rural is helping shape the future of neighbourhood health across Kent and Medway. This is about health and social care organisations and the voluntary and community sector, working differently together for patients, intervening earlier and making care feel more connected and meaningful.”
Wider trend: Neighbourhood health
HTN ran an industry thought piece on neighbourhood health in May, collecting thoughts from across the industry on the greatest digital/industry/healthcare challenges and how digital can be an enabler to successful neighbourhood health. Views and insights were offered from a range of industry experts, detailing issues around siloed information, interoperability, inconsistency, and misaligned incentives.
NHS England is seeking feedback on its proposed contracting models for multi-neighbourhood provider (MNP) and single neighbourhood provider (SNP) contracts, aiming to promote joined up services, improve health and outcomes, better organise services around local population needs, and outline clearer responsibility for services or pathways. MNPs will plan and organise services spanning several neighbourhoods, ensuring consistency and collaboration, managing how incentive payments are allocated, and working closely with local providers including SNPs, GPs, community health services, NHS trusts, and wider public services. Under the proposals, NHSE suggests two options for MNP organisation: helping organisations work together and keeping existing contracts with providers in place; or taking full responsibility for outcomes across multiple neighbourhoods and bringing existing services together under one contract.
Norfolk and Suffolk ICB has addressed future plans for strategic commissioning and neighbourhood health, in a written response to NHS chief executive Jim Mackey’s questions to ICBs around planning and priorities for 2026/27. The ICB recognises “many important local successes” over the last year, with plans to combine “the best of both legacy ICBs to create a healthcare system shaped by strategic commissioning”. The short-term focus is remaining on plan and achieving national standards for performance and quality of care, it states, whilst longer term ambitions revolve around supporting populations in living healthier and longer lives, supported by evidence-led digital transformation shifting focus to prevention and neighbourhood-based care.
