NHS England has published guidance for progressing and delivering neighbourhood health, asking ICBs to plan a neighbourhood health and care model, with an initial focus on people with the most complex health and care needs.
It notes the need to develop a consistent, system-wide population health management approach and to “utilise quantitative data and qualitative insights to understand needs and risks for different population cohorts”. It adds how this information should inform the design and delivery of care, and that systems should aim for “improving coordination, personalisation and continuity of care”. Here, it notes the use of a single electronic health and care record that is actively used in real-time, to provide “care coordination functionality between the person or their carer and the wider multi-professional team, working across organisational boundaries.”
NHS England details the requirement for a person-level, longitudinal, linked dataset to include: general practice and wider primary care; community health services; mental health; acute care; social care and public health data. It details the dataset “should be broadened to include other data held by local or central government, including employment, education and safeguarding”. The aim is to support the “analysis of population health outcomes, biopsychosocial risk drivers and health and care system resource use”.
On tech systems, the guidance notes the need for clinical data systems to have “complementary functionality”, including compatibility and integration between GP systems, digital social care records and other provider systems, with the aim to support care navigation, case management and risk based prioritisation. Further guidance on using data to segment and risk stratify populations, to be used to support navigating and triaging, is to be published later this year.
For secondary care contributions to neighbourhood health, notable improvements hone in on home-first and person-centred approaches, such as neighbourhood MDTs using digital technology and infrastructure, and establishing pathways into the hospital which avoid the emergency department. The guidance also highlights the development of virtual wards, single point of access and community diagnostic centres, along with ensuring that frailty services are joined up in all settings. It goes on to recommend that community diagnostic centres be “considered anchor sites between primary, community and secondary care”, and shares an aim for there to be more than one CDC in each ICB.
A key focus area of “partnership working” is noted, to include: a mechanism for joint senior leadership such as a neighbourhood taskforce; a collaborative high-support, high-challenge culture which fosters strong relationships; visible clinical and professional leadership; making the best use of all funding; and having effective IT processes in place to help with training and workforce development.
Further on, there’s an emphasis on the need to tackle health inequalities when developing a neighbourhood health service. This includes: getting the basics right by ensuring services are accessible to all; engaging with local communities and working with them as equals to design and deliver services; and analysing outcomes by population demographics, deprivation, age, ethnicity, disability, supported by the reasonable adjustment digital flag and inclusion health groups.
The guidelines go on to outline the importance of learning from emerging research and innovation to help inform the future development of the neighbourhood health and care model. They prompt ICBs to consider evaluating the impact of the changes they make in a “systematic, consistent and scalable way”, to help build the case for future expansion.
The guidance ends with an appendix that centres around the initial six components of neighbourhood health, which are: population health management; modern general practice (in which ICBs are to continue supporting general practices with the delivery of the modern general practice model); standardising community health services; establishing neighbourhood multidisciplinary teams (MDTs); delivering integrated intermediate care with a home-first approach; and urgent neighbourhood service through urgent community response and virtual ward services.
Read more on the neighbourhood health guidelines for 2025/26 here.
NHS reform: the wider trend
NHS England has also recently published its 2025/26 priorities and operational planning guidance, with a focus on local prioritisation and planning, reducing wait times and improving access and patient flow. It introduces a wealth of objectives and priorities for the year, encouraging systems to “shift their focus” from inputs to outcomes for patients and local communities.
For a recent HTN Now webinar, we were joined by a panel of experts to discuss the role of digital in supporting NHS reform. This included talk around modernising services, shifting from hospital to community, and supporting the move from reactive to proactive care.
Back in December, NHS England began a review of digital clinical safety standards, seeking input from a range of stakeholders across the NHS, as well as IT manufacturers and those involved in digital risk assessment. The review starts with DCB0129, with plans for it to take part across two phases, the first of which is scheduled for February 2025, involving online focus groups designed to gather feedback on “the sufficiency of the standard”.
