NHS serves up insight on best practice neighbourhood healthcare

NHS England has published case studies to show best practice when developing neighbourhood healthcare, with three out of the 12 featuring PCNs.

The publication of these case studies were to provide examples of existing good practice to ‘form the foundations’ of neighbourhood health, according to NHS England. However, it added that there were no known examples that delivered all six core components of neighbourhood health (see box).

It said: ‘For 2025/26, we ask all systems to consider how they can increase the consistency, integration and scale in delivering health and care to adults, children and young people with complex health and social care needs who require support from multiple services and organisations.’

The three case studies that featured PCNs, focused on population health management,  health inequalities and frailty.

In Cambridge and Peterborough, the neighbourhood health case study addressed health inequalities faced by people with severe mental illness through using mental health practitioners in primary care teams.

The practitioners, called mental health community connectors, were hired through the Additional Roles Reimbursement Scheme (ARRS).

The team was built across multiple PCNs in the area, with mental health practitioners supported by a ‘host’ PCN, and delivered collaboratively with two providers: Greater Peterborough Network and Cambridgeshire, Peterborough and South Lincolnshire Mind.

The clinical director of Ely PCN said of the programme: ‘With the help of the mental health community connectors, many are finding ways to manage their mental health and are leading more stable lives. This shift not only enhances their wellbeing but also helps reduce the demand on our general practice.’

Northamptonshire’s neighbourhood healthcare focused on holistic care planning for frail people and was ‘built around’ PCN footprints, with local integrated teams delivering interventions. Teams were built from cross-sector organisations, including healthcare, social care, voluntary, community and social enterprise and local authorities.

In the 18 months up to March 2023, the programme saw a 9% reduction in hospital attendances for over 65s and a 20% reduction in falls-related acute attendance due to improved rapid response unit. It also reported improved retention of GPs.

The final example mentioning PCNs, within Lincolnshire ICS, was to link data and embed a system-wide approach to population health management and was delivered by Trent PCN in partnership with the Lincolnshire ICB primary transformation team.

Trent PCN used the dataset and population health management approach to co-design, implement and evaluate a ‘more targeted, relationship-based care approach’ for people with high intensity use of emergency departments.

It resulted in a nearly 3:1 potential return on investment, as £230,000 was saved through emergency department admission avoidance in six months, compared to an £80,000 investment in the service.

Of the case studies that did not mention PCNs, two were led by GP practices, one was by GP practice Lime Tree Surgery in Waltham Forest in North East London ICB, and the other Brookside Group Practice in Frimley ICB. One was also led by a GP hub for children and young people in North West London.

Other programmes spotlighted included a Birmingham-based ICS-led community care collaborative, a virtual ward in Kent, a women’s health hub in Tower Hamlets, North East London, a care transformation programme led by Leeds Health and Care Partnership, called HomeFirst, and a North Central London ICS community services offer.

It comes after NHS England said the NHS will need to ‘build on’ existing cross-team working, such as PCNs, to move to a neighbourhood health service.