North Yorkshire Council

 

Health Overview and Scrutiny Committee

 

March 6th 2025

 

Neighbourhood Health in North Yorkshire

 

 

1.0       PURPOSE OF REPORT

 

As requested by the Committee, this is an update on the latest NHS policy and planning relating to the development of Neighbourhood Health in North Yorkshire.

 

 

 

2.0       BACKGROUND        

 

Neighbourhood working has been a key component of NHS strategy since its introduction in The NHS Five Year Forward View (2014) and was further reinforced in the NHS Long Term Plan (2019). These strategic documents recognise the importance of delivering personalised, integrated care within communities. The approach has been refined over time, with a greater emphasis on the role of Integrated Neighbourhood Teams (INTs) in supporting proactive care, prevention, and stronger local partnerships to address health inequalities in smaller sub-populations experiencing the greatest need. Subsequent reports, including the Darzi Review released in 2024, have highlighted the need for more community-based care, integration, and innovation. Further direction is expected with the publication of the forthcoming NHS 10-Year Plan, which will provide greater clarity on the future of neighbourhood health.

 

3.0       NEIGHBOURHOOD HEALTH POLICY

 

On January 30 2025, NHS England published the 2025/26 Priorities and Operational Planning Guidance, setting out key priorities for the coming year. The guidance focuses on neighbourhood working, emphasising the need to reduce silos and duplication between teams and organisations, and increase collaboration and connectivity in service of improving population health outcomes, reducing hospital and care home admissions, and supporting independence.

To drive transformation, NHS England has outlined three key shifts that are sought nationally;

1. Moving care from hospital to community

2. Shifting focus from treatment to prevention

3. Advancing from analogue to digital

To deliver these shifts, the guidance identifies seven core components essential for strengthening local services. It asks that system partners consider each component within the context of the needs of their local population and the current configuration of services. Integrated Care Boards (ICBs) and local authorities are also asked to work together to evaluate how effectively individual interventions link together to improve the way services are delivered for their local population. The seven components of neighbourhood health are;

•       Population Health Managementto target preventative interventions.

•       Modern General Practiceensuring access to primary care.

•       Standardising Community Health Services for consistency and equity.

•       Urgent Neighbourhood Services to reduce unnecessary hospital admissions.

•       Integrated Intermediate Care(Home First Approach) for timely discharge and recovery, and to reduce avoidable care home admissions.

•       Neighbourhood Multidisciplinary Teams (otherwise called Integrated Neighbourhood Teams (INTS)) to provide focused, coordinated support for people facing complex health and socioeconomic issues.

•       Secondary Care Contributionto neighbourhoods to ensure specialist services are effectively integrated within local care models.

The cumulative impact of work on these components seek to deliver three key national impacts, which will act as the measures of success:

•       Access – Improving timely access to general practice and urgent and emergency care (UEC) services to ensure people receive the right care, in the right place, at the right time.

•       Prevention – Reducing avoidable hospital admissions and minimising the long-term costs of care by promoting early intervention and proactive management of health conditions.

•       Personalised Care – Supporting individuals to remain independent and avoid unnecessary long-term admissions to residential and nursing homes by delivering tailored, community-based care.

 

4.0 LOCAL APPROACH TO NEIGHBOURHOOD HEALTH

 

The national neighbourhood working guidelines and ambitions closely align with local priorities identified across the Integrated Care Board (ICB) and multi-partner North Yorkshire Place Board. The neighbourhood agenda, and its component parts, will be wrapped into the emerging Ambitious for Health programme which North Yorkshire Place and North Yorkshire Council (NYC) are co-producing as a joint approach to health and social care transformation. Ambitious for Health sits under the auspices of the North Yorkshire Health Collaborative (NYHC) which will hold its inaugural meeting in April 2025. The NYHC, which will be chaired by NYCs Chief Executive and supported by the Chief Executives of local health and care partners, will be a multi-year joint programme which aims to improve the outcomes of local people through collaboration, prevention and a strong focus on community health and wellbeing.  

The North Yorkshire approach to neighbourhood working will continue to emerge as a core component of the wider Ambitious for Health programme, building on the significant progress already made by health, social care and voluntary sector organisations (particularly community anchor organisations) within communities. The roadmap for change will include the following elements.

•       Advancing the development of multi-partner Local Care Partnerships, community anchor organisations and integrated neighbourhood teams

•       Development and application of a population health management approach

•       Further optimising and integrating the core components of neighbourhood health

 

4.1 Advancing the development of multi-partner Local Care Partnerships, neighbourhoods and integrated neighbourhood teams

Strategically, Local Care Partnerships (LCPs) will play a crucial role in enabling and embedding neighbourhood working across North Yorkshire, ensuring decision-making, resource allocation, and efforts to reduce inequalities are aligned with local population needs. There are four LCPs in North Yorkshire covering the East Coast, Vale and Selby, Hambleton and Richmondshire, and Harrogate and Rural. These partnerships act as a bridge between locality-level service provision and the wider system, ensuring that the sum of services and the connectivity between them addresses local need and inequalities. These partnerships are leading efforts to utilise population health data to segment and risk-stratify communities, enabling more targeted and proactive interventions, and identification of where the development of INTs will have most impact on population health. Layered under the LCPs are 11 proposed neighbourhoods, broadly aligned to primary care networks, which will act as the foundation for hyper-local service planning and delivery.

The development of delivery-focused INTs will catalyse existing areas of excellent practice, with their scale dependent on the target population. A proactive frailty INT may operate at an LCP scale to provide economies of scale, whereas an INT focused on young families may be geographical, focusing on a few roads or around one school to address a specific identified need or inequality.

4.2 Development and application of a population health management approach

Population Health Management (PHM) is a data-driven approach that enables partners to identify, segment, and develop support for communities based on health risks and needs. By analysing health and care data, and triangulating this data with partner experience and insight, partners can proactively target resources where they are needed most. Locally, this will allow tailored interventions ensuring that care is delivered at the right scale for each community.

4.3 Further optimising and integrating the seven core components of neighbourhood health

Neighbourhood health encompasses a range of integrated services, including urgent care, intermediate care and general practice. The national guidance asks that ICBs and NYC jointly plan to connect the components of neighbourhood care at scale, with the structures and processes to enable this in North Yorkshire already in place. Through the planning rounds currently underway, change and delivery plans will be drafted for each component to contribute to the national goals of reducing hospital admissions, improving access to primary and urgent care, and reducing avoidable admissions to care homes.  

 

5.0       FINANCIAL IMPLICATIONS

 

Nationally, there is no additional funding allocated specifically to neighbourhood working. Progress locally will continue to be driven through the development of trusted relationships, changes to working practices and resource reallocation.  

 

 

6.0

RECOMMENDATION(S)      

 

 

The committee is asked to note the content of this report.

 

 

           

Report Author and Presenter – Gemma O'Neil, Deputy Director, North Yorkshire Place (Humber and North Yorkshire  Integrated Care Board

Sponsoring Director – Lisa Pope, Deputy Place Director, North Yorkshire Place (Humber and North Yorkshire  Integrated Care Board