The government wants a ‘neighbourhood health service’. The first step is to agree what that means.

The government has put the idea of a ‘neighbourhood health service’ at the heart of its vision for the NHS. The term was introduced in Labour’s election manifesto as part of its commitment to shift resources to community-based services and deliver care closer to home. Health ministers are so keen to see the soundbite being worked up into practical proposals that rather than waiting for the publication of the 10 Year Health Plan, guidance fleshing out the idea has already been produced.

At our event in early March we heard lots of enthusiasm for the idea of working differently at neighbourhood level to improve health and care. However, it was clear from the various presentations and discussions that while everyone seems to be talking about neighbourhoods, we are not all talking about the same thing.

I’ve come across at least three different versions of neighbourhood working. For the sake of simplicity, I’m going to call them the NHS version, the local government version, and the community-led version – although in reality the divide is not quite as neat as those labels suggest.

The NHS version aims to strengthen community-based health and social care services so that care is better co-ordinated and more responsive to people’s needs. ​The approach is driven in part by patterns of resource use across the local population, with a focus on identifying people who are using services most frequently (or are at highest risk of doing so in future) and providing them with proactive support to improve their health and prevent hospitalisation. One of the most commonly discussed interventions is the development of integrated neighbourhood teams bringing together a range of health and social care professionals and covering populations of 30,000 to 50,000, as recommended by the Fuller stocktake. These multi-disciplinary teams form one of the six core components described in the recent neighbourhood health guidance published by NHS England (none of which are new in themselves – as Anna Charles explains in this blog).

The local government version also has multi-agency working at its heart, but typically a much broader version of it. Participants in a neighbourhood team meeting might include representatives from services for families, children and young people, adult social care, housing, employment and welfare services, the police, antisocial behaviour teams, voluntary sector organisations, and community-based health professionals, such as district nurses and health visitors. The focus of discussions tends to be on supporting individuals and families experiencing poverty or deprivation, at high risk of social exclusion or other adverse outcomes, such as contact with the criminal justice system, and with highly complex needs that are not served well by individual agencies. Mental or physical health needs are often one of the issues that will be considered when discussing how best to help someone but may not be the primary issue.

In contrast, the community-led version of neighbourhood working is less about co-ordinating the work of professionally led services and more about people and communities themselves. Here, the goal is to help people tackle the health and other issues that matter most to them by working with their strengths, building community leadership, and making better use of the assets, relationships and infrastructure available in the local neighbourhood. Culturally, this is a different way of working based on ‘doing with’ rather than ‘doing to’, with professionals acting as facilitators of changes led by local people and communities. The geographical area is also very different, with a hyper-local approach often focused on two or three streets rather than the larger populations of up to 50,000 covered by integrated neighbourhood teams.

I’m not going to argue that these contrasting visions of neighbourhood working are mutually exclusive or that one is better than the others. All three are needed to improve health outcomes and reduce inequalities in line with the government’s health mission. In practice, many of the places we heard from at the conference are attempting to combine aspects of several of the versions I’ve described (as are places The King’s Fund has worked with in the past, such as Wigan).

However, I do think there is a risk of overloading the concept of neighbourhood working by trying to pack so much into it that it becomes anything and everything (or nothing at all). As Luca Tiratelli discusses in his blog on the ‘synergy illusion’, definitional fuzziness can have real-world consequences and lead to less being achieved than was hoped for.

This kind of issue is an inherent risk in system working – whenever people from different sectors or professional backgrounds come together, there is the prospect of false consensus, where partners appear to agree but are in fact talking about subtly different things. It’s one of the reasons that collaboration can be hard work. As systems put the government’s vision of a neighbourhood health service into practice, they will need to take time to ensure that all local partners – and national bodies – share a common understanding of what the goal is.