What can England and Singapore learn from each other on neighbourhood health?

There are obvious differences between England’s and Singapore’s health and care systems, not least in the two countries’ per capita resources and their systems’ performance. However, despite the differing contexts, both systems are set up to provide efficient, universal care for a whole population.

In both countries, there is central oversight of services and a systems-based approach to care. Both countries are seeking to shift from treatment to prevention, to recalibrate their systems towards primary and community care in neighbourhoods and to piece together fragmented services for people with complex needs. In short, there are opportunities for co-learning between two systems facing at least some similar challenges. 

In November 2025, senior leaders from across health and care in England met leaders from NHG Health, one of the three regional health organisations (known as managers) in Singapore, to discuss the shift to population health, prevention and neighbourhood-based health and care. We convened this discussion to identify key themes or lines of enquiry for a longer-term research partnership between The King’s Fund and NHG Health on population health and neighbourhood health in 2026 and 2027. This builds on our previous population health work setting out a vision for population health to now working with different health and care systems to think about the changes needed to achieve real improvements in health. In this research we’re asking: are clearer approaches now emerging for delivering specialist care more effectively in community settings? And are there neighbourhood-based approaches to health creation that offer a credible alternative to traditional public health approaches to prevention, which might be invested in and scaled?

The English and Singaporean health and care system structures

Over the past decade, both England and Singapore have pursued administrative reforms to restructure their health and care services into integrated local or regional systems. In England, integrated care boards (ICBs) bring together the leadership of NHS commissioners and service providers, and work in partnership with local authorities, to allocate resources and plan service delivery for populations of 1 to 2 million people. In Singapore, the three regional health managers, NHG Health, SingHealth and National University Health System, deliver a wide range of preventative care, primary care, acute hospital care and community and aged care for populations of 1–1.5 million people.

While integrated care systems (ICSs) in England bring together partners to oversee the local health and care system through ICBs, the regional health managers in Singapore bring hospital, community and some primary care services together in a single organisation. ICBs and the regional health managers both play important co-ordination roles with a wider network of partners including independent primary care and the voluntary or community sector. In England, almost all funding for health services comes from general taxation. In Singapore, health and care providers receive funding from a range of sources including from government, insurers and service users.

There are strong similarities in how health and care leaders in the two countries describe their systems’ challenges. They are both seeking to shift the focus from treatment to prevention, to address variation in access, engagement and outcomes across population groups, and to implement effective care for ageing populations. Both countries are seeking to piece together fragmented services for people with more complex needs, to become less reliant on hospital-based care, to implement digital transformation and to secure long-term sustainability.

In England, the 2025 10 Year Health Plan promises to reinvent the NHS through three shifts: from hospital to community, analogue to digital and sickness to prevention. In Singapore, the 2022 Healthier SG White Paper committed to shifting from a reactive system to one that prevents ill health, including through anchoring Singapore residents with a family doctor and building with partner organisations a more effective ecosystem of community-based care.

In both countries, these papers are preceded by many similar policy statements over the last two decades on the need to shift to prevention, join up services and reduce inappropriate usage of hospital care. Progress has been uneven with glimmers of success alongside failures. In England, the government has committed to reducing the proportion of spending on hospitals, but it continues to rise. In short, the challenge is not defining the high-level vision but envisioning what the future looks like with a sufficient level of granularity to provide a basis for concerted action, and the task of reorganising systems of monumental complexity, where every building block has been put in place with a different vision and mode of operation in mind.

Singapore leaders began the discussion by outlining their vision for a health and care system organised not around existing service structures but around people and the life course. Such a system would offer effective support for children and families in early years, help people to maintain health and wellbeing in adulthood, respond quickly when people face episodes of ill-health and support people to maintain their health and independence in older age.

Such a system needs a strong foundation of generalist, relational, continuity-oriented primary and community care that is capable of delivering holistic health and social support throughout the life course. This means providing effective support for healthy living in schools, workplaces and neighbourhoods, an efficient specialist model of care for periods of acute ill-health (‘so if people fall into the river we can fish them out’) and flexible support for people, their families and carers in older age.

Team-based care in neighbourhoods

Our roundtable started with the first of these objectives, creating a strong foundation of primary and community care in neighbourhoods. This is an area where England and Singapore face some similar challenges. In England, the model of holistic general practice was established in the 1950s. However, we invested disproportionately in hospital care while creating a patchwork of disconnected community services in the following decades. In Singapore, there was an initial focus on developing hospital-based care in the 1960s. Small-scale independent primary care developed alongside the hospitals focused on delivering routine, episodic care.

Both countries, now need to develop coherent models of primary and community care for ageing populations and other groups with complex health and social needs. In England, there have been many initiatives over the last decade to develop more integrated, proactive and population health focused models, including primary care medical home pilots, the vanguard new care models programme and now integrated neighbourhood teams. There has also been substantial investment in new primary care roles. Singapore has developed polyclinics alongside independent general practices to deliver integrated primary, community and more specialist care for people with long-term conditions. Both countries have developed integrated models of intermediate care bringing together doctors, nurses, therapists and social support for people coming out of hospital or to avoid hospital admissions.  

However, both countries are some distance from implementing integrated, team-based primary and community care at scale for a substantial part of their population. Moreover, in both countries, there are also competing or overlapping integrated services within local systems. For example, there are multi-disciplinary teams sitting within hospitals, community services, mental health and primary care, each responsible for delivering integrated care for overlapping cohorts of people with multiple physical health, mental health and social needs. 

Examples of neighbourhood health in England and Singapore

One exemplar considered by our roundtable is the Foundry group of GP practices in Lewes in East Sussex. Over the past decade, the Foundry has developed a team-based patient-centred medical home model for a population of 30,000, including care co-ordinators, social prescribers, dementia key workers and palliative care nurses. GPs hold the clinical risk, allowing other staff to focus on non-medical support for people with underlying social challenges. The teams take a proactive, population health approach to identifying people who need support, seek to deliver relational, continuity-based care and work in small teams to make best use of staff skills. GPs at the group now spend a smaller amount of time with many patient groups, for example, people with dementia, who need social support more than medical support.

The roundtable also heard from leaders at West London Trust, which runs an integrated team-based primary and community care service for care home residents in the London Borough of Ealing. The trust is also taking part in a pathfinder project in Hounslow, which brings a wide range of staff together from across GP practices, additional primary care roles, community services and local authority services in small teams to support the most complex patients on GP practices’ lists.

While they are still small scale, these initiatives have some similarities with the well-established and highly respected model of care in Singapore’s polyclinics. Since the late 1970s, Singapore has run an increasing number of polyclinics delivering preventive and primary care alongside independent general practice. NHG Health now runs ten polyclinics, which provide primary care for approximately 20% of its catchment population. The polyclinics focus primarily on delivering integrated primary and community care for people with long-term health conditions and more complex health and care needs. The polyclinics are structured into ‘teamlets’ that bring together a general practitioner, nurse, health care assistant and administrator, with each teamlet responsible for care planning and delivery for a defined panel of patients. Other staff such as pharmacists and allied health professionals support the teams.

Convergence in neighbourhood models

There are also similarities between these models in England and Singapore and many other well-established international models of integrated primary and community care. Participants in our roundtable highlighted a common set of features of successful models: clearly defined small teams; empanelment and accountability for improving care for a defined group of patients; a focus on building strong relationships between team members and with patients and carers; and shifting towards more social approaches to care for at least some patient groups. One issue we will explore in our study is how far these features apply to all models of community and primary care, and where there are still significant differences in approach. We will also consider whether systems are simplifying their integrated services over time, with fewer competing or overlapping models of integration for similar population groups.

Central specification versus local discretion

If successful models are moving towards similar approaches, this raises the question of whether our health and care system could deliver change faster through specifying more clearly the key features of effective models. On this question, our roundtable divided into two camps: those in favour of locally led processes to design integrated services, and others in favour of greater central direction. Proponents of localism emphasised the benefits of empowering staff and developing services that reflect the history and specific features of a neighbourhood. They also highlighted the differences between urban and rural populations and service structures. Those in favour of greater central direction questioned how much services need to vary from one neighbourhood to another. They argued that there is as much variation within neighbourhoods as between them and that there are only so many well-evidenced approaches. They also raised the slow pace of change in England. As one participant put it, we have allowed many flowers to bloom but we are still struggling to find working examples of integrated team-based care at scale.

Some leaders argued for middle ground: some aspects of the design of integrated neighbourhood teams should be specified centrally and replicated precisely across neighbourhoods, while other aspects should be left to local discretion. Some successful team models give staff considerable autonomy to shape care within a framework that is applied consistently across services. For example, the Dutch community nursing organisation Buurtzorg specifies a defined team structure and particular practices such as the use of team coaches and peer support. However, staff have considerable freedom within these structures to decide how to organise day-to-day care and how to use financial and other resources.

Some participants suggested that health and care systems may be centrally specifying issues that should be determined locally, while leaving issues that should be mandated centrally to local discretion. For example, the NHS’s neighbourhood health guidelines set out high-level principles on the development of neighbourhood health services but leave the details of the structure and care models of neighbourhood teams for local determination. This is arguably despite a body of evidence from patient-centred medical homes, accountable care organisations and other integrated systems on effective approaches. Meanwhile, there are national objectives for disease prevention in the NHS operational planning guidance and Core20PLUS5 framework, while health promotion might be much better pursued locally, in ways that reflect the priorities of local people and specific challenges faced by individual communities.

There were differences of view within the group on the merits of seeking to set out the details of a common service offer that should be delivered consistently across different neighbourhood-based services, while allowing for variation to reflect local needs. The proponents argued that this would give the public a reasonable degree of confidence about what they could expect from neighbourhood-based services and make it easier to co-ordinate services. The sceptics were concerned that specifying existing patterns of service provision can hold back service innovation, requiring each neighbourhood to have a particular set of separate services. They noted the risk of embedding fragmented models of care, particularly if financing and contracting arrangements break services down into small parcels of care. 

Extent of reorganisation of existing services

There were also different views on the extent of substantive reorganisation needed to bring staff together across many different primary, community and social care services into coherent integrated teams. The examples we discussed all bring a core group of staff from across services together into a substantive small team. In England, the 10 Year Health Plan highlights the limitations of some approaches to integration that rely heavily on coordination rather than structural change to integrate care and dismantle service silos. However, bringing too many staff and services into an integrated team structure risks creating overly complex service models. There will always be limits to what a generalist multi-disciplinary team can deliver safely, with some community services better delivered by specialist teams.

One question we will explore in our research is how much care can be provided by a generalist multi-disciplinary team such as the ‘teamlets’ in Singapore’s polyclinics or nascent generalist primary and community teams in England, without reducing the need for referrals to other services, how much can be delivered safely through specialist consultation into the teams, and what needs to remain separate in more specialist primary, community or social services.

Prevention of illness and health creation

As well as examples of restructuring fragmented services into integrated teams, our roundtable discussed England’s and Singapore’s approaches to preventing disease and promoting health and wellbeing. Both countries have well established public health programmes delivering vaccinations and screening and national programmes to encourage positive behaviours and discourage harmful behaviours for health and wellbeing. Singapore has clearly gone considerably further than England in discouraging harmful behaviours, for example entirely prohibiting the use of vaping and pursuing a zero-tolerance policy against all illegal drugs. Singapore has also developed much stronger incentives, levers and infrastructure to encourage the population to live healthily, for example through its HealthHub digital platform and its network of active ageing centres. Most striking for an English observer is the concerted action of public services including education, housing, employment and health to create heathier communities. One example is the collaboration of different public services in planning and developing Singapore’s public housing to support health and wellbeing. In our case study of NHG health, we will seek to capture at a high level how these partnerships work in practice.

Health creation in neighbourhoods

Our discussion in this area focused on the opportunities to develop new approaches to health creation as our systems reorient towards primary and community care in neighbourhoods. The roundtable heard from health and care leaders in Fleetwood who in 2016 created a new initiative, Healthier Fleetwood, to help public services and the local community work together to improve health and wellbeing. The initiative focuses on listening to the local community, understanding people’s priorities rather than telling them what they need. Three years ago, the local ICB was suggesting Fleetwood should focus on respiratory disease, but locally there was a desire to focus on children and young people’s mental health.

After the Covid 19 pandemic, concerns were being raised by parents, teachers and health professionals around spiralling rates of mental illness among children and young people. This led to a two-year conversation with the local community on how to address this. Local people did not focus on the issues that professionals are likely to raise in relation to children’s mental health, such as access to counselling or waiting times for services. Instead, they wanted to remove ‘county lines’ drug dealers at school gates, create happier environments in schools, establish safe spaces and things for families to do, and support young people into work. Over the two years, local services and community members helped children to develop their own youth centre, helped to develop a new Youth Hub, created new sports and leisure opportunities, created a new scheme to help young people into work, and worked with schools to create a more supportive environment. Two years after this work started, annual referrals into Child and Adolescent Mental Health Services, A&E attendance for self-harm and referrals into in-patient mental health care had all reduced by 50% or more. The police have reported similar reductions in anti-social behaviour.

The more holistic and community-led approach across Fleetwood highlights the limitations of the current national focus on improving outcomes in single conditions.

Potential of neighbourhood approaches to prevention

Participants in our roundtable saw huge potential to develop these community-oriented, social approaches to health creation as part of the shift to neighbourhood-based care. Some believed that they provide an essential counterpart, or potential alternative, to traditional public health approaches to preventing disease, particularly in deprived communities. The art of effective health creation lies in building meaningful partnerships with local communities, so that public services, the voluntary sector and community members can work together to the underlying issues driving poor health. As one discussant noted, ‘There is no point driving vaccination buses into areas where the population had such low confidence in public institutions that they would throw bricks at them’.

A key message from the discussion was that the development of neighbourhood teams and the establishment of health creation partnerships ought to go hand in hand as the main foundations for an effective neighbourhood health system. If we reorganise siloed public services operating across large geographies into multi-disciplinary teams for neighbourhoods, we create a group of staff who are much better placed to collaborate with community members and community organisations and to support health creation initiatives that matter to local people.

Barriers to focusing on health creation in neighbourhoods

In practice, roundtable participants saw substantial challenges in spreading these partnership and asset-based approaches to health creation. In England, NHS leaders are, much more used to top-down, homogenous programmes focused on traditional public health priorities. There is uneven understanding of the rationale for and potential of asset-based approaches to health creation in partnership with communities. While there are many examples demonstrating the impact of these approaches, the evidence is qualitatively different and less well understood and accepted than the evidence for traditional, single issue public health interventions applied across large populations. Some NHS leaders are sceptical about these types of initiatives, and it is difficult to secure stable funding for them.

As part of our research, we will look for examples of local health and care systems that have implemented asset-based approaches to community health creation  across multiple neighbourhoods. If they exist, we will explore the style of leadership being applied, the evidence base, funding arrangements and how systems overcame the common barriers to mainstreaming these approaches.

The future of hospitals

Our roundtable discussed briefly the implications of the shift to neighbourhood health for hospital-based care. Participants argued that the English NHS was allocating too much funding to hospital-based care, a trend that has persisted over decades. Singapore also allocates a relatively high proportion of health and care resources to hospital-based care in comparison with some other high performing systems and has signalled a desire to shift resources from hospitals to primary and community services. While England’s financial constraints are greater than Singapore’s, it seems unlikely that either country will easily be able to deliver a gold standard model of primary and community care for the whole population while keeping the funding and structure of hospital-based care intact.

Unanswered questions on future hospital care

Beyond this high-level ambition, there was less clarity about exactly how much resource should shift from hospitals into primary and community care, what hospital services should be decommissioned or moved into the primary and community system, or the future shape of a slimmed down and refocused hospital sector. Participants recognised that England has developed at least some services in hospitals over the past two decades that would be better delivered within an appropriately resourced and sensibly structured primary and community system. Participants noted that there would only be substantial benefits in moving services from hospitals to the primary and community system if this also meant shifting to a different model of care, for example one that is more based on relationships and continuity, more focused on health and social support or is more cautious in its use of high-cost medical procedures.

Redesigning hospital outpatients

One participant explained that a moderately sized neighbourhood with a population of 50,000 in England would generate on average 27,600 in-person hospital first appointments and a further 4,300 phone consultations for outpatient services each year. It also leads to more than 52,000 follow-up hospital appointments in person and 12,500 by phone each year. These hospital-based services may often address only a narrow set of health needs, in isolation from other services, before sending the patient back to primary care. The establishment of more effective models of primary and community care creates a huge opportunity to restructure hospital outpatients, most obviously through reorienting hospital specialists from being separate practitioners to being advisors and members of integrated primary and community care teams.

As part of our forthcoming research, we will seek to find examples of international health systems that shed light on these questions relating to the structure of hospital services. How much have successful systems shifted the balance of funding from hospitals to primary and community-based care, which hospital services did they restructure to enable this, and what models have they adopted for intermediate care and for the delivery of the types of services delivered by hospital outpatient services in England.

Leadership, workforce and barriers to change

The group discussed briefly which leaders and parts of our health and care systems are best placed to lead the development of neighbourhood-based care. In England, the debate continues to focus on the relative merits of primary care or hospital leadership. Those advocating primary care leadership argue that general practitioners bring the best understanding of generalist, relationship-based, medical and social care in the community. Some also argue that hospitals make problematic managers of primary and community services, in part because they come with the wrong mindset, for example an episodic, medical specialist approach to delivering services. When hospitals lead the development of community care, there is a risk that they simply replicate hospital approaches in community settings or move resources from the community to hospital-based care. Others argue that hospital leaders bring the greatest management skill and the resources and apparatus of large institutions.

Leadership skills in transformation

There are of course successful international examples of hospital-led, primary care-led and partnership-led transformation of health and care systems. Some roundtable participants argued that leaders’ skills and experience might be as important or more important than which institutions they come from. One notable feature of the Singapore system is the extent of the investment made in developing senior leaders’ leadership skills, technical skills and knowledge base. Another is the proportion of leaders who have clinical backgrounds. In our research, we will look specifically at NHG Health’s approach to developing leaders, including clinical leaders, with the skills to transform care across institutional boundaries.

Approaches to service redesign and spread

We will also consider in our research the processes that leaders in high-performing systems follow to redesign care and to spread new care models. Local systems in England have typically involved different stakeholders and followed different processes when developing neighbourhood models. This may in part explain some of the differences between the different approaches to integrated neighbourhood teams across the country. As part of our research on NHG Health and other high-performing systems, we will consider what types of processes systems follow when designing or spreading service change. For example, what approach do they take to involving stakeholders and service users, how do they convene stakeholders and ensure that different perspectives are heard, do they conduct rigorous evidence reviews, do they follow specific methodologies such as such as human-centred design or the double diamond model and how do they seek inspiration and challenge to established ways of thinking? We will also consider how the approaches chosen influence the shape and delivery of services.

Preparing our workforce

Our roundtable discussed the investments that will need to be made in both health and care workforces to support the transition to neighbourhood-based care. Participants highlighted the need to rebuild the generalist skillsets of clinical staff and to train staff to work in more integrated and holistic services. Staff in integrated neighbourhood-based services will need to take on a broader range of roles while maintaining their specialisms, so that they can hold responsibility for the patient and minimise the transitions between services. They will need to become more confident in taking on tasks for other team members and become used to advising and supporting others as an alternative to direct care. None of this sits easily with established approaches to training clinicians, specifying job roles or ensuring clinical governance and safety.

Barriers and enablers to change

Finally, at least in England, leaders often focus on the barriers and enablers of transformation. When explaining why it has been difficult to make faster progress in developing integrated, neighbourhood-based services, leaders often rehearse a common list of challenges including lack of financial resources to enable the change, financial and contracting arrangements that lock us into existing service models, lack of influence over specific services such as core primary care, lack of appropriate IT infrastructure and lack of appropriate estate. Plans to develop integrated services typically include large workstreams to address these barriers and build enabling infrastructure.

What’s interesting from our discussions with leaders in Singapore and other systems is that the obstacles clearly vary across health and care systems, but the perception that leaders do not have the tools to deliver change, and the very real challenges of making rapid and substantial change, are consistent across all of them. Singapore does not have some of the challenges that England faces, say being able to continue funding legacy services while operationalising the new services that will replace them, or access to interoperable IT systems. The regional health managers in Singapore also have, in their polyclinics, an established model of primary and community care that they can invest in to improve population health, prevention and the proactive management of long-term conditions. However, they also acknowledge significant challenges in delivering transformation at scale and pace.

Our research on NHG Health and other international systems will therefore try to shed a little further light on the true barriers and enablers to transformative change in population health, prevention and primary and community care. Are the factors that leaders highlight the real reasons why change has proved so difficult? Or are other factors at play, say leadership mindset, organisational cultures or institutional and professional vested interests?

Next steps

The next phase of this two-year study is to examine NHG Health’s approach to implementing population health approaches, its approach to prevention of illness and health creation with communities and its approach to developing new models of primary and community-based care. The final phase of the study will be to examine a small number of comparator health and care systems, with the aim of highlighting the areas where high-performing systems are pursuing similar approaches, and the areas where there are important strategic choices about the direction of travel.