Towards a whole-person, whole-population, whole-system model

The concept of a neighbourhood health service, taken at face value, is one of the most ambitious and radical attempts yet proposed, to address the complex challenges facing individuals, communities and healthcare systems as a whole.

At the core is a simple idea: health and care should be organised around the needs and assets of people and communities rather than around the services and structures of the institutions that serve them. This is a significant change. Even more radical is the idea we could make this the ‘default' for populations as a whole.

If neighbourhood health is seen as separate from, or in competition with, existing health and care services and support, it will fail, as so many attempts at reform have failed before. Success depends on strong collaboration between our hospitals, primary care, community and mental health services, adult and children's social care, public health, wider local government, voluntary & community sector organisations, and private sector partners (from the local café to the major providers domiciliary and residential care).

There are not many people who disagree with the ambition. Yet progress remains fragmented and health inequalities continue to grow.

Why has this been so difficult?

If we trace the process of development of person and community centred care in England, it tends to follow a familiar pattern.

Early discussions often focus on definitions, in this case: ‘What do we mean by integration?' ‘What is a neighbourhood?' and ‘Who is on the team?'.

Beneath these lie deeper, less often vocalised but no less important, questions: ‘Who will lead this?' ‘How will it be managed?' ‘How exactly will it be paid for?' and ‘Who will be held accountable, when something goes wrong?'.

In this process, people can become strongly committed to a particular interpretation, a particular moral, organisational, sectoral or technical lens.  This may be expressed as: 'This should be led by X,' ‘We can't do anything until we have Y,' or, 'This can only be properly organised by Z'.

We want to offer a frame that might open up a different kind of conversation.

A different kind of conversation

There is a risk that we approach neighbourhood health as a straightforward like-for-like swap: replacing one set of institutions, funding flows and relational dynamics with another. In this case, the questions above are key – who is in charge becomes material because the change remains grounded in traditional power dynamics.

Clarity of roles and responsibility clearly matters, particularly when billions of pounds of public money and millions of lives are at stake. But reconfiguring what we have, simply to be wrong in a different way, won't help with either.

Worse, due to the higher burden of proof we inevitably ask of the new, more innovative approaches never even get the chance to fail — leaving us unable to move from a current paradigm that, by common agreement, is no longer working.

We need to ask not how we should structure ourselves, but what we will do differently: sharing information freely, rather than using it to maintain authority and control; creating joint definitions that are ‘good enough'; mobilising total resources towards whole-population goals; and providing ‘air cover' for their people to work differently, now.

What needs to change

Neighbourhood health is not just a policy, it is a test of whether we can build the relational infrastructure needed for a more complex world. One where care is organised around communities, funding is aligned to goals, data drives proactive understanding rather than retrospective reporting and national, regional and system oversight focuses on outcomes (including those linked to inequality, employment and economic growth). 

Such changes are not straightforward, but the alternative – sticking with a system designed for the problems of the past – will inevitably fail. 

We must move to ‘a state of partnership'

Growing pressures on society and the idea that society is broken are a product of ways of working which are no longer fit for purpose. We need a reframing of social relationships and societal infrastructure at a scale not seen since the establishment of the post war settlement. 

If we want different outcomes, we must be prepared to relate differently. We need a new era where partnership is core – not as a slogan, a committee or a memorandum of understanding but as both mindset and operating model. We need, what we call ‘a state of partnership'. To be successful, neighbourhoods must embrace this new era where different parts of society come together around shared goals: improving health; reducing inequality; transforming opportunity; and helping people live well. 

The real question is whether we are prepared to make the deeper changes needed to make it happen, at all levels. Because ultimately, the future of health and care will depend less on the institutions we build, than on the connections between them.