Neighbourhoods & INTs
Why Neighbourhood Working Matters?
Neighbourhood working brings health, social care, mental health, community and voluntary sector services together around local populations. This helps people access more joined up support closer to home, reducing the need to repeat their story to multiple services and making it easier to navigate care. Neighbourhood health aims to improve access, experience and outcomes while helping people stay healthy, active and independent for longer.
More joined up care across health, care and community services
Better access to support closer to home
Improved continuity of care for residents with complex or long-term conditions
Earlier support to prevent health problems worsening
Greater involvement in decisions about their own health and wellbeing
Neighbourhoods provide a framework for practices and PCNs to work more closely with community, mental health, social care and voluntary sector partners. By sharing knowledge, expertise and resources, practices can better support people with complex needs while reducing duplication and improving coordination between services.
Key benefits for practices and PCNs
Stronger multidisciplinary working across organisations
Better coordination for residents with complex needs
Increased opportunities for proactive and preventative care
Improved use of local workforce, data and community assets
Reduced duplication and more efficient use of resources
A core aim of neighbourhood working is to improve population health by identifying local needs, tackling health inequalities and intervening earlier. By using population health management approaches and local intelligence, neighbourhood teams can focus on prevention, support high-risk groups and address the wider factors that influence health, such as housing, employment and social isolation.
Key benefits for population health
Earlier identification of residents at risk of poor health outcomes
Greater focus on prevention and proactive care
Reduction in health inequalities across communities
Better use of community and voluntary sector assets
Reduced avoidable hospital admissions through earlier intervention and coordinated support
- NHS England Population Health Management
- The King's Fund: What is Neighbourhood Health?
- DHSC Neighbourhood Health Framework
The Role of General Practice
Clinical Leadership
General practice plays a central leadership role within neighbourhoods because it has a detailed understanding of the health needs of local communities and long-standing relationships with patients. GPs, practice teams and PCN Clinical Directors help shape local priorities, influence service development and bring partners together around shared goals.
By working closely with community services, mental health teams, local authorities and the voluntary sector, General practice can help ensure that neighbourhood services are designed around the needs of residents and support the shift towards more integrated, proactive and preventative care.
Population Health Management
General practice plays a vital role in population health management by using practice and PCN data to understand the health needs of local populations, identify unwarranted variation and proactively support people who may be at risk of poorer health outcomes. This includes identifying patients who may benefit from earlier intervention, supporting long-term condition management, improving uptake of screening and vaccinations, and helping to address health inequalities.
Working at neighbourhood level enables practices to combine data, insights and local knowledge with partners across health, care and the voluntary sector to deliver more targeted and preventative approaches to care.
Care Coordination
General practice is often the first point of contact for patients and is therefore well placed to coordinate care across multiple services. Within neighbourhoods, practices work closely with community services, mental health teams, social care providers and voluntary, community and social enterprise (VCSE) organisations to ensure patients receive joined-up support.
This is particularly important for people living with multiple long-term conditions, frailty or complex needs, who may require input from a range of professionals. Effective care coordination can improve patient experience, reduce duplication and help individuals access the right support at the right time.
Working as part of Integrated Neighbourhood Teams (INTs)
General practice is fundamental to the success of INTs and should be represented at every stage of neighbourhood development, from design and planning through to delivery and evaluation. As the service that knows its population best, General Practice offers a unique combination of clinical expertise, continuity of care and understanding of local need.
When practices and PCNs are fully engaged alongside community health services, mental health teams, social care, local authorities and VCSE partners, neighbourhoods are better able to deliver joined-up, person-centred care. In NCL, strong general practice involvement will be critical to achieving the ambitions of neighbourhood working, improving population health and reducing health inequalities.
INTs - what are they and why are they important?
An INT is a partnership of health, care and community organisations that work together to provide more coordinated, proactive and person-centred support for local populations. INTs focus on identifying local priorities, supporting people with complex needs, coordinating care across services and addressing the wider factors that influence health and wellbeing. Their aim is to improve health outcomes, reduce inequalities and help people remain independent for longer.
Who is involved?
INTs bring together professionals and organisations from across the local health and care system, including:
General practice | PCNs | Community Health Services | Local Authorities | VCSE Organisations | Adult Social Care Services
General practice plays a key role within INTs by providing clinical expertise, continuity of care and valuable insight into the needs of local communities.
Teams work collaboratively to identify
local priorities,
support people with complex needs,
coordinate care and address the wider factors that affect health and wellbeing.
INT meetings provide opportunities for professionals to share knowledge, build relationships and develop coordinated approaches to care. General Practice is a key partner within INTs, bringing clinical expertise, continuity of care and valuable insight into the needs of local communities. By working together, INTs aim to improve outcomes, reduce health inequalities and help people remain well and independent for longer.