What is neighbourhood health and care working?

Services working together to meet people’s health and care needs where they live, in their neighbourhoods.  This includes health, care, social services, housing and more, working as connected teams. Services are organised and delivered locally, designed around the needs of people in that neighbourhood, so they can access support close to home. It is also about developing a deeper understanding of the people we serve and proactively identifying need at the earliest opportunity.

What is a neighbourhood?

Areas which people would recognise as the area where they live their lives. Every neighbourhood includes many different services, who will work closely together. In south east London, our boroughs are divided into four or five neighbourhoods, each with a population of about 50,000 people.  The neighbourhoods are groups of electoral wards, so they follow established community boundaries.

What do we mean by Place?

Place is used as another word for ‘borough’ in London. Our places (boroughs) are made up of four or five neighbourhoods.  Neighbourhood working will be organised at borough level. This will make sure that we can build on existing services and relationships and arrange services in a way that meets the particular needs of the people living in each borough.

What is an integrator?

An integrator is the term we use to describe an organisation or a partnership of organisations in each borough responsible for neighbourhood working. Neighbourhood working is a change for how we deliver health and care services, and so it needs to be organised and coordinated. Integrators will be organisations that already exist in boroughs, with local knowledge and established relationships. They will bring their experience of their borough and combine it with this new way of working. Integrators will build on what already exists in each borough, and patients will be treated by the same health and care professionals.  What will change is how those professionals work with each other.

Who is involved in neighbourhood working?

It involves professionals from across the NHS, local councils, and the voluntary, community, faith and social enterprise (VCFSE) sector. This includes GPs, nurses, social workers, care coordinators, mental health teams, public health specialists, and community support workers, all working as one team around a neighbourhood. It will also involve more in-reach into neighbourhood teams from specialists working within our hospitals. Local communities are also involved in neighbourhood working as there is a focus on prevention of ill health and enabling people to have more control over their care needs by supporting self-care where that is appropriate.

How is this different from how we have worked before?

Neighbourhood working breaks down traditional organisational and service boundaries. Rather than referring between siloed services, teams collaborate more closely, share information, and work with residents to plan care that reflects individual needs and local priorities. It will also mean changing the way that our residents access services, with a greater emphasis on proactively identifying the people that most need support at the earliest opportunity.

Why are we doing this now?

The NHS 10 Year Plan sets out a national shift towards more proactive, preventative care delivered in the community. In south east London, neighbourhood working is our way of delivering this, building on existing partnerships and responding to what our residents and staff have told us they need.

What guidance is there from NHS England?

NHS England’s Neighbourhood Health Guidelines 2025/26 outline a transformative approach to health and social care, focusing on delivering integrated services at the neighbourhood level. This strategy aims to provide care closer to home, enhance patient experiences, and ensure the sustainability of health and social care systems.

What are integrated neighbourhood teams (INTs)?

Teams of people from different services who work together in, and for, neighbourhoods. Teams will be organised according to the needs of each neighbourhood, and for the people who live in them. Teams will not be fixed and rigid, they will adapt depending on the needs of individuals and communities. One health or care professional could work in multiple teams. But each patient will only be cared for by one team, designed around them.

Who is involved in an INT?

An INT typically includes professionals from primary care, community services, social care, and the voluntary, community, faith and social enterprise sector (VCFSE). This may include GPs, nurses, social workers, pharmacists, social prescribers and VCFSE workers, among others. Hospital specialists will also begin to work differently, in-reaching into neighbourhoods and working as part of the INT.

How do INTs benefit communities?

By working collaboratively, INTs deliver personalised care tailored to the needs of individuals within a neighbourhood.  There is a focus on prevention and proactive management of people’s conditions.  Population health management approaches ensure INTs target their work at populations where the need is greatest. This approach leads to improved health outcomes, care closer to home, fewer hospital admissions, and greater patient satisfaction.  It is also expected to deliver social benefits for example, a reduction in people economically inactive because of health issues.

How do INTs help reduce health inequalities?

INTs provide holistic care. This will include preventative care, using population health data to identify residents at risk of poor health and address the root causes of health disparities. By bringing together public services and community-led initiatives, they aim to improve health and wellbeing at a neighbourhood level.  This may include for example, helping to address a person’s housing issues first so that they are better able to look after their physical health.

How do INTs work with the voluntary sector?

INTs partner with VCSE organisations to improve the support available to local people to provide more holistic and responsive care that meets people where they are and recognises the context within which they live.  This includes supporting the inclusion of the views of local people in how health and care services are delivered.

What challenges do INTs face?

Challenges can include coordinating across multiple organisations, aligning different working cultures, and ensuring clear communication. However, with strong leadership and a shared vision, these challenges can be effectively managed.  Increasingly joined up digital solutions will also help.

How can local people and communities get involved with INTs?

INTs will engage local people and communities by working with the VCFSE sector, including small community groups, to co-design services. Local people will also be able to participate in health initiatives and provide feedback on services to help continual improvement.

What are we doing to support the development of INTs in south east London?

The ICB is supporting the development of INTs by developing a shared definition, along with an overarching framework setting out common objectives for how we deliver INTs locally at place, building on previous work we have undertaken to integrate services.  In addition, the ICB is providing resources in terms of funding and staff to support and work alongside NHS provider, Council and VCFSE colleagues in the implementation of neighbourhoods and INTs.

For further details, see the NHS Confederation’s report: The Case for Neighbourhood Health and Care.

How will this benefit me as a staff member?

Neighbourhood working can support better communication, stronger teamwork, reduced duplication, and more shared learning. Staff have reported greater job satisfaction from being able to deliver more holistic, meaningful care.

What does this mean for my day-to-day work?

You may find yourself:

• Working more closely with professionals from other sectors
• Taking part in multi-agency planning or learning sessions
• Contributing to more proactive care for people with complex needs
• Having more influence over how care is delivered in your local area

Will I have a job going forward?

Yes, as neighbourhood working is not about reducing roles or cutting jobs. It is about supporting staff more effectively, strengthening local teams, and building new ways of working that recognise and value your contribution. As we develop integrated neighbourhood teams, your skills and experience will continue to be essential, and new opportunities for development and collaboration may also emerge. We are committed to working with staff throughout this process, ensuring transparency, support, and involvement in shaping what comes next.

How will I work proactively when there is so much reactive work to undertake?

This is a real and shared challenge across all areas. Neighbourhood working is designed to help manage demand by supporting earlier intervention, stronger community connections, and better teamwork, so the volume of reactive work can gradually be reduced. It won’t happen overnight, but by working in integrated teams, sharing information, and aligning resources locally, we can begin to shift the balance. Your role in this is crucial, and we will continue to provide support, space for learning, and shared planning so this change works for both staff and residents.

How will we know if neighbourhood working is making a difference?

We will measure impact through outcomes like reduced hospital use, better patient and carer experience, staff feedback, and improved health and wellbeing at community level. Local examples of success are being shared on the ICS website and in borough updates.

What does this mean for the GP partnership model?

General practice continues to be the foundation of community care, and neighbourhood teams are being built around, not in place of, primary care. This approach is about strengthening support for GPs by improving coordination, sharing workload, and enabling earlier intervention through better connections with community, social care, and voluntary services.

Locally, we are building on the strengths of the existing partnership model and ensuring strong general practice in design and delivery of new care models. Neighbourhood working is about aligning how we work and moving to a more pro-active model, that over time supports a left shift in our overall resources to enable us to deliver sustainable, preventative health services.

An integrator is a partnership model, hosted by an existing statutory organisation within each borough. It’s not a new organisation, but a way of organising and coordinating neighbourhood working through a trusted local host with strong relationships and local knowledge.

Who makes up the integrator partnership?

The integrator partnership typically includes representatives from health (primary care, community care, mental health services and acute care), social care, local government, and the voluntary, community, faith and social enterprise (VCFSE) sector. The host organisation provides infrastructure and support, but decision-making is shared equally across the partnership.

Who are the integrators in south east London?

• Bexley:  The borough’s health and care partnership between the London Borough of Bexley, Bexley Health Neighbourhood CiC, Primary Care Networks, and Oxleas NHS Foundation Trust. Oxleas will host the arrangement.
• The One Bromley Partnership, set up as a neighbourhood provider group with members from the One Bromley Executive, will serve as the integrator for Bromley Place. King’s College Hospital NHS Foundation Trust will host the arrangement.

• The Healthier Greenwich Partnership, which brings together a wide range of partners in the borough including the council, local Trusts and Community Hospice will serve as the integrator for Greenwich place.  Oxleas NHS Foundation Trust will host the arrangement.
• Lambeth: A partnership between Guy’s & St Thomas’ NHS Foundation Trust (GSTT) and Lambeth General Practice Provider Alliance. GSTT will host the arrangement.
• Lewisham:  A partnership between the London Borough of Lewisham, Lewisham and Greenwich NHS Trust, primary care, South London and Maudsley NHS Foundation Trust and the voluntary and community sector. Lewisham and Greenwich NHS Trust will host the arrangement.
• Southwark: A partnership between GSTT and GP federations: Improving Health Ltd and Quay Health Solutions.  GSTT will host the arrangement.

What does the host organisation do?
The host organisation provides the operational backbone, supporting coordination, convening partners, managing resources, and ensuring delivery aligns with borough priorities. It also acts as a key link between the borough and the wider system.

Do integrators manage services directly?
Currently, their role is to support coordination and collaboration across services, helping teams work together more effectively around neighbourhoods.

How do integrators support integrated neighbourhood teams (INTs)?
Integrators help set the conditions for INTs to thrive, aligning priorities, supporting shared planning, resolving barriers, and ensuring teams have the tools and relationships they need to work collaboratively.

How is accountability managed?
Whilst the host organisation provides leadership, accountability is shared across the partnership. Clear governance arrangements, including clinical governance, are put in place to ensure transparency, shared decision-making, and alignment with borough and system priorities.