Neighbourhood based care board update – September 2025
This is the first update from the south east London Neighbourhood Based Care Board (NBCB) on our work to develop a neighbourhood health service. We will publish these in future after each Board meeting, sharing highlights from the Board’s discussions, along with key developments you can expect to see across our system.
The NBCB oversees the transformation towards a neighbourhood-based model of care, making services more proactive, joined-up, and responsive to the needs of local communities.
At the September meeting, we saw clear signs of progress across boroughs, programmes, and enablers – reflecting our shared commitment to integrated, sustainable health and care.
What’s coming up:
- Expansion of integrated neighbourhood teams (INTs) across boroughs
- Launch of a new support package for general practice
- Publication of a strategic roadmap aligned with the NHS 10-Year Health Plan
- Rollout of Population Health Management (PHM) tools.
Integrated neighbourhood teams
We are transforming how care is delivered, bringing services closer to communities through integrated neighbourhood teams (INTs). These teams focus on:
- People with multiple long-term conditions
- Older adults and those living with frailty
- Children and young people
Each borough is tailoring its approach, with several INTs already live. Teams are co-designed with residents and frontline staff, supported by digital tools and shared care planning systems.
Planning ahead: A roadmap for change
To meet the ambitions of the NHS 10-Year Health Plan, we are developing a Neighbourhood Health Roadmap which sets out the steps we will take to build and improve neighbourhood-based care over time.
It will help us stay organised and focused by setting out where and how we will transform care first and what will follow later, and co-ordinating support areas. These are the things that help services run smoothly such as workforce, estates and having the right technology and systems to support joined up care.
This will help all our stakeholders understand where, when and how they can contribute to neighbourhood care.
Population Health Management
Population Health Management (PHM) is becoming a core part of how we plan and deliver care and is essential in supporting effective neighbourhood working. It uses robust demographic, public health and other data to identify and respond to the specific needs of all ages within a locality so that interventions can be put in place based on those needs.
A shared PHM approach is being developed to:
- Give clinicians and teams real-time access to data
- Help integrators and neighbourhood teams plan services
- Support the ICB to strategically commission care
- Enable system-wide learning and evaluation
Supporting General Practice
To help respond to the increasing pressure in primary care services and recognising the foundational role of general practice in neighbourhoods, we are providing a tiered support package for general practices. This will include:
- Universal support for business operations, digital tools, and data use
- Shared programmes for workforce development and neighbourhood collaboration
- Tailored help for practices with specific challenges, including CQC ratings and estates
This offer has been co-designed with GPs, nurses, and practice managers to ensure it’s practical, fair, and easy to access. Over time we will review the support provided to other primary care providers (eg. pharmacy).