Neighbourhood health: Learning from our pioneer site
By Dr Sarah Phillips, Chief Medical Officer for Neighbourhoods, Dr Aravinth Balachandran, Clinical Director at Folkestone Hythe and Rural Primary Care Network, Dr Tuan Nguyen, Clinical Director Total Health Excellence PCN and Dr Antonio Monochello, Clinical Director Marsh PCN.
People often tell us they want care to feel simpler, more joined up and closer to home. That is exactly what we are working towards across Kent and Medway.
In Folkestone and Hythe, local health and care organisations are testing a new neighbourhood approach. This brings services together around local communities so people can get the right support at the right time and, wherever possible, closer to where they live.
What we are learning in Folkestone and Hythe will help shape how this way of working grows across Kent and Medway.
If you would like to read more about the local work, visit our Folkestone and Hythe neighbourhood health page.
WATCH: Dr Aravinth Balachandran, Clinical Director at Folkestone Hythe and Rural Primary Care Network talk about neighbourhood teams:
From pioneer to system-wide change
While this work is taking place in Folkestone, Hythe and Romney Marsh, it is part of a much bigger vision for Kent and Medway. In the future, services will be organised around 45 local neighbourhoods, helping health and care teams work more closely with the communities they serve.
These will be supported by nine larger neighbourhood partnerships, bringing together community health, mental health, social care and other services.
What we are learning locally will help shape how neighbourhood health develops across Kent and Medway in the years ahead.
Multi-neighbourhood team boundaries
Single neighbourhood team boundaries
At the heart of the neighbourhood model are three ways of caring that work together: Proactive care, reactive care and outpatient care.
Proactive care – helping people stay well
One of the biggest opportunities is identifying people who may need extra support before they reach a crisis point.
In Folkestone and Hythe, teams are using nationally recognised tools to identify people who may be most at risk of their health deteriorating. This helps us move from reacting when someone becomes very unwell to offering support earlier, when it can make the biggest difference.
Using Patient Need Groups and Johns Hopkins risk stratification, teams can better understand the needs of local populations. For patients, that means professionals working together to help them stay well and independent for longer.
The Joy app is also being rolled out more widely, to help our patients to play a more active role in managing their health and wellbeing.
Reactive care – responding quickly when it matters
When people become unwell, neighbourhood teams are working together to provide faster, more joined-up support. GPs, nurses, therapists, mental health colleagues and social care professionals work as one team to make sure patients get the right care from the right person, as quickly as possible.
Urgent requests can be assessed and directed to the most appropriate professional, helping people get support sooner and reducing delays. By working more closely together, services can provide a more coordinated response, helping people receive care at home whenever it is safe to do so and avoiding unnecessary hospital admissions.
Outpatient care – bringing care closer to home
We know on the Romney Marsh, poor transport links can make travelling to hospital difficult, so we are testing how outpatient services can be redesigned to deliver more care closer to home.
More than 600 local residents helped us identify the key barriers. In response, we are exploring options such as mobile breast screening and chemotherapy services, as well as pre-operative assessment and testing carried out in primary care settings.
We hope this will reduce the need to travel to William Harvey Hospital, a journey that can take up to two and a half hours and involve multiple bus journeys for those without access to a car.
What are we learning?
One of the most encouraging things we have learned is that the best solutions come from the people closest to the work and the communities they serve.
We have seen the value of involving patients, local communities and colleagues in shaping services. We have also seen how important strong relationships are between GPs, health and care professionals, charities and community groups.
While every neighbourhood is different, the principles remain the same. Working together, listening to local people and making sure support is joined up around patients and their needs.
What difference is this making?
Although it is still early, we are already seeing encouraging signs. There are early indications of reduced hospital admissions in some high-need groups, alongside improved coordination and faster, more responsive support for people with complex needs.
Just as importantly, feedback from both patients and colleagues suggests that care is beginning to feel more joined-up.
How are we measuring success?
It is important that we measure whether this work is making a real difference to people's lives.
We are asking patients how confident they feel in looking after their own health and colleagues whether they feel part of a joined-up team.
We are also tracking things such as hospital attendances, admissions and whether more care is being provided closer to home.
Together, these measures help us understand whether neighbourhood health is improving people's experience of care, supporting them to stay well and helping services work better together.
What next?
The next phase is about connecting what we are learning into wider delivery across Kent and Medway. This work is being driven by the commitment, openness and creativity of teams, partners and local communities.
What we are building is more than a new service model – it is a new way of working together.
