Here we talk about our ambition to build strong neighbourhood teams in line with the Government’s 10-Year Health Plan and what this means for your care and your health.
What’s the issue we need to fix?
At the moment, care can feel fragmented. People may see a GP, attend hospital, speak to social care and connect with community services – yet these teams do not always share information or coordinate support.
This can mean repeating the same story, waiting for referrals and travelling between appointments, which can be frustrating for patients and carers.
Care is often reactive, stepping in when problems escalate rather than preventing them earlier.
This can lead to an increase in hospital admissions, resulting in waiting lists going up and a rise in ‘corridor care’.
What will be different under neighbourhood health?
Neighbourhood health changes this, by creating NHS and social care teams built around local communities.
Instead of services working separately, it will bring together GP practices, community health teams, mental health services, social care and voluntary organisations to work as one local team, working together.
Care is more joined-up, easier to access and centred around what matters to people, not organisational boundaries.
More care will be delivered in GP practices, community clinics, neighbourhood settings or in people’s own homes, with hospitals used for specialist or urgent care.
It will support people to stay at home and retain their independence rather than go to hospital.
Each team supports a population of around 30,000 to 50,000 people and brings together GPs, community nurses, social workers, mental health colleagues and voluntary sector partners.
These professionals will work as one team, sharing responsibility for people’s care and focusing on what matters most to them.
What does this mean for patients?
For patients and their carers and families, this means having one local team that understands their situation. There is a single point of contact, so people do not need to repeat their story.
Care is more personal, proactive and delivered closer to home.
When someone’s needs change, the team can respond quickly to provide the right support and help avoid unnecessary hospital visits.
Patient need groups (PNGs)
As neighbourhood care develops, you may begin to see more use of Johns Hopkins patient need groups (PNGs). These groups help us understand the complexity of a person’s health and wellbeing needs, so they can be offered the right level of support.
You may notice a test result appear in your NHS app referring to segmentation, PNGs or Johns Hopkins.
If you see this test result, don't worry. No action is needed from you.
Every patient is placed into a group, using the information we have about their health, ranging from one to 11. The higher the number, the more complex the person’s physical, social or psychological needs are likely to be.
The groups help health and care teams to identify:
- who may need more proactive or preventive care
- who is at higher risk of hospital admission
- who might benefit from multi-disciplinary support
- where neighbourhood teams can make the most difference to wellbeing and independence.
These groups do not ‘label’ people and someone’s number can change over time. They simply guide us to consider the level of coordinated support groups of people are likely to need so we can plan our services to meet those needs and help us plan care.
What does this mean for colleagues working in health and social care?
Daily team discussions will help colleagues make decisions quickly and confidently. Instead of sending referrals and waiting for responses, colleagues can act straight away because they are part of the same team.
Shared records will mean less duplication, fewer hand-offs and fewer forms.
This gives colleagues more time to focus on care, build relationships with patients and use their expertise proactively. It also strengthens collaboration, as everyone works towards shared goals rather than organisational priorities.
They don’t care about what’s on their badge, or what organisation or trust they work for. They are a genuine team.
Colleagues will focus more on proactive support for patients in their neighbourhood, which will prevent people from getting into crisis. Less fire-fighting and more planned support means less stress for colleagues, patients and carers.
Specialist services are an important part of neighbourhood health. Rather than sitting outside the system, specialists will work alongside neighbourhood teams. They can join discussions virtually or visit patients at home, helping to provide expert advice early and avoid hospital admissions where possible.
A more connected and compassionate system
This is a significant change, which relies on collaboration, trust and a shared commitment to doing things differently.
Whether you are a patient, carer or colleague, everyone has a role to play in shaping neighbourhood health.
Together, we can build healthier communities and a system that works better for everyone.
Real examples from Kent and Medway
We’re not starting from scratch. Across the county, we’re already seeing the power of this approach in action.
East Kent has been chosen as one of the national ‘neighbourhood health’ pioneer sites.
There are many more examples across the county, here’s just a few….
Case studies
Neighbourhood care helps Carol and Tony stay at home
Why we believe this approach works
This isn’t just about reacting to illness – it’s about helping people stay well:
- Spotting problems early: Smart tools and shared records help teams identify risks before they become emergencies.
- Supporting people at home: Remote monitoring and home visits mean fewer hospital trips.
- Reducing stress: Joined-up care means fewer forms, fewer delays and less repetition.
- Improving outcomes: Patients feel more confident, stay healthier, and spend more time at home.
So, what next?
We’ll continue expanding our neighbourhood team model across Kent and Medway. We’ll listen, learn, and adapt. We’ll build on what works and fix what doesn’t. We’ll keep working with our partners – and most importantly, with the people we serve.
This won’t be easy. It requires trust, collaboration and a willingness to do things differently. But the prize is worth it: healthier communities, reduced inequalities, and a system that works better for everyone.
Join us on the journey
Whether you’re a clinician, a volunteer or someone who uses our services – you have a role to play.
Together, we can build a system that’s more compassionate, more connected and more human.