We have an ambition to build strong neighbourhood teams, in-line with the Government’s 10-Year Health Plan. This is what it means for your care and your health.
Why do we think things need to change?
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.
Single neighbourhoods
Kent and Medway is divided into 45 single neighbourhood health footprints. Each footprint covers a population of around 30,000–50,000 people – roughly the size of a primary care network. These neighbourhoods are where day‑to‑day care will be planned and coordinated.
Multi-neighbourhoods
Some services work better when they are delivered at a slightly larger scale. For this reason, several neighbourhoods come together to form multi-neighbourhoods. There are nine multi-neighbourhoods proposed across Kent and Medway, each covering around 250,000–300,000 people. These help ensure consistency, resilience and access to specialist support.
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.
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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.
Read more about PNGs:
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.
Learning from Folkestone and Hythe pioneer site
In Folkestone, Hythe and Romney Marsh, we’re testing a new approach to neighbourhood health, bringing services together around local communities to deliver more proactive, joined-up care.
The area is acting as a pioneer site, helping to show what neighbourhood health looks like in practice and what it will take to do the same thing successfully across the rest of Kent and Medway.
The work is already shaping the wider development of single neighbourhoods across the system, bringing together community health, primary care, mental health, social care and voluntary sector services to better support local populations.
Read more below.
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….
The Dover INT partnered with housing services and mental health teams to support people at risk of homelessness. Wraparound care – including medication reviews and benefit support – led to fewer crises and stronger community resilience.
Thanet’s INT is supporting patients with multiple long-term conditions, including mental health needs. For patients with multiple long-term conditions who are frequently attending A&E, the Thanet team coordinate care planning, home visits and voluntary sector support. The result? Fewer hospital visits, better health, and a more stable life.
In Canterbury, health and care teams are focusing on housebound patients aged 50 to 70 who have needed at least two home visits in the past year. These patients receive a full assessment from health and social care coordinators, looking at both medical and personal needs.
Care is then planned and coordinated through regular team meetings involving different professionals. This joined-up approach helps patients manage long-term conditions, improves housing and social support and reduces feelings of isolation – making it easier for people to stay well at home.
Late-stage cancer diagnoses were common in Romney Marsh. The INT introduced the ‘Think, Talk, Act’ approach, encouraging early conversations about care preferences. Community nurses, hospices and GPs worked together to ensure dignified, personalised end-of-life care – often at home. Targeted lung health checks identified 43 cancers and stop smoking support reached 595 patients – one of the highest uptakes nationally.
Tonbridge INT created daily huddles with GPs, paramedics, and nurses to plan who should visit each patient. It supports 664 housebound patients, with more than 50 home visits per week. The new way of doing this sees a frailty coordinator triage and allocate visits, this reduces duplication, improves care quality, and ensures patients are seen by the right person at the right time.
Primary care networks have identified patients who are most at risk and worked with care coordinators in the GP practice to proactively manage their care. This has resulted in A&E visits dropping from 223 to 33 in six months for this group of patients, with unplanned GP appointments falling from 671 to 126. That’s empowering the patient, giving you the tools to manage your conditions, supporting you to stay healthier.
GP practices are working closely with local councils and voluntary groups to connect patients with wider support services. They’ve set up a Health and Wellbeing Hub that helps people with everyday needs – like cleaning, shopping, quitting smoking, finding a job, or making friends.
Non-clinical staff help resolve issues quickly, so patients get the support they need alongside their medical care. Feedback has been very positive and this may be expanded to support other teams.
A special home-visiting team is helping frail, housebound patients get the care they need quickly and easily. The team includes GPs, community nurses, paramedics, complex care staff, and a frailty coordinator. They offer one point of contact and clear support pathways.
In one year, the team received more than 1,000 referrals. More than half of these patients didn’t need to be referred elsewhere and 99 per cent of patients, carers, and staff said care was delivered faster than before.
A team of professionals is helping children and young people who are struggling with their mental health. The team includes a GP with extra training, a social prescriber, a mental health expert and staff who support frequent attenders at hospital.
They work with families to reduce stress caused by things like money worries, poor relationships, or lack of access to healthy food. They also help children manage early signs of anxiety and depression through therapy and support.
This service has brought different organisations together and made a real impact – 82 per cent of young people said they felt less anxious and 35 per cent felt less lonely. GP visits dropped by 39 per cent, and emergency department visits by more than 60 per cent.
In Maidstone and the Weald, health and care teams are joining forces to support adults whose mental health hasn’t been improving, even after regular GP visits. These patients are now being discussed in special team meetings that include GPs, community nurses, social workers, and voluntary organisations. Together, they create a care plan with the patient and their family to tackle not just health issues, but also personal challenges like housing problems or loneliness.
This joined-up approach has made a big difference. Patients say their quality of life has improved and they feel healthier. They also need fewer GP and hospital visits –appointments dropped by 54 per cent, and hospital visits by 61 per cent.
In Medway and Swale, INTs are supporting patients with COPD, heart failure, and cardiovascular disease to avoid emergency admissions through proactive care, while others are focused on addressing self-harm in 10 to 24-year olds through tailored community-based support.
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.
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