A
- Anchor Institution
- Anchor institutions are typically large organisations that are unlikely to relocate, meaning they are deeply embedded in their local communities and environments. They possess significant assets, resources, and influence, which they can leverage to improve social, economic, and environmental conditions in their area. While often public sector organisations like hospitals, universities, and local authorities, anchor institutions can also include private and voluntary sector organisations with a long-term stake in their community.
Examples of anchor institutions include healthcare organisations, educational institutions, large local businesses, or infrastructure organisations.
C
- Care Coordination
- The organisation of care activities across professionals, organisations and settings to ensure people receive joined up, timely and person-centred support. Often led by a named coordinator within the MDT or INT.
- Case Management
- A targeted approach for individuals with complex or high intensity needs where a lead professional coordinates assessment, care planning, intervention and review across agencies.
- Clinical Commissioning Group (CCG)
- A membership organisation made up of general practices and based on their registered patient lists, responsible for commissioning healthcare services for local populations. CCGs were replaced by Integrated Care Boards (ICBs).
- Clinical Director (CD)
- A Clinical Director is a senior-level healthcare leader responsible for overseeing the delivery of clinical services and ensuring that patient care standards are met across a department or facility. Their role combines clinical expertise with operational leadership, requiring them to manage personnel, budgets, compliance, and strategic planning.
- Co-production
- A way of designing, delivering and improving services with people and communities rather than for them. It means citizens, carers and community organisations are involved as equal partners in shaping neighbourhood priorities, services and solutions.
- Community Asset Based Approach
- An approach that starts with the strengths, skills, relationships and resources already present within communities rather than focusing solely on needs and deficits. Often linked to prevention, resilience and community empowerment.
- Community Assets / Asset-Based Approach
- An approach that starts with the strengths, relationships, knowledge and resources already present within communities, rather than focusing only on needs and deficits. This includes residents, community groups, peer support, faith groups, local organisations and neighbourhood networks.
- Community Health and Wellbeing Worker (CHWW)
- Local community workers who build trusted relationships with residents, support access to services and community resources, and help improve health and wellbeing in neighbourhoods.
- Community-Led Neighbourhood Working
- A model of neighbourhood development in which residents, communities and local organisations help shape priorities, relationships and solutions. It recognises that healthier communities are built with people, not solely through formal services
- Continuity of Care
- The experience of people receiving coordinated and consistent care over time, often through ongoing relationships with professionals and teams within the neighbourhood. This is shown to improve quality and reduce cost.
- Core20PLUS5
- Core20PLUS5 is a national NHS England approach to reducing healthcare inequalities at both national and system level by focusing on the most deprived 20% of the population (Core20), locally identified vulnerable groups (PLUS), and five priority clinical areas (5). It is used to target action and inform neighbourhood planning and Population Health Management (PHM) approaches.
D
- Department of Health and Social Care (DHSC)
- The Department of Health and Social Care (DHSC) is a department of His Majesty’s Government responsible for government policy on health and adult social care matters in England. The DHSC leads, shapes, and funds health and care in England, making sure people have the support, care, and treatment they need, with the compassion, respect, and dignity they deserve.
- Digital Inclusion
- Ensuring people and communities can access and use digital technology, services and information regardless of age, income, disability or confidence with technology.
E
- End of Life care (EoL)
- End of life care is a form of palliative care you receive when you’re close to the end of life.
G
- General Medical Council (GMC)
- National registration body for doctors
- General Practice (GP)
- General practice is a branch of medicine that provides primary healthcare to individuals and families in the community. General practitioners (GPs) are usually the first point of contact for patients, offering a wide range of medical services.
- General Practice Nursing (GPN)
- General Practice Nursing (GPN) is a specialised field within the healthcare system where registered nurses work autonomously within GP surgeries as part of a multidisciplinary team. GPNs assess, screen, diagnose, and treat patients of all ages, offering a broad range of services including health promotion, long-term condition management, contraception, weight management, smoking cessation, travel consultations, vaccinations, and wound care. They play a crucial role in patient care, often taking on multiple roles and responsibilities, and may have direct supervision of healthcare assistants at the practice.
- General Practitioner (GP)
- A GP is a doctor who is a consultant in general practice. GPs have distinct expertise and experience in providing whole person medical care whilst managing the complexity, uncertainty and risk associated with the continuous care they provide. GPs work at the heart of their communities, striving to provide comprehensive and equitable care for everyone, taking into account their health care needs, stage of life and background. GPs work in, connect with and lead multidisciplinary teams that care for people and their families, respecting the context in which they live, aiming to ensure all of their physical and mental health needs are met.
H
- Health and Wellbeing Board (HWB)
- Health and wellbeing boards were established under the Health and Social Care Act 2012 to act as a forum in which key leaders from the local health and care system could work together to improve the health and wellbeing of their local population. They became fully operational on 1 April 2013 in all 152 local authorities with adult social care and public heath responsibilities.
- Health Inequalities
- Systematic differences in health outcomes between groups. Neighbourhood working aims to reduce inequalities by tailoring interventions to local need and addressing wider determinants. These should be identified and scoped within each of the neighbourhood delivery plans.
- Health Outcomes
- Consequences brought about by the treatment of a health condition or as a result of an interaction with a healthcare professional.
I
- Integrated Care Board (ICB)
- The statutory NHS organisation responsible for planning NHS services, allocating resources and improving health outcomes across an Integrated Care System (ICS).
- Integrated Care System (ICS)
- A partnership of NHS organisations, local authorities, VCSE organisations and other partners working together to improve population health, reduce inequalities and coordinate services across a wider geographical area.
- Integrated Neighbourhood Team (INT)
- A multidisciplinary, multi-agency team working as one around a defined neighbourhood population. INTs bring together professionals from community health, mental health, primary care, social care, local government, the voluntary, community and faith sector (VCSE), and specialist services to coordinate and deliver proactive, preventative and responsive support for individuals, families and communities. As a core delivery mechanism within the wider Neighbourhood system, INTs share caseloads, intelligence, decision-making and accountability for outcomes, while contributing to neighbourhood priorities as part of a broader partnership with communities, citizens and local organisations.
- Interoperability
- The ability of different digital systems to securely share and use information across organisations.
L
- Left Shift
- Moving care, support and resources away from hospitals and crisis services towards earlier prevention, community support and neighbourhood-based care.
- Length of Stay (LoS)
- Length of stay (LOS) is a clinical metric that measures the time elapsed between a patient’s hospital admittance and discharge. LOS can be calculated on a hospital-wide basis or by therapy area, including acute myocardial infarctions (heart attacks) and diabetes. Numerous factors can contribute to a patient’s length of stay, including comorbidities, patient acuity or case mix, hospital quality performance, and provider staffing levels, among others.
- Loaclly Enhanced Services (LES)
- Local payment system for additional services provided by a practice
- Local Medical Committee (LMC)
- Professional body representing GP’s locally
- Local Pharmaceutical Committee (LPC)
- Professional body representing local pharmacists
- Long-Term Conditions (LTC’s)
- Long-Term Conditions (LTCs) are health issues that persist over an extended period and typically require ongoing management. These conditions can significantly impact an individual’s quality of life and often involve complex and multi-faceted treatment approaches. Common LTCs include chronic diseases such as diabetes, cardiovascular diseases, chronic respiratory diseases, and mental health disorders. LTCs are characterized by their persistence and slow progression, demanding continuous medical attention and limiting activities of daily living. The management of LTCs involves not only medical treatment but also lifestyle modifications and supportive care.
M
- Multi-neighbourhood provider
- The 10 Year Health Plan signals the intention to create a new multi-neighbourhood provider contract to support the consistent delivery of services across multiple neighbourhoods. This contract could be held by a number of organisations but will require the support of the GPs in the neighbourhoods it serves. More detail will be provided in the Model System Archetypes Blueprint.
- Multidisciplinary Team (MDT)
- A group of professionals from different disciplines who collaborate on assessment, planning and delivery of care for individuals or cohorts. MDTs sit within INTs and are the operational engine of neighbourhood working. The Mersey Cre Integrated Care teams are examples of these MDTs. There are a number of MDT’s or multi-agency teams within an INT.
N
- National Health Service (NHS)
- The National Health Service (NHS) is the public health service that provides free medical care to everyone in the UK. It is funded by taxes and overseen by the government. The NHS covers all aspects of health care, from general practitioners to hospitals, dentists, and pharmacies.
- National Health Service England (NHSE)
- NHS England has a wide range of statutory functions, responsibilities and regulatory powers, which are focused on supporting and overseeing the wider NHS to deliver effective and high quality care, as well as doing those things that are best done once for the whole NHS. NHSE became responsible for direct commissioning of primary care services on 1 April 2013.
- National Neighbourhood Health Implementation Programme (NNHIP)
- The National Neighbourhood Health Implementation Programme (NNHIP) is a collaborative initiative by the NHS, led by NHS England, aimed at transforming health and care services in England. It focuses on bringing care closer to where people live, strengthening prevention, and joining up services across the NHS, local government, social care, and the voluntary sector. The NNHIP is part of the 10 Year Health Plan and seeks to create healthier, more resilient communities where people of all ages can live active, independent lives for as long as possible. The programme is designed to systematically share existing knowledge and improve health outcomes by engaging people and communities in decision-making and transforming care approaches. It is a shared movement for change that brings together people and organizations from across health, social care, and the voluntary sector with a common purpose: helping more people live healthier, fairer communities.
- Neighbourhood Hub
- A physical or virtual focal point where neighbourhood services are coordinated. May include community nursing, therapy, mental health, social care, PCN staff, and VCSE presence. There are a number of these described in the different neighbourhood frameworks i.e. 24/7 Mental Health Hubs, family hubs and the roll out of neighbourhood health centres as part of the neighbourhood health framework.
- Neighbourhood Leadership
- A distributed leadership model across the neighbourhood [primary care, community, mental health, local authority and VCSE etc] partners. As the neighbourhood model matures, leaders are collectively accountable for outcomes, inequalities and experience within the neighbourhood and for driving forward the neighbourhood priorities.
- Neighbourhood Maturity
- Neighbourhood Maturity refers to the process of moving from aspiration to embedded practice in neighborhood health. It is a structured approach to have honest conversations about neighborhood health, focusing on both the domains of what good looks like on the ground and the system enablers that support these practices. The framework includes four maturity levels: Mobilisation, Integration, Optimisation, and finally, Optimisation. Each level reflects a journey from early alignment to fully embedded, outcome-driven neighborhood working.
- Neighbourhoods
- A meaningful place-based partnership and core building block of integrated care delivery, typically serving a population of 30,000 to 50,000 people and aligned to natural communities and Primary Care Network footprints. Neighbourhoods bring together citizens, communities, statutory services and the voluntary, community and social enterprise (VCSE) sector to improve health and wellbeing outcomes through shared leadership, collective decision-making and partnership working. They provide the primary level at which outcomes are owned and shaped, organising care around communities rather than institutions and creating a sustainable framework for prevention, community resilience, care and support.
- Non-Elective Admissions (NEL)
- Non-elective admissions are unscheduled hospitalisations for urgent or emergency medical conditions that cannot be safely postponed. These admissions are categorised into ’emergent’ (life-threatening) and ‘urgent’ (requires timely, but not immediate, attention). Non-elective admissions create significant, unpredictable demands on hospital resources, including beds, staff, and finances. They are triggered by a patient’s acute medical condition, which requires immediate or very timely intervention to prevent further deterioration or a life-threatening situation.
O
- Outpatient (OP)
- Outpatient care refers to medical treatment that does not require an overnight hospital stay. Patients attend an appointment, procedure, or test and return home the same day
P
- Patient Reported Experience Measures (PREMs)
- Feedback from patients about their experience of services and care.
- Patient Reported Outcome Measures (PROMs)
- Information provided directly by patients about how their health condition and treatment affect their quality of life.
- Person Activation
- A measure of how confident, informed and supported people feel to manage their own health and wellbeing.
- Personalised Care
- An approach where people have choice, control and involvement in decisions about their health and wellbeing, based on “what matters to me” conversations and shared decision making.
- Place
- An area covered by a local authority – an area where partners can come together and take action to support local communities.
- Place-Based Partnership (PBP)
- A collaborative leadership and delivery arrangement at Place level that brings together NHS organisations, local authorities, the voluntary, community and social enterprise (VCSE) sector, community partners and other stakeholders responsible for improving health and wellbeing. Place-Based Partnerships provide shared strategic leadership, coordinate the planning and delivery of health and care services, and oversee neighbourhood-level delivery to improve outcomes for local populations.
- Population Health Management (PHM)
- A systematic approach to improving the health and wellbeing of local populations by using data, risk stratification, segmentation, local knowledge and community insight to understand health needs, identify people and groups at risk of poor outcomes, and target interventions earlier. PHM supports proactive planning and delivery of services, helping partners prevent ill health, improve outcomes and reduce health inequalities through coordinated neighbourhood working.
- Prevention
- Action taken to reduce the likelihood of illness, deterioration or crisis. Prevention includes primary prevention, which aims to prevent illness before it occurs; secondary prevention, which focuses on early detection and intervention; and tertiary prevention, which seeks to reduce complications, manage long-term conditions and prevent further deterioration. Neighbourhood working supports all three levels of prevention to improve health outcomes and wellbeing.
- Primary Care
- The first point of contact in the health service, usually a GP, practice nurse, local pharmacist, dentist or NHS walk-in centre
- Primary Care Network (PCN)
- A group of GP practices working together with community, health, social care, pharmacy and other local partners to deliver integrated services for a defined population, typically between 30,000 and 50,000 people. As a core component of neighbourhood delivery, PCNs coordinate care, support people with long-term conditions, improve access to services, promote prevention, and help identify and address the health needs of local communities.
- Primary Care Trust (PCT)
- Primary care trusts (PCTs) were part of the National Health Service in England from 2001 to 2013. PCTs were largely administrative bodies, responsible for commissioning primary, community and secondary health services from providers. They also provided community health services directly. Their work was taken over by clinical commissioning groups (CCG).
- Proactive and Anticipatory Care
- An approach that shifts care from reactive responses to early identification, prevention and planned support. MDTs and INTs use PHM, risk stratification and the CIPHA platform to identify people at risk of deterioration or crisis and provide timely interventions, particularly for those living with frailty, long term conditions or complex needs.
R
- Risk Stratification
- A method of using data to identify and categorise individuals or population groups based on their likelihood of illness, deterioration, hospital admission or other poor outcomes. Risk stratification helps Integrated Neighbourhood Teams (INTs) and other services prioritise proactive support and targeted interventions, enabling earlier action to prevent crises, improve outcomes and make best use of available resources.
- Royal College of General Practitioners (RCGP)
- Professional membership body for UK GPs
- Royal College of Nurses (RCN)
- Organisation representing nurses and nursing in the UK
S
- Shared Care Record
- A digital record enabling professionals across organisations to access relevant information about a person’s care, supporting coordinated neighbourhood working.
- Single neighbourhood provider
- The 10 Year Health Plan sets out a commitment to create single neighbourhood provider contracts to deliver the enhanced neighbourhood services. In many areas, the existing primary care network (PCN) footprint is geographically coherent and is well set up as a springboard. More detail will be provided in the Model System Archetypes Blueprint.
- Social Determinants of Health
- The wider factors influencing health outcomes, including housing, employment, education, income, social connection and environment. Neighbourhood approaches aim to address these determinants alongside clinical care.
- Social Prescribing
- A way of connecting people to practical, social and community-based support to improve wellbeing and address non medical factors affecting health.
- Sustainability and transformation plan (STP)
- A local blueprint for delivering the ambitions NHS bodies have for a transformed health service
- System Flow
- The movement of people through health and care services, including admissions, discharge and community support pathways. Effective neighbourhood working helps improve flow by preventing avoidable escalation and delays.
T
- Trusted Assessor
- A professional whose assessment is accepted across organisations, reducing duplication and enabling faster decision making, discharge or access to services.
U
- Unwarranted Variation
- Differences in care, access or outcomes that cannot be explained by population need or preference. PHM and neighbourhood intelligence are often used to identify and reduce unwarranted variation.
V
- Voluntary, Community and Social Enterprise Sector (VCSE)
- Local organisations providing community-based support, prevention, wellbeing and social connection. A core partner in INTs and neighbourhood delivery.
- Voluntary, Community, Faith and Social Enterprise sector (VCFSE)
- Across the UK, the Voluntary, Community, Faith and Social Enterprise (VCFSE) sector is a vital partner in improving the health and wellbeing of local communities, developing preventative approaches and enabling people to live longer and healthier lives.
W
- Wider Determinants of Health
- The social, economic and environmental conditions that influence health and wellbeing, including poverty, housing, transport, education and employment.
- Wraparound Care
- Coordinated, holistic support provided across services and organisations to meet the full range of a person’s health, care and wellbeing needs.
