The NHS is on the brink of publishing its new 10-year plan, which will be a blueprint for recovery, reform and long-term sustainability. Central to this will be the need to deliver three major transformational shifts: “hospital to community”, “treatment to prevention” and “analogue to digital”. These three shifts are interdependent and designed to improve population health, enhance people’s care experience and provide better value from finite resources.
Primary care is expected to play a pivotal role in delivering this transformational change. But this will only be possible through new models of working that move beyond reactive, fragmented care and towards more joined-up, proactive and relational approaches.
Neighbourhood health has emerged as a powerful mechanism to make this ambition real. Grounded in natural communities and built on trusted relationships, it enables professionals across services and sectors to work together in support of what matters most to people, especially those with complex health & well-being needs.
As neighbourhood health gains momentum, a critical design challenge has emerged: getting the scale and structure right.
While the definition of neighbourhood health is beginning to take shape, it is still not universally understood or consistently applied. More significantly, the core functions and enabling behaviours that underpin successful neighbourhood working are not yet being clearly articulated. Without this clarity, there is a real danger that structural decisions will be made based on precedent or power, not purpose.
The risk is that we design systems that promise transformation but drift back toward reactive, biomedical models, dominated by the institutional logic of large acute and community providers. These organisations may hold the bulk of NHS resources but they are not necessarily best placed, culturally or operationally, to lead the kind of relational, proactive, and community-rooted care that neighbourhood health demands.
Unless form is explicitly shaped by function, we risk falling into a model that is structurally familiar but strategically misplaced.
If we intend that the purpose of neighbourhood health is to support people to live well in their communities and to enable the NHS workforce to experience joy and meaning in their work, then we must ask:
What kind of system culture, behaviours and structures are needed to honour that purpose?
How do we organise ourselves, not around existing power or institutional convenience, but around the needs of people, the strength of relationships and the conditions that allow teams to thrive and to achieve the greatest impact from public resources?
To realise the full potential of neighbourhood health, we must start with clarity around two distinct and equally essential functions we need to design for and support with the right cultures, behaviours and structures.
1. High-Performing Neighbourhood Teams
These are the local, multi-professional teams aligned to natural communities to build trust, deliver continuity and respond to what matters most to residents.
Their purpose is to work relationally and in a more proactive way with individuals and families in support of what matters most to them, especially those with complex lives whose needs span traditional health & care boundaries.
These teams will thrive when they:
- Are stable, psychologically safe and focused on shared goals
- Are empowered to act with autonomy and flexibility
- Are integrated across primary healthcare, community services, social care and VCSE etc.
- Have the time, data and leadership support to reflect, learn and improve
This is the human-scale foundation of neighbourhood health: real, high-functioning teams that are close enough to know their communities and trusted enough to make a difference.
In most places, this will mean footprints of around 30,000–50,000, though in some cases the range may vary from 5,000 to 100,000 depending on geography and local identity.
2. Neighbourhood health stewardship function
To support these local teams and to ensure that collective resources are used wisely, we need a stewardship function that should:
- Enable subsidiarity by creating the conditions in which local teams can lead change
- Steward shared investment in digital infrastructure, workforce development, estates, and long-term planning
- Realign financial investment and incentives to reward prevention, continuity and improved population health
- Act independently of provider interest, with its accountability grounded in population health impact, equity and sustainability
This is not a delivery function. It is a system enabler, a function that exists to serve the front line, not to control it. It would need to be delivered at a footprint that enables it to attract the leadership, governance and financial capability needed to enable transformation, manage risk or influence major system decisions in dialogue with all partners. This is going to require a population coverage that is probably around the same sort of size as existing ICBs.
Culture, Behaviours and Structure: What Neighbourhood Health Demands
Both functions require a shared culture of collaboration, humility and trust. Professionals must be supported to work across boundaries driven by purpose, not constrained by hierarchy. Pseudo-teams built around services or institutions will not deliver the relational care people need.
The behaviours that underpin success include:
- Listening first, acting together
- Focusing on people, not pathways
- Sharing accountability for population outcomes, not individual service metrics
Structurally, we must create forms that enable these behaviours, not constrain them. That means clear roles, proportional governance and the ability to act with agility at the point of care.
Getting the Scale Right: Avoiding the Middle Ground
However, there is a danger that these two functions become blurred and we settle for a single structure designed around a mid-sized population. This would result in the loss of both the intimacy of neighbourhood working and the reach of population stewardship. It is a false compromise that creates a system too big to be personal and too small to be strategic. It sets us up to fail.
Neighbourhood health will fail if we design it around existing footprints, legacy power or institutional comfort. It will succeed only if we start from purpose, define the functions that serve that purpose and truly understand the required skills and behaviours. Only then can we successfully shape the form and scale accordingly.
Conclusion: Form Must Follow Purpose
Neighbourhood health offers a bold and necessary shift towards care that is relational, preventative, and locally owned. But its success depends entirely on how we design for it.
If we truly want to create a health and care system that delivers better population health outcomes, a great user experience, wiser use of resources and joy and meaning for those who work within it, then we must resist the pull of compromise and convenience.
That means:
- Backing neighbourhood teams that are small enough to know and be known
- Building a stewardship function capable of enabling transformation and safeguarding sustainability, something that we are not currently equipped to deliver
- And above all, ensuring that we fully understand our shared purpose, necessary function and required capabilities before we determine our form
This is not about adding complexity. It is about creating coherence around a shared common purpose. By designing clearly for what each part of the system is meant to do and aligning behaviours, incentives and structures around that then we can build something better: a neighbourhood health system rooted in trust, shared responsibility and real impact.
Neighbourhood health is the opportunity. But only if we choose not to get stuck in the middle.
Addendum: Supporting Evidence Base
- Gesundes Kinzigtal (Germany): Demonstrates improved outcomes and cost-efficiency through an independent integrator that empowers local teams.
- Michael West’s ‘Real Teams’: Emphasises the need for psychological safety, role clarity, and shared goals — critical for team-based performance.
- Buurtzorg (Netherlands): Shows how small, self-managed teams can deliver high-quality, personalised care with lower overheads.
- Nuka System (Alaska): Illustrates the impact of community-led, relationship-based care models that embed trust and long-term engagement.
- NHS staff engagement literature: Links joy and meaning at work to improved outcomes and lower turnover.
- International subsidiarity models: Provide evidence that devolved decision-making enhances responsiveness, innovation and value.
