Beyond the hospital: How boards can lead the digital shift to neighbourhood working

Why neighbourhood working needs digital ways of working

Neighbourhood working is central to the 'shift left' where care is delivered earlier in the patient journey and outside of costly hospital settings. This strategy moves from hospital to community and from treatment to prevention, ensuring patients have improved access to care and avoid unnecessary admissions.

This requires a rewiring of the way services are delivered. It requires information to flow in new ways and tools that support new ways of working. Many of the enablers of neighbourhood working are digital, and cannot be delivered without a focus on data and data management, and different ways of working.

Designing services to support holistic healthcare

Neighbourhood working follows a biopsychosocial model. Biopsychosocial refers to a holistic model in healthcare that recognises health and illness as products of the interaction between biological, psychological, and social factors. It contrasts with the traditional biomedical model by encouraging healthcare professionals to treat patients as whole people, considering their life experiences, social context, and mental wellbeing alongside physical symptoms when treating health conditions. This holistic approach has proven valuable in improving healthcare outcomes, patient satisfaction, and quality of life.

The role of design

This has profound implications for how services are designed. The partnerships that come together for neighbourhood working will need to use co-design and research techniques to design digital experiences which take account of the biopsychosocial model. User experience design of patient facing digital services can be the best way to accommodate users’ emotional and practical needs alongside their clinical needs.

Better decisions through shared data at the point of care

The biopsychosocial model of care requires Integrated Neighbourhood Teams (INTs) to work together from diverse organisations. These teams can be made up of team members from GP practices, community services, mental health, acute care, social care, third-sector, housing providers, employment support and faith groups. This requires excellent care co-ordination where everyone in the team can see what others have done with a patient, planned care and their care plans. It also allows care gaps to be identified for instance:

If a patient has an appointment, they can see the appointment and work together to support the patient to get to the appointment.
If a patient has a care plan, everyone in the team can see it, so they can all work with the patient to help them achieve their goals.
If a patient has an unplanned admission into hospital then the care team is automatically notified.

Effective neighbourhood care will be reliant on timely and consistent data that can be used to make informed decisions and enable real-time collaboration.

In order to support this, boards:

Should ensure data sharing is treated as a strategic enabler to the delivery of care through the use of data sharing agreements.
Build trust and shared accountability with system partners recognising that there will be varying risk appetites.
Ensure data governance promotes data sharing safely in order to break down silos.

Interoperability and the ability to share information across systems will be fundamental to neighbourhood working. Shared Care Records (SCRs) are a vital part of the digital infrastructure, enabling a consistent patient record accessible across all organisations. They can also provide real-time care coordination to help manage unplanned admissions. In order for SCRs and other data sharing systems to be successful, the design of new workflows must be led by clinicians and care professionals to ensure they capture all the data required.

Core infrastructure like devices and connectivity need to be in place. Boards need to ensure frontline staff have the right resources, including mobile devices that work offline and across organisational boundaries.

Case study: Universal care plan

This NHS service digitally shares preferences and support needs for any patients based in London with end-of-life, palliative care or other long-term conditions such as sickle cell disease and dementia. The information in the care plan is visible to all health and care services that use it including London Ambulance, GP services, through the London Care Record and within some local electronic patient records (EPRs). Four EPR platforms currently link directly to the Universal care plan (UCP) and where an EPR does not integrate, care providers can view the UCP through an online web portal. Importantly, health and care teams outside of London can also access this data using the National Record Locator Service, ensuring continuity of care for patients, wherever they are. It currently provides care plans to over 80,000 patients and almost 80% of people with sickle cell disease in London now have a UCP.

Data for strategic planning

Successful neighbourhood working means recognising that data is a valuable organisational resource that drives decision-making and can generate tangible financial or operational benefits. Whilst in trusts today a lot of data is captured, it is mostly for recording performance and for reporting purposes rather than for truly driving strategy.

Population health analytics analyse data from a range of sources including health records, social care, housing, and demographic statistics to generate a detailed, granular understanding of a specific population’s health profile. These analytics can help to segment the local population into groups with similar health needs or risks, enabling neighbourhood teams to accurately identify and prioritise vulnerable cohorts. This evidence-based approach allows neighbourhoods to move from reactive treatment to proactive management of community and population health. It will help them allocate resources more efficiently, reduce inequalities, prevent disease, and measure the effectiveness of interventions at scale.

In order to support this population health approach, boards:

Should look to their existing systems, including EPRs for reporting and tracking health inequalities and ensure this data is used to inform clinical and operational decision making.
Consider where they might have analytics capability or resource within the trust that can be utilised across organisations.

Case study: Population health

People living in the more deprived areas of the Bristol, North Somerset and South Gloucestershire Integrated Care System (ICS) are more likely to die earlier and on average have 10 fewer years of good health. By using new techniques such as segmentation and risk stratification, the ICS found 100 people aged 40 to 69 living in high levels of deprivation in Bristol inner city, who also had a combination of obesity, high blood pressure, depression and anxiety. These patients were offered a medication review, a healthy hearts group consultation and an appointment with a social prescriber to help with exercise, mental health and lifestyle issues. By addressing factors affecting their health beyond healthcare, it is hoped the project will improve patients’ understanding of their health and improve their physical and mental health, with wider positive implications including a reduction in unnecessary appointments and admissions to A&E, outpatients, and general practice.

Looking after patients remotely

Remote monitoring and patient-generated data are important in shifting care from reactive to proactive and personalised, supporting people in their homes and reducing unnecessary and unplanned admissions. They transform traditional care from reactive, episodic interventions that use the expensive and finite NHS resources to data-driven, coordinated management of populations managing them outside of hospitals that unlocks both clinical and operational benefits along with a greatly improved patient experience.

Capturing data from patients' own devices such as smart phones, watches, blood pressure or blood sugar devices means key measurements can be made at home and trends followed to enable data-driven coordinated management.

In order to support this, boards should:

View remote monitoring as a core part of your service delivery.
Look to new technologies, such as artificial intelligence, to speed up assessments, reduce clinical workload and improve the capacity to care (but be careful to ensure any new tooling is well integrated into existing workflows).

Case study: Population health management and remote monitoring

Frimley Integrated Care System (ICS) uses a combination of Population Health Management analytics and Remote Monitoring to support CORE20PLUS5 and wider inequalities programmes, informing service redesign and resource allocation rather than direct patient‑facing care alone.

Frimley ICS identified specific cohorts across its population that could be managed at home through remote monitoring and enrolled over 3,500 high‑need patients. They reported around a 38–39% reduction in A&E attendances and about a 54% reduction in hospital admissions compared with similar patients not yet enrolled. Outpatient attendances fell by roughly 27%, with GP appointments down by about 19% and marked falls in 111 and 999 contacts (around 36–37% reductions).

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