1. Organise care around residents, not organisational boundaries

At its core, neighbourhood working means local teams delivering care within communities, working with and for residents. These frontline teams bring together professionals from across primary care, secondary care, community health, mental health, social care, housing, education, and the voluntary, community and social enterprise sector (VCSE). While teams will have different areas of expertise within their core team, they will also draw on wider specialist expertise according to the issues they are tackling in a neighbourhood.

The Neighbourhood Health Framework deliberately avoids defining a national model for integrated neighbourhood team (INT). Instead, INTs should be shaped locally around the needs, assets and priorities of their different populations.

What makes neighbourhood teams powerful is their ability to organise support around residents rather than services. Strong neighbourhood teams are not just implementers – they are agents of change. Their close connection to communities provides real-time understanding of what is working, what is missing and where earlier intervention is needed.

Places with strong neighbourhood teams reported improved health and wellbeing, preventing crises and supporting residents through innovative partnership working.

For example, leaders reflected that what initially began as periodic case discussions between teams evolved into a structured rhythm of joint working, with regular touchpoints anchored around the needs of local residents rather than organisational boundaries. Teams focused on ‘what matters’ to each resident and were able to redirect people to more appropriate support without unnecessary referral pathways or administrative burden.

These sessions bring together professionals such as GPs, community nurses, mental health practitioners, social workers, housing officers, voluntary sector coordinators and others with valuable insight into the circumstances of individuals and families.

Over time, this approach built trust, strengthened shared accountability and problem solving. This has led to improved handling of complex cases, greater professional satisfaction, and a more proactive and preventative approach.

Residents described feeling better supported and more able to manage their daily lives.

Develop workforce models that encourage collaboration across traditional organisational boundaries, including:

• multidisciplinary team (MDT) design with shared objectives, pooled resources and flexible staffing approaches
• cross-organisational workforce planning that aligns skills, capacity and demand across system partners matched to local needs
• system-wide workforce governance to oversee collaborative practice, monitor impact and drive continuous improvement.

Invest in leadership capability at neighbourhood and place level, including:

• leadership development focused on collaboration, adaptive leadership and distributed authority
• talent pipelines that support emerging leaders through cross-sector and development opportunities.

Foster a shared culture of accountability and continuous improvement, including:

• common values and behaviours, co-developed across organisations
• transparent communication practices, regular feedback and consistent messaging across partners.