The opportunities of neighbourhood working

• Population health management approach

• System working

• Hyper-localised support

Background

London North West University Healthcare NHS Trust (LNWUH) is an integrated healthcare provider delivering acute and community services to a diverse population of more than one million people across the boroughs of Brent, Ealing and Harrow. The trust employs approximately 9,000 members of staff who deliver services from urgent and emergency care and elective surgery to rehabilitation and sexual health services.

Over the past few years, the trust has been working closely with system partners to improve services for children and young people in Harrow through the Harrow Health and Care Partnership, building on the success of existing GP child health hubs in the area. Child health hubs have been running in Harrow for over a decade, bringing together children’s services through multi-disciplinary teams to discuss cases and support families in a holistic, person-centred way.

Infants under the age of one are some of the highest frequency users of LNWUH’s emergency department (ED). The majority are low-acuity attendances with no investigation or treatment needed. Leaders across Harrow Health and Care Partnership therefore wanted to understand the drivers behind these presentations and determine how greater collaboration at a hyper-local level could prevent them.

Using population health data, Harrow Health and Care Partnership has developed a proactive model of care that allows local teams to identify and address children and young people’s needs at the earliest possible opportunity. The key objective is to improve the health and wellbeing of infants, and reflects recommendations made in both the Fuller (Dr Claire Fuller, 2022) and Hewitt (Rt Hon Patricia Hewitt, 2023) reports to deliver more preventative care at a local level.

The Optivita project

The Optivita project ran from April 2023 to March 2025 and was developed after North West London Integrated Care Board (ICB) won a bid for funding from NHS England (NHSE) to further improve services for children and families in the area. The project builds on, and is in  addition to, the success of well-established GP child health hubs, and recent work at place level.

Harrow was one of three boroughs in northwest London to be selected as a pilot site by the ICB to establish a hyper-local preventative care team to support the most vulnerable families in the communities where they live. The vision was to bring together existing child health hubs in the area with wider system partners, including the voluntary sector and local authority family hubs and children’s centres, to develop an integrated neighbourhood team (INT) for infants, children and young people. Strengthening collaboration across organisational boundaries at a hyper-local level helps health and care professionals to get to know and trust one another, which contributes to the provision of high-quality, joined-up support for families.

This preventative care team, known as Optivita, is made up of a range of professionals who are involved in supporting the health and wellbeing of children and young people, including: GPs, nurses, health visitors, paediatricians, primary care network clinical directors, and data analysts. The funding also enabled the team to employ four part-time community health and wellbeing workers, known as community connectors, who work with the wider INT and visit families at home every month, offering tailored support in the community.

Lessons learned from the Optivita project

Across the three sites that were selected to establish a hyper-local preventative care team in northwest London, approximately 2,300 families from disadvantaged areas have been supported by at least one funded service, with the most mature neighbourhood working model operating in Harrow. Following an evaluation of the Optivita project, leaders of the programme have identified a number of key learnings from the work that has been carried out.

It takes time and patience to co-design and establish service models based on meaningful engagement with the community. In Harrow, the use of funded community connectors has enabled INTs to effectively engage with families and link them with wider system partners to provide more personalised, wrap-around support. These community connectors are key to extending clinical effectiveness and enabling greater primary care ‘listening’ capability. The pilot clearly highlighted the complex factors driving infant ED presentations, and the importance of families having access to a professional who they trust, who can support them in the community and, in some cases, signpost  them to other services.

Clinical and leadership buy-in across organisational boundaries is also important. Without a coalition of the willing, the project would have struggled to meaningfully shift to neighbourhood working. The use of population health data to make the case for change is also a vital enabler to delivering more integrated services at a local level. This data helps to bring a range of professionals together to create a shared understanding of the aims and objectives.

Barriers to scaling up

Despite the benefits of the project for children and young people across Harrow, the limited, non-recurrent funding from NHSE means it is unclear how learnings from the pilot could be scaled up in the future, following its official end in March 2025. Leaders do not expect additional funding to extend the pilot into 2025/26 and beyond. Looking ahead, it is important that the government’s commitment to neighbourhood health and making the shift to prevention leads to support for proven interventions for infants and families that can bring long term gains.