Neighbourhood working

The government’s Fit for the Future: 10 Year Plan for Health in England (2025) marks a decisive shift in how health and care will be organised. At the heart of the plan is the creation of a dedicated "Neighbourhood Health Service”, designed to be more responsive, proactive, and closer to people's homes.
Neighbourhood working isn’t a new way of working, but delivering it at scale is. For the last 6 months we’ve been researching and spending time with teams on the ground already delivering neighbourhood working, to understand what’s working, what isn’t and what is needed to deliver a Neighbourhood Health Service.
Our reports offer insights into neighbourhood working exemplars (both locally and abroad), analysis of the digital and data challenges facing teams, and a digital operating for how teams can communicate, coordinate and act.
Download the Digital Operating Model reportDownload the international exemplars report
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International exemplars

Ribera Salud (Valencia, Spain)
Pioneered by Ribera Salud, the “Alzira model” in Valencia is a fully integrated public-private healthcare partnership. A private provider receives a long-term contract and fixed annual capitation to deliver all primary, secondary, and specialist care for a set population. This structure aligns financial incentives: the provider profits only by keeping people healthy and out of expensive hospital settings, strongly encouraging prevention and efficiency.
Cityblock (New York, USA)
Cityblock Health is a US-based care organisation using a value-based, capitated model to transform care for people with complex medical, behavioral, and social needs. By combining local community hubs with a powerful digital platform, Cityblock delivers proactive, personalised care right in people's homes, not hospitals. The result is a holistic, data-driven approach that improves outcomes, reduces costly hospital use, and fosters greater health equity.
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Download the exemplars report

What we’ve heard: the digital and data challenges facing neighbourhood teams

Fragmented patient information leads to endless chasing: patient information is scattered across multiple systems. Unless the team happens to be co-located or has a local data-sharing agreement, the only way to build a full picture of a patient’s situation is manual detective work.
Communication that isn’t patient centred: neighbourhood teams communicate primarily through general purpose tools - email, Microsoft Teams and phone calls. These tools are designed for office admin, not patient care. Conversations about patients scatter across inboxes, threads, and calendars with no link back to the record or plan.
No shared views of actions: after every MDT or patient contact, there’s a list of actions - referrals to make, visits to schedule, medications to check. But because no shared task management system exists across organisations, tracking progress depends on memory, meetings or email reminders.
Caseload management by spreadsheet: professionals manage patient lists in whatever tool they can - in their EPR, in Excel sheets, in Word documents. None offer real-time updates or visibility across organisations. Each team maintains its own version of the truth.
Care plans that don’t live in the real world: care plans - the supposed backbone of coordinated care - are often static documents buried deep in EPRs. Many professionals can’t even access them, let alone update them collaboratively.
Download the Digital Operating Model report

Seven principles of the Digital Operating Model

Work as one team: create a single, unified digital team space where every member of the neighbourhood team can communicate and collaborate securely across organisational boundaries.
Standardise intake: review structured referrals in one place, request missing information, and direct patients to the right service quickly and safely.
Triage and direct: review structured referrals in one place, request missing information, and direct patients to the right service quickly and safely.
Build the caseload: maintain a real-time, shared view of all patients under the team’s care to improve workload visibility and proactive management.
Collaborate on care: enable asynchronous, multidisciplinary conversations that follow the patient, reducing meeting dependency and communication gaps.
Work from the care plan: create a living, digital care plan visible to everyone involved, linking agreed actions directly to patient communication.
Action and outcome: record and take action - prioritised intelligently for the team and for the individual, close the loop through shared task visibility and progress tracking.

Read all of our neighbourhoods reports here

Download the Digital Operating Model reportDownload the international exemplars report