One of the most significant messages from the Darzi Investigation of the NHS is a recognition that the restoring our health and care system isn't something that can be done by the NHS alone – a point also reiterated by the Health Secretary in recent interviews.

We believe this is emerging as an important shaping principle for the new government’s strategy – a candid acknowledgment that so much of what drives demand and pressure on NHS services falls well outside a clinic or hospital’s walls, and therefore requires a co-ordinated response.

As a result, the idea of creating an integrated neighbourhood health service – a load-bearing, out-of-hospital structure that can support preventative healthcare and reduce pressure on hospitals by leveraging community-based resources – has never been more important.

Leveraging the expertise within our communities

Yet achieving the shift away from hospital-based care cannot simply mean putting more weight on primary care, or creating unrealistic burdens on council, community or voluntary sector bodies, many of which face their own resourcing challenges.

We need a better way of leveraging the expertise embedded in our communities to deliver more holistic, person-centred care, tackle deep-rooted inequalities and influence the wider determinants of population health.

And this must be delivered in a way that’s practically-grounded – giving teams the time, space and permission to innovate and adapt their working practices based on what’s realistic for them and best for the citizens and populations they support.

Population health management as an enabler for change

That’s why we believe population health management (PHM) needs to become an intrinsic part of the new operating model for integrated neighbourhood teams.

Using data and intelligence to pinpoint how and where to apply collective efforts across a community is crucial for making this a genuine solution – rather than an exercise in shifting a problem from one part of the system to another.

This question – of how we build an integrated neighbourhood service in practice – forms the backdrop for a new Optum webinar we’ll be running later this month, which will focus on the principles and practicalities of applying data-driven PHM techniques to the task ahead.

We will look at how data and analytics can support local teams in a variety of different ways:

• Informing decisions about what – and who – to prioritise
• Anchoring activity around a sense of common purpose
• Supporting meaningful conversations between professionals and the citizens they support

And we’ll also draw on domestic and international examples of best practice, showing how evidence-based methods are helping to drive more proactive, personalised and hyper-local approaches where they are needed most.

Creating a ‘philosophy of partnership’

As our recent white paper shows, there’s considerable appetite on the ground for operating in a more diverse, inclusive and data-driven way to understand and act on people’s needs – and much good practice to celebrate too.

It’s therefore encouraging that the emerging political narrative seems to be aligned with the direction of travel that many systems are already taking – this is hugely validating for the approach that many of our customers are pursuing.

Much will now depend on whether the government’s 10 Year Plan can deliver the necessary enablers for delivering this type of change at scale, including ensuring financial flows are rebalanced in a way that supports shifting resource into community-based programmes.

In our experience, success will also be driven by the extent to which local leaders can establish the right conditions for change – including what Clare Fuller described as a ‘philosophy of partnership’ between statutory and non-statutory organisations.

Key pillars of integrated neighbourhood working

Building on this, Optum recently held a roundtable with senior figures across a number of provider organisations and ICBs to discuss the key pillars to support integrated neighbourhood working in practice.

Although not exhaustive, the following checklist reflects what we agreed:

• Culture and buy-in – have you created and shared a compelling culture within your INTs that advances your collective aims?
• Data and analytics – do you have a ‘single source of truth’ that enables data-driven collective decision-making around service design and delivery?
• People and structures – have you built a team that reflects the diversity of need within your focus segments of the population?
• Outcomes-driven evaluation – have you established how you will evaluate your models based on outcomes that matter to citizens and the wider system?
• Scaling up for value-based care – do you understand current and future needs and use evidence of what’s working (and not working) to inform how you scale up?

While the principle of integrated neighbourhood working is not new, it’s still a relatively nascent agenda in practice – and like any transformation, it will need sustained investment of time, energy and resource to bring it to fruition.

Optum has already helped several ICSs in successfully applying PHM methods to build the conditions for integrated neighbourhood working. If you’d like further resources or a conversation about how we can support you, please contact [email protected].