Neighbourhood health in action: lessons from HETT 2026

Neighbourhood health starts before someone arrives in crisis. It starts with finding the person whose condition has gone unrecognised, whose health is deteriorating or whose care needs have fallen between services - and having a team ready to respond.

At HETT 2026, NHS leaders described how they are already doing this: using connected data and population health intelligence to identify people earlier, bringing professionals together around their needs and supporting them at home through remote monitoring. Their experiences offer practical lessons for systems looking to turn neighbourhood health ambitions into everyday care.

Across the discussions, a recurring question was how to connect information with a service capable of responding to it. Finding someone at risk is only useful if teams can organise appropriate support; demonstrating an improvement is only useful if there is a way to sustain it. Speakers explored those connections through examples of clinical practice, alongside the leadership and funding decisions that shape delivery.

Find the people who need support

"The first step is finding the patients," said Sharon Boundy, Director of Transformation and Digital at NHS Thames Valley ICB, during the panel Why Connected Neighbourhood Care Depends on Hub Models.

Sharon described how teams can use population health intelligence to identify people who may have an undiagnosed condition, be approaching a crisis or need a care plan that is not yet in place. Services can then reach out, arrange an assessment and offer appropriate support. This extends their ability to help people whose needs have not yet resulted in a consultation or referral.

Early identification of chronic kidney disease was one example she discussed. Relevant information may already exist in a person’s records without the condition having been recognised or coded. Analysing that information helps teams identify who may need further investigation, with clinical assessment and testing establishing the appropriate next steps. It is a practical illustration of how information already held by services can prompt earlier care.

In Thames Valley and Surrey, a longstanding Graphnet customer, this approach connects population health analytics with shared care records and remote monitoring. Sharon explained how Johns Hopkins patient need groupings help teams understand levels of complexity across their population and identify people who may benefit from additional support. Bringing that insight into the systems used by frontline professionals means it can inform decisions at the point of care.

The ability to distinguish between different levels of need matters. Two people presenting with the same problem may have very different underlying health, support at home and ability to manage an illness. A fuller understanding of those circumstances helps professionals consider which intervention or service is appropriate, rather than treating a diagnosis as the complete picture.

Build a service around the person

Once someone has been identified, there needs to be a clear route into support. Sharon described how proactive outreach can lead to an offer of remote monitoring, with a digital healthcare team providing the hub for reviewing information and responding when further action is required.

She also spoke about the value residents gain from becoming familiar with their own readings and understanding what is normal for them. Regular monitoring can help people recognise changes in their health, while giving the clinical team information to assess whether additional support is needed. Her account of residents remaining committed to taking their readings illustrated how engaged people can become when a service feels useful and reassuring.

Those readings flow into the shared care record, making relevant information available to other professionals involved in the person’s care. This supports continuity when someone moves between services and places remote monitoring within the wider picture of their health.

That wider view was central to Sharon’s challenge to condition-specific pathways. People living with several long-term conditions may be asked to navigate separate applications, appointments and instructions for each diagnosis. Neighbourhood services need to consider how those activities fit together, particularly where much of the support concerns the same person’s ability to live well and manage their health.

Graphnet’s Markus Bolton described this wider approach through the concept of a Care System Platform. An Electronic Patient Record supports care within an organisation; a Care System Platform supports the work of the wider care community, connecting information and activity across organisational boundaries.

He outlined four capabilities - Connected, Coordinated, Intelligent and Engaged Care - brought together in CIPHA, Graphnet’s Care System Platform. These encompass shared care records, cross-organisational planning, population health intelligence and tools that help people participate in their care. His argument was that neighbourhood teams need these capabilities to work together: identifying need should lead into a coordinated response, with the person involved and outcomes available for evaluation.

This also raises a practical question about service design. When analytics, care planning and monitoring operate separately, teams have to bridge those gaps themselves. Connecting them gives professionals a way to follow the person through assessment, intervention and ongoing support, while retaining a shared view of what other services are doing.

Markus emphasised local ownership of that process. His challenge to systems was to use the capabilities already available and develop them alongside frontline teams, with delivery shaped by the needs of their communities.

Use a common view of need to plan care

Neighbourhood health also requires decisions about where to direct staff, services and investment. Markus highlighted the differences that can exist between neighbouring communities, including substantial variation in health outcomes and life expectancy. Understanding those differences helps systems focus support where it is most needed.

Population health intelligence gives teams a way to examine unmet need, identify groups who could benefit from targeted interventions and follow changes over time. Combining information from primary care, hospitals, community services and social care creates a broader picture than any one organisation can provide.

Sharon extended this point to strategic planning. Commissioners, providers and neighbourhood teams need a shared understanding of their population and the pressures on services. She described how a common view of activity had helped challenge assumptions about where demand was increasing, allowing organisations to move beyond disagreement and focus on the problem.

This connection between clinical use and system planning is valuable. The information that helps a professional understand an individual’s needs can also help a neighbourhood team consider its priorities or a commissioner shape a future service. Working from a common foundation makes it easier to align those decisions.

Measure outcomes and plan for lasting benefit

Markus stressed that every intervention needs a way to establish whether it is improving outcomes. That means being clear about who received support, their starting level of need and how their results compare with an appropriate group. Connected data allows teams to follow people’s use of services over time and examine the contribution of a programme.

Results also need to be communicated in context. A reduction in emergency attendances among people receiving a targeted intervention describes the experience of that cohort. Its contribution to wider hospital demand depends on the programme’s reach and what else is happening across the system. Several targeted programmes may be needed to achieve a broader change, making evaluation important both for individual services and for the overall neighbourhood health strategy.

The financial picture requires similar precision. Preventing an admission can improve someone’s experience and free capacity, while a hospital’s operating costs may remain. Avoided activity, cost avoidance and cash-releasing savings describe different benefits. Understanding each helps systems make credible decisions about investment, particularly where growing demand is putting existing capacity under pressure.

In the separate panel, From Policy to Procurement - Accelerating Frontline Digital Investment and Innovation Under the 10-Year Plan, Dan Bunstone, Clinical Director and GP Partner at Cheshire & Merseyside ICB, explored how programmes can balance immediate pressures with longer-term prevention. Drawing on COPD and hypertension work in Cheshire and Merseyside, a Graphnet customer, he described the different timescales involved: some interventions may affect hospital demand sooner, while others aim to prevent events such as heart attacks and strokes over several years.

Dan also challenged systems to agree early how successful work will be sustained. A pilot can demonstrate benefits and still struggle to continue if partners have not decided how resources will be reinvested. Establishing those arrangements upfront gives teams a clearer route to expand effective services and helps build trust between organisations sharing the risks and benefits.

Give teams the support to deliver

The panel Clear Accountability and Risk Ownership to Accelerate Digital Success, on the Workforce, Adoption and Productivity stage, explored the conditions that help digital programmes succeed. Former NHS CIO Diarmaid Crean drew on his experience delivering Sussex’s shared care record, describing a leadership approach based on taking responsibility, removing obstacles and giving project teams the freedom to adapt. Executive involvement was most useful when it helped teams secure resources and collaboration across organisational boundaries.

That lesson applies directly to neighbourhood services, where delivery depends on several partners. Clear ownership of the overall outcome helps address gaps between organisations, while close involvement with frontline teams allows leaders to understand difficulties and respond before they undermine progress.

Speaking on the same panel, Victoria Betton, Director for Digital, Data and AI at Health Innovation Network Kent Surrey Sussex, emphasised the value of observing how staff actually work. Her example of people continuing to use paper alongside an electronic patient record showed why a system going live does not, by itself, establish that the expected benefits have been realised. Spending time with users can reveal workarounds, concerns and pressures that are easily missed in formal meetings.

Fellow panellist Amanda Begley, Executive Director of Digital Transformation at Health Innovation Network South London, extended that discussion to the experiences of people receiving care. Engagement around digital support in young people’s mental health services had initially been steered towards waiting lists. Conversations with young people, families and professionals revealed that discharge also needed attention, changing the understanding of where digital support could be most useful.

For neighbourhood health, these examples underline the importance of designing services around the experiences of people receiving care and those delivering it. Their involvement should shape the service from the beginning and continue to inform its development.

What this means for neighbourhood health

The examples shared at HETT suggest that systems can make progress by choosing a population with a clearly understood need and working through the whole response: who will contact people, what support will be offered, how professionals will coordinate and what evidence will show whether it has helped. Those decisions need clinical, operational and digital teams at the table together, with the experience of residents informing the design.

Scaling that work brings further questions. Can the service accommodate more people? Have partners agreed how it will be funded beyond the initial programme? Does the evidence justify extending the approach, or point to changes first? The discussions at HETT brought these questions into focus. As neighbourhood health develops, answering them will be essential to turning promising local work into dependable, everyday care.

Talk to Graphnet about supporting your neighbourhood health programme.