Neighbourhood Health & Care
Connecting information, teams and services to deliver more proactive, preventative care closer to home.
Neighbourhood health is central to the NHS's ambition to shift care from hospitals into communities, with greater emphasis on prevention, earlier intervention and more joined-up support.
Delivering this ambition means bringing health and care services together around the needs of individuals and local populations. From identifying people at risk of deteriorating health to coordinating multidisciplinary care and supporting patients at home, neighbourhood teams need the right information and digital tools to take action.
Graphnet Health supports neighbourhood health and care through its Care System Platform, connecting shared care records, population health intelligence, care planning, cross-organisational workflows, patient engagement and remote monitoring.
These capabilities help local health and care organisations make better use of existing information, target support where it is needed most and deliver more coordinated, personalised care.
What is neighbourhood health?
Neighbourhood health is an approach to organising health and care services around people and communities, rather than individual organisations. It brings together primary care, community services, hospitals, mental health, social care and voluntary sector partners to provide more coordinated, preventative support.
A central part of the NHS 10 Year Health Plan, neighbourhood health aims to improve outcomes, reduce health inequalities and help people remain independent for longer.
This means moving beyond responding to illness when people reach crisis point. By understanding population needs, identifying risks earlier and coordinating support across services, local teams can intervene sooner and help prevent avoidable deterioration.
Enabling integrated neighbourhood teams
Integrated neighbourhood teams bring together professionals from primary care, community services, mental health, social care and other local organisations to deliver more joined-up, personalised care.
For these teams to work effectively, professionals need access to relevant information, a shared understanding of individual needs and the ability to coordinate support across organisational boundaries.
This means being able to identify people who would benefit from earlier intervention, develop shared care plans, coordinate activity between services and monitor outcomes.
Graphnet's Care System Platform connects the information, intelligence and digital tools needed to support this way of working, helping neighbourhood teams move from identifying need to delivering coordinated care.
Supporting neighbourhood care through connected technology
Neighbourhood health requires more than information sharing. Local teams need the ability to identify need, coordinate care, support people at home and understand whether interventions are making a difference.
Graphnet's Care System Platform brings together four complementary capabilities to support this approach.
Connected Care – a shared understanding of the individual
Shared care records give authorised health and care professionals access to relevant information from across different organisations.
By bringing together information from primary care, hospitals, community services, mental health and social care, professionals can make more informed decisions and reduce the need for patients to repeat their story.
Coordinated Care – supporting multidisciplinary working
Digital care plans, assessments and cross-organisational workflows enable professionals to coordinate support around an individual's needs.
Teams can work from shared information, understand agreed interventions and support continuity of care across services, particularly for people living with frailty, multiple long-term conditions or complex needs.
Intelligent Care – identifying need and targeting support
Population health management enables local systems to understand the needs of their communities, identify people at risk and prioritise preventative interventions.
By combining information from different care settings, teams can identify people who may benefit from earlier support, including those who have not yet presented to services.
Analytics also help organisations understand health inequalities, allocate resources more effectively and evaluate outcomes.
Engaged Care – helping people stay well at home
Patient-facing digital tools, supported self-management and remote monitoring help people take a more active role in managing their health.
Remote monitoring enables clinical teams to support people with long-term conditions at home, identify changes in their health and intervene when necessary.
This can help reduce unnecessary hospital visits while giving patients greater confidence in managing their conditions.
From population health intelligence to proactive neighbourhood care
One of the greatest opportunities for neighbourhood health is the ability to move from understanding population needs to taking action. Population health analytics can help identify individuals and groups who may be at increased risk of deterioration, living with multiple long-term conditions or experiencing health inequalities. But identifying risk is only the starting point.
Neighbourhood teams also need the means to contact individuals, coordinate assessments, develop personalised care plans and arrange appropriate support.
By connecting population health intelligence with shared care information and coordinated workflows, Graphnet helps local systems turn insights into practical interventions. This supports a more proactive approach to care, where services can respond to emerging needs rather than waiting until someone requires urgent or emergency treatment.
Neighbourhood health in practice
Neighbourhood health is already being supported through digital programmes across England, bringing together information, analytics and multidisciplinary working to deliver more coordinated care.
Proactive neighbourhood care in Cheshire East
Integrated care communities in Cheshire East are using the CIPHA platform to support proactive neighbourhood care.
Population health intelligence helps identify residents who may be at risk of deterioration, enabling multidisciplinary teams to coordinate assessments and interventions around individual needs.
The approach brings together population health management and integrated care delivery, helping local teams identify people who could benefit from earlier support.
Connecting shared care, population health and remote monitoring
Graphnet's technology supports approaches that combine shared care information, population health intelligence and remote monitoring.
These capabilities help health and care organisations identify people who may benefit from proactive support, coordinate care across services and enable patients to manage their health at home.
Measuring the impact of neighbourhood care
Demonstrating the impact of neighbourhood health is essential to developing sustainable services.
Local systems need to understand not only how many people are receiving support, but whether interventions are improving outcomes, reducing avoidable demand and addressing inequalities.
Population health analytics can help organisations evaluate programmes by examining measures such as:
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Emergency admissions and A&E attendances.
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Changes in the use of health and care services.
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Outcomes for people receiving proactive interventions.
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Health inequalities across different population groups.
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The effectiveness of targeted interventions.
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Opportunities to avoid future demand and make better use of available resources.
This evidence can help commissioners and service leaders understand which approaches are working and where investment and support may have the greatest impact.
Building on existing digital infrastructure
Different health and care systems have different starting points. Many already have elements of the technology needed to support neighbourhood health, including shared care records, population health analytics and digital care planning.
The priority is to connect these capabilities and make them useful to the professionals delivering care.
Graphnet's Care System Platform supports this by bringing together information and digital tools across organisational boundaries, while working alongside existing clinical and operational systems.
This enables local organisations to develop neighbourhood care approaches that reflect the needs of their populations, services and communities.
Delivering neighbourhood health together
Neighbourhood health offers an opportunity to make better use of information, connect services and support people before their health deteriorates.
Graphnet Health works with NHS and care organisations to provide the digital capabilities that support more connected, coordinated and preventative care.
Discover how Graphnet can support your neighbourhood health ambitions.
