By Dr Aaminah Verity

The NHS 10 Year Health Plan places neighbourhood health at the centre of the future NHS, with ambitions to shift care from hospital to community, move from sickness to prevention, and reduce health inequalities through more proactive, community-based care. At the Pathway conference one thing was clear: unless neighbourhood health is intentionally designed around those facing the greatest inequity—people in inclusion health groups—it risks reproducing the same inequalities it aims to solve.

People in inclusion health groups experience mortality rates 8 to 12 times higher than the most socioeconomically deprived in the general population. Yet they are often invisible in data, overlooked in commissioning, and poorly served by mainstream models of care.

As one speaker put it: “if you’re not counted, you don’t count.”

But this is not just about a small marginalised group. Inclusion health populations are the thin end of the wedge. They expose a deeper problem: a system increasingly unable to respond to rising multimorbidity, growing frailty, and complex social need.

If neighbourhood health can work for those with the greatest barriers to care, it will create models that work better for many others living with complex needs.

What we heard at Pathway 

Dr Lucy Chiddick, Clinical Lead, Humber & North Yorkshire ICB and colleagues described how creating inclusion health registers in general practice was the essential first step towards proactive care for this population. Without identification, people remain excluded from planning, funding, and care. Inclusion health populations often sit outside traditional categories – meaning they are systematically overlooked unless explicitly counted. This reflects a wider challenge: without clear definitions and coding, population health management approaches cannot plan services or commission appropriately as they will be unable to prioritise those at greatest risk. This matters because the NHS 10 Year Health Plan places population health management and proactive identification of risk at the heart of neighbourhood health.  

General practice is delivering more appointments than ever before, yet many patients continue to experience unmet need. Dr Louise Clarke, GP and Lead GP for Transformation, Bevan Healthcare Community Benefit Society reflected in her presentation: “it’s not a failure – it’s a mismatch.” A reactive, appointment-driven model struggles to respond to trauma, instability, and complex social needs. Short consultations risk offering “sticking plaster” solutions while missing root causes, contributing to repeated urgent care use, avoidable hospital admissions and poorer outcomes.  

Louise shared that an analysis they did found small proportion of patients account for a disproportionate share of demand, with estimates that 2% of patients use around 20% of appointments and 5-10% accounting for up to 40% of activity across health services. The analysis highlighted that many of these patients have common underlying characteristics -histories of trauma, safeguarding concerns, unstable housing, and substance dependence. These are often people with the greatest need – yet the system is not designed around them.  

The discussion highlighted that continuity should be targeted to those who benefit most, alongside more effective triaging of demand. There was also a clear recognition that community-based care does not have infinite capacity to simply do more. This shifts the question from “how do we increase access?” to “how do we use limited capacity wisely?” 

Early prototype work in Bevan backs up wider evidence that targeted continuity can generate system capacity – reducing repeat attendances, missed appointments, and unmanaged conditions that drive both poor outcomes and system cost. Relational care is not a luxury; it is a more effective use of scarce resource. 

Humber and North Yorkshire used a locally enhanced service (LES) model – a commissioned GP contract add-on providing additional funding and structured support – to embed inclusion health into mainstream primary care. Rather than asking practices to do more within existing contracts, it enabled them to work differently through protected time, training and multidisciplinary support. This illustrates an important implementation lesson. We already know what works. The challenge is not generating more evidence but aligning funding, incentives and accountability so that evidence-based practice becomes routine rather than exceptional. 

Neighbourhood health must go beyond geography 

The NHS Neighbourhood Health Framework guidance describes neighbourhoods as partnerships organised around populations rather than simply places. This distinction matters. The Framework gives local systems considerable freedom to define the populations around which neighbourhood teams are organised. That presents an opportunity to move beyond geographical neighbourhoods and deliberately design services around populations experiencing the greatest inequity. 

Natalie Knowles, Primary Care Partnership & Transformation Lead, Wakefield Health & Care Partnership, West Yorkshire ICB, and Mark Hobson, Clinical Service Development Manager, Bevan Healthcare, spoke about neighbourhood models that are bringing together primary care, community services, housing, and outreach. This includes mobile services, multidisciplinary teams, and embedding healthcare within housing support. But with an explicit ask that the design and delivery of services started with considering inclusion health populations. 

Without this lens, neighbourhood health risks only serving those within a stable “neighbourhood”. People missing from healthcare are often known to other services and fall between organisational boundaries. In Wakefield, they’ve taken the opportunity of neighbourhood health to connect these systems and reach those currently excluded. This reflects a broader shift needed across the system – from reactive care to proactive identification and prevention, particularly for those at highest risk.

What this means for system leaders 

Neighbourhood health will only reduce inequity if it is designed intentionally. 

Start with those with the greatest need.  

  • Designing neighbourhood models around those patients driving the highest need is both equitable and efficient. Starting with inclusion health groups can reshape services to deliver value for the whole system, particularly where complex medical and social needs intersect. 

Shift from volume to value 

  • More appointments do not necessarily mean better care. Systems should focus on outcomes: who is not accessing care, who repeatedly misses appointments, and who remains stuck in cycles of crisis and drive expensive hospital admissions. These patterns often reflect unmet need rather than inappropriate demand. If the NHS 10 Year Health Plan is to achieve its ambition of shifting care from hospital to the community, neighbourhood health must proactively identify those who are most likely to experience repeated crisis and provide coordinated, holistic and preventative support before hospital care becomes necessary.  

Invest in targeted continuity  

  • With finite resources, choices are unavoidable. Targeted continuity, proactive care, and multidisciplinary support should be prioritised for those with the most complex needs—rather than spreading resource thinly. We need to think equity not equality, with targeted population health management approaches being advocated. This also requires addressing structural barriers: practices serving the most deprived populations often face greater demand with fewer resources.

Design Integrated Neighbourhood Teams (INT) around complexity  

  • The Neighbourhood Health Framework positions INTs as the bedrock of neighbourhood health. If INTs are designed only around medically complex populations already visible to services or do not account for social complexity in their interventions, they risk missing many of the people experiencing the greatest inequity and failing to provide the support needed to change outcomes. There is a real risk that INTs simply add another pathway for people already known to multiple services, rather than integrating the care they already receive. Many inclusion health residents are already interacting with health, housing, mental health, substance misuse and social care—they are simply receiving fragmented care. 
  • The INT offer must then address the full range of people’s needs across organisational boundaries, overcoming the fragmentation that continues to fail many inclusion health, older complex and multimorbid populations. 

A moment of opportunity – and risk 

There was a strong sense at Pathway that change is possible. Local areas are already using the neighbourhood health opportunity to deliver for inclusion health populations. We saw testing new models: targeted commissioning, inclusion health at the centre of neighbourhood design leading to longer appointments, multidisciplinary teams, outreach, and closer partnerships with community organisations, but these innovations remain exceptions.  

Neighbourhood health has enormous potential to reduce inequalities, improve continuity and help people stay well at home. Yet none of this will happen automatically. It requires sustained investment, different incentives and the confidence to redesign services around those who have historically been excluded and a willingness to challenge established ways of working—even, as one speaker noted, to “push through the eye rolls”. 

The NHS 10 Year Health Plan rightly sets an ambitious direction for neighbourhood health, however, national priorities continue to emphasise rapid access, particularly same-day urgent care and rapid digitisation harnessing the benefits of AI and other technological innovations. But without protecting time for relational and preventative work, the ambitions set out in the neighbourhood health framework risk being squeezed out. More fundamentally, without aligning funding, incentives and accountability with the goal of reducing inequity, the gap between what we know works and what is delivered will persist. 

Inclusion health is not a niche issue. It is a stress test of whether neighbourhood health can deliver on its promises.  

So, the question for system leaders is this: 

Will we design neighbourhood health around those experiencing the greatest inequity—or will we continue expecting them to navigate a system that was never designed for them?