Neighbourhood health is moving from policy into delivery. For PCNs, GP federations and other primary care leaders, the question is increasingly not whether services will change, but how local population needs can be translated into practical, sustainable clinical services.
The direction of travel is clear.
The Neighbourhood Health Framework, published in March 2026, sets out an ambition to organise more care around people and communities, integrate services across organisational boundaries, focus more strongly on prevention and deliver more care closer to home.
For the NHS, there is a particular focus on priority populations including people living with frailty, care home residents, housebound patients, people approaching the end of life, and people living with conditions including cardiovascular disease, diabetes, COPD, dementia and mental health conditions. Local systems can also identify additional priority cohorts based on their own population needs.
The Medium Term Planning Framework is similarly clear: systems are expected to develop more joined up care through integrated neighbourhood teams, reduce avoidable hospital admissions among priority cohorts and enable more specialised support to be delivered closer to home.
So what does that mean in practice for PCNs and GP federations?
Neighbourhood health is already becoming a delivery issue
There is still significant development taking place nationally.
Proposed Single Neighbourhood Provider (SNP) and Multi-Neighbourhood Provider (MNP) contracting models have been consulted on during 2026. These are intended to provide new mechanisms for bringing services and funding together around defined populations, but the final arrangements continue to develop.
That doesn’t mean local organisations need to wait.
Indeed, NHS planning guidance has explicitly encouraged systems and providers not to wait for every element of national guidance to be finalised where there are opportunities to improve neighbourhood delivery locally.
We are already seeing examples of this happening.
In Bexley, for example, a redesigned GP premium worth more than £2 million is commissioning services in primary care that might otherwise sit in secondary care or not be delivered at all. The model focuses on population need and includes areas such as frailty and multimorbidity, prevention, long-term conditions and proactive care.
This is important because neighbourhood health should not simply be viewed as a new organisational structure or a future national contract.
At its heart, it is about understanding who needs support, what outcomes need to improve, and how services can be organised differently to achieve them.
“The opportunity for primary care is to start with the population, not the job title. Where is the unmet need? Which patients could benefit from earlier or more proactive support? Once you’ve answered those questions, you can design the pathway, workforce and delivery model around them.”
Amit Sarna, Director of Service Development & Strategy, Promni Health
Start with the population, not the workforce
For PCNs and federations considering their next service development, the starting question shouldn’t necessarily be:
“Which role should we recruit?“
A better question is:
“Which part of our population isn’t getting the support it needs?”
That requires bringing together local population data, practice intelligence, service utilisation, patient and carer experience and an understanding of existing provision.
The answer will differ between neighbourhoods.
It might be a cohort of older people with declining mobility who are at increasing risk of losing their independence.
It could be care home residents experiencing fragmented clinical support and avoidable escalation.
It might be patients whose mental health needs are consuming significant general practice capacity but who do not meet thresholds for secondary mental health services.
Or it could be people with persistent musculoskeletal pain whose condition is affecting their ability to work and participate in everyday life.
The important point is that the population need should determine the service rather than the availability of a particular professional determining the service.
From identified need to a deliverable service
Identifying the problem is only the beginning.
For neighbourhood health to make a measurable difference, population-health priorities need to become practical clinical pathways.
We believe there are 6 important questions for PCNs, federations and their partners to work through:
- Which population are we trying to support? Define the cohort, the unmet need and the outcomes that matter.
- What already exists? Map current primary, community, mental health, local authority, pharmacy and voluntary sector provision to understand whether the gap relates to access, capacity, coordination or a missing intervention.
- What should the pathway look like? Establish how patients will be identified, assessed, treated or supported, followed up, escalated and discharged before deciding the workforce required.
- Who is responsible for what? Clinical accountability, supervision, prescribing, results handling, safeguarding, information governance and regulatory responsibilities need to be clear from the outset.
- How will the service be funded and delivered? Build a realistic model covering clinical capacity, non-clinical time, management, supervision, travel, equipment and other delivery costs alongside a clear commissioning and contracting route.
- How will we know whether it works? Agree meaningful measures before mobilisation, including patient outcomes and experience, access, inequalities, activity, relevant service utilisation and value.
This is particularly important as neighbourhood models develop. Simply moving activity into the community does not automatically improve outcomes or reduce pressure elsewhere in the system. The clinical model, capacity, interfaces and measures of success all matter.
Different neighbourhoods will need different solutions
There is unlikely to be a single neighbourhood service model that works everywhere.
The national framework deliberately allows local systems to respond to their populations, and the proposed contracting reforms similarly envisage services being determined locally rather than prescribed entirely from the centre.
For one neighbourhood, the priority may be frailty and maintaining independence, supported by occupational therapists, physiotherapists and other members of an integrated team.
For another, it may be strengthening clinical support within care homes.
Elsewhere, the priority could be improving access to mental health expertise within primary care, developing more proactive podiatry and preventative care, or redesigning pathways for people with MSK conditions and persistent pain.
What matters is the connection between population need, clinical intervention, workforce, delivery model and measurable outcome.
Where Promni Health can help
At Promni Health, we work with primary care and community partners to turn identified population needs into fully managed clinical services.
Rather than starting with a particular profession, we can work with PCNs, GP federations and neighbourhood partners to understand the problem they are trying to solve and develop the clinical delivery model around it.
That can include:
- Defining the clinical service and pathway;
- Developing workforce and capacity requirements;
- Producing indicative costs and supporting business cases;
- Recruitment and employment;
- Mobilisation and implementation;
- Clinical leadership and supervision;
- Governance and operational management; and
- Activity, outcome and performance reporting.
Our existing services span frailty, care home nursing, mental health, MSK, podiatry, persistent pain, occupational therapy and work and wellbeing, allowing us to bring different clinical capabilities together around local population needs.
Neighbourhood health is not simply about creating new structures. It is an opportunity to rethink where and how care is delivered, and to build services around the people who need them.
If your PCN, GP federation or neighbourhood partnership has identified a population need or service gap but hasn’t yet developed the delivery model, we’d be happy to explore the pathway, workforce requirements and indicative cost with you.
Contact Promni Health to start the conversation.
