Neighbourhood health teams: a Q&A with Thea Stein

What are neighbourhood health teams and how do they feature in the 10 Year Plan?

A neighbourhood health team is a group of people who come together to serve the needs of a particular geographical population. They would be drawn ideally from all parts of the NHS and primary care, as well as from various sections of the local authority and voluntary sector, alongside members of the community. They all work in a particular place. In an organisation you could call it matrix working. For a neighbourhood, it would be those people who best serve the needs of a particular group or part of the community identified.

Neighbourhood health teams are a central part of the 10 Year Plan. The document states that the NHS is “hospital centric” and “detached from communities”, with the neighbourhood health service being the chosen alternative to embody a new preventative principle that care should happen as locally as it can. The plan aims to establish a neighbourhood health centre in every community, as a place from which “multidisciplinary teams” will operate.

What are multidisciplinary teams?

I consider a multidisciplinary team to be a group of professionals, usually led by a medic or a nursing professional, although it could be by someone else. But it is not necessarily a broader neighbourhood team – it could be purely health staff, for example, working with a patient on physical rehabilitation. However, you also can have broader neighbourhood teams where the team is drawn from a wider group of people, where it's about much more than just those primarily health-focused professionals. 

So in those broader neighbourhood teams, who do you mean by everyone?

The health and social care workers in that place, but also many of the council professionals in that same place – so those in education, social care, housing, road safety, the councillor who runs the local area committee, the key third sector organisations, the local Age UK, the local Mind, the faith groups, the citizens themselves, as well as the pharmacist, dentist or opticians. It may not even stop there – the manager at your local barber, hairdresser or supermarket may also be involved. That's your biggest neighbourhood – it’s the one people actually live in.

So might the two things – multidisciplinary teams and broader neighbourhoods teams – be confused?

I suspect that a lot of the emphasis is currently on that multidisciplinary health and social care bit. While that may be understandable, they’re not the same.

Imagine someone in the community called Mary. She’s in and out of the hospital with falls and other issues. She sees her GP regularly, the district nurse visits her, as does the falls coordinator. But Mary is also a member of the local church and that provides important social contact for her, while some people in the church also care for her at times. Mary has also been going to the same local hairdressers for 40 years, and they are always the first to see when she’s a bit wobbly and off her feet. The local café owner also knows her in a similar way. Because she’s in social housing and has issues with damp, Mary also sometimes pulls in her local councillor through her daughter to improve things. These people are all part of Mary’s neighbourhood team – it is not just the health and care professionals.

That is just an example, as I’m not suggesting that the NHS will plug into all local hairdressers and café owners in this way, but it illustrates the principle. Neighbourhood health care that thinks in that preventative way, while also treating and supporting an individual, is the real vision of the comprehensive ‘everybody working together in a place’.

But don't neighbourhood health teams already exist?

They do, which is acknowledged in the plan. This sort of work and wider thinking about working in communities with all partners has been happening in certain areas for years, across the NHS and local government. There are excellent examples of teams working with specific communities, age groups or geographies, but it's not evenly distributed. And it has never been centre stage.

So what needs to happen for neighbourhood health teams to work successfully?

You’ve got to have the right types of money flows and incentives, and the employment terms and conditions will be crucial. But relationships and trust may matter as much as anything else. If people don't understand how to share power, don’t share an understanding of risk, don't understand how to work with respect with each other, don't know how to give power away if they are the most powerful, or don’t know how to work with parity of esteem, then it will fail.

Do you agree with that broader focus on neighbourhoods?

People live in their homes, people live in a place. I don’t like the phrase “out of hospital” because it immediately tells you everything you need to know about the English health service, that somehow health care is either in hospital or in this ‘other place’. But actually our lives are in this ‘other place’. Unfortunately, most of us will have to go to a hospital at different points, but that's usually a small part of our lives. For most of the care we receive for a condition, it won’t be in a hospital, but at home or at a clinic. So should the majority of our care be conceptualised and thought about in that space? Absolutely.

The 10 Year Plan states it will support the flow of money from hospital into community. So is that a good and feasible idea?

The plan promises to spend a greater proportion of the NHS budget on community care. If that is successful, what the hospital becomes is an organisation that does what it was set up to do – not one that houses people who should be cared for at home or one that is dealing with the effects of poverty. But rather one that provides elective and emergency care in the best and most efficient way possible.

However, with a fixed budget, it will come down to choices. If you want your hospital to be at the heart of everything – so at the cutting edge of all surgical technique or robotics, or AI or new medicines – or if you want every patient in hospital to be in a single en-suite room with hospital bed numbers that are to European average, I don't know if that hospital money shrinks. While virtual wards (where people are monitored and treated at home) can help with the number of people being admitted to hospital, the NHS doesn’t have a great record when it comes to saving money by moving care away from hospitals.

We know that previous NHS plans have not been as successful as they wished on delivering more care in communities. What needs to happen this time for this plan to be more successful?

There has to be a relentless, endless and boringly consistent focus on it. Nobody should be able to doubt that this government means it. They’ve made a good start – with the launch of the 10 Year Plan being in a community base and the Secretary of State’s first visit in that role being to a GP practice. But the decisions they now make and the leaders they support – they have to show that they mean it and don’t deviate away from it. All policies, including workforce, financial architecture and performance management policies, need to line up with the intent.

There also needs to be an understanding that this isn't going to happen either magically or swiftly. I'd love to be able to say that it could happen everywhere by next Thursday, but it can't.

So how long might it take?

In many ways, it will come down to trust – the quicker that is achieved, the quicker the process. And money helps too of course. Some areas may otherwise get there quicker than others if they’ve already laid the foundations, seeing as it’s already been a policy aim for a number of years. There is some fantastic work going on in places, with brilliant leadership. But if you were starting from scratch today to create a functioning team that works optimally, I think it would likely take two to three years to get there fully, even if you would see progress before then.

What do you think is the main obstacle to this becoming a success?

Clearly money matters. If you've got a choice between putting money into having more district nurses or more ICU nurses, no decision is easy. But other than that, one obstacle could be an over-obsession with organisational form or a focus on buildings. The focus needs to be on relationships – trusting each other, getting on with it, taking risks, going to the edge of what is possible, backing the leaders. And when I say leaders, that could be a local clinical leader, a local nurse leader or a local third sector leader – freeing people up at local level.

Now that the plan has been published, what do you think the next steps should be on neighbourhood health teams?

Very significant things need to happen. Clarity is needed on whether the aim is for enhanced multidisciplinary team working or really trying to create full neighbourhood teams. We’ve then got to understand the workforce implications of that – having teams where people do similar jobs on different salaries is not going to aid joint working. More broadly, we must make sure that the workforce planning demonstrates how we will grow the workforce that's needed for truly brilliant community-based neighbourhood care.

But there needs to be patience. It needs to be understood that not all of this can happen very quickly. If it's going to be done within the financial envelope that is there, it will be slower because you simply cannot close the hospital ward and give the money to the neighbourhood.