Designing an effective neighbourhood health model to bring care closer to home
Working with James Paget University Hospitals NHS Foundation Trust and partners across Great Yarmouth & Waveney to design neighbourhood models of care that bring services closer to home and improve population health.
In recent decades, there has been a discernible shift toward the concentration of care and resources within acute hospital settings. The New Hospital Programme created an opportunity not simply to replace buildings, but to rethink how care is delivered across Great Yarmouth & Waveney.
James Paget University Hospitals NHS Foundation Trust commissioned The PSC to work alongside partners across Great Yarmouth & Waveney to design new neighbourhood models of care, using the New Hospital Programme as a catalyst for wider system transformation – improving outcomes and reducing reliance on hospital-based care – rather than simply replacing existing hospital capacity.
The challenge
Across the NHS, growing demand and increasingly complex needs mean hospitals cannot meet future need alone. Delivering more proactive, preventative and community-based care has become central to creating sustainable health systems and improving outcomes for local populations.
James Paget is a RAAC affected site and had been selected for redevelopment under the new hospitals programme (NHP). The new hospital is expected to have a lifespan of 60 years and must be operational by 2031.
James Paget’s own demand and capacity modelling suggested they would need 688 beds to meet demand in 2040, while the NHP would fund significantly fewer. To ensure that demand was rightsized to the inpatient provision of the new site, James Paget worked with The PSC to redesign clinical models to mitigate demand for 132 inpatient beds. By ensuring that more people could receive proactive support closer to home the system could reduce reliance on inpatient care and build a long-term path to a healthier Great Yarmouth & Waveney.
The approach
Over 16 weeks, the programme brought together over 90 staff from across trust, place, the ICS, primary, community and social care to develop a shared vision for neighbourhood health. Together the partnership explored:
- What were the most significant demographic, environmental, economic, social and health challenges the area was experiencing and how were these projected to change over the medium and long term?
- What existing work was already being undertaken across the trust and wider system partners and how could we ensure that the new models of care were not in conflict with these?
- Which areas could the trust look at first where there was significant opportunity to quickly mitigate a large amount of acute bed demand and make substantial impacts to patient experience and outcomes.
- At both a national and international level, what examples were there of exemplary practice and what lessons could we take when creating a bespoke model for Great Yarmouth & Waveney?
- How could we ensure our new models were highly specific, tangible, had significant buy-in and a clear path to delivery?
- What should the trust do next to maximise its chances of success, both in mitigating acute bed demand and improving the health of local residents?
Engagement was divided between a clinically focused leadership group and broader strategic oversight groups. The clinical leadership group – comprising doctors, nurses, and therapists – designed the future state models and identified key areas for change. They also evaluated enabling factors such as infrastructure, technology, and workforce to understand how these elements interact across priority areas.
The impact
The programme established strong cross-organisational consensus for a defined and tangible programme to improve and recentre frailty and type 2 diabetes care within the community setting, reducing demand for hospital care. Each model contained five core functions describing a future ‘ideal state’, with a strong focus on proactive upstream intervention within communities. These were codeveloped with clinical leaders in the trust and informed by real life tested examples of international best practice of neighbourhood and preventative healthcare.
A thorough current state assessment identified the major obstacles to achieving each of these model functions, and crafted achievable solutions to overcome these. This included testing and developing a range of levers to enable affordability of the models, and recommending a strategy of continued focus on and early delivery frailty and type 2 diabetes to ensure continued momentum and rapid delivery of change.
As the programme progressed, emerging work on neighbourhood frailty care enabled the partnership to develop a business case for an urgent frailty response unit, supporting a successful bid for capital investment and accelerating implementation.
The PSC exists to make public services brilliant. To find out more about our work creating neighbourhood health systems and designing new clinical models, please contact Elanor Bond.