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Meeting: |
Executive |
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Meeting date: |
4 November 2025 |
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Report of: |
Director of Housing and Communities |
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Portfolio of: |
Executive Member Housing, Planning and Safer Communities and Executive Member for Health, Wellbeing and Adult Social Care |
Decision Report: City of York Council Neighbourhood Model - Implementation Phase
1. In December 2024, Executive approved a set of design principles for the creation of Integrated Neighbourhood Teams (INTs), also referred to as the York Neighbourhood Model. These teams bring together multi-disciplinary professionals across community services, health and care, in partnership with the voluntary and community sector (VCS) and residents themselves.
2. The model aims to ensure that York residents can access the right information, support and care at the earliest possible stage, and as close to home as possible. This approach will relieve pressure on acute services, free up scarce resources for those with the most complex needs and build greater resilience in communities.
3. Since approval of the design principles, significant work has taken place with system partners. This includes development of a shared outcomes framework, alignment of resources at neighbourhood level, and the testing of practice through case studies and prototypes. Local examples such as the Groves and Walmgate (see Case Studies) demonstrate the model’s potential, while clinical initiatives such as Complex Frailty INTs show how health services can be reoriented around neighbourhood delivery, joining up care across primary, secondary and community services.
4. Integrated Neighbourhood Teams will now form one of the three key workstreams of the overall corporate transformation programme. This is to ensure it receives the appropriate amount of resource, has the right cross Council governance and forms part of the long term sustainability of the Council.
5. The Executive is now asked to consider detailed proposals for the implementation phase, agreement of a shared outcomes framework, and endorsement of the neighbourhood practice model.
Benefits and Challenges
Benefits
6. Once implemented, the Neighbourhood Model will deliver significant benefits for residents, staff and the wider system of partners working together within places and across the health and care system:
· Continuity and wraparound support - services work as one team around the person, minimising transitions and duplication.
· Person-centred decision making - partners can see the “whole person” in their local context, leading to tailored, strength-based support.
· Staff satisfaction and retention - by trusting teams on the frontline and reducing central control, staff feel empowered to use their professional judgement.
· Community strength and resilience - advice, information and capacity building in communities support those who can help themselves, freeing capacity in specialist services for those with greater needs.
· Shared accountability - all partners work towards common outcomes, building unity of effort across public realm, health, care, and community services.
· System efficiency - earlier intervention reduces demand on costly health and care services and creates opportunities for joint funding across partners.
· Practical tools - development of area directories, regular multi-agency forums and referral/triage technologies will make it easier for staff and residents to navigate services, accelerating early help.
· Learning from other models - experience from local schemes (e.g. Groves, Clifton, Walmgate) and clinical prototypes (Complex Frailty INTs) provides York with a strong evidence base for scaling up.
Challenges
7. Implementation will also require addressing several challenges and risks:
· Defining integration - different across organisations risk misalignment of priorities.
· Financial pressures - constrained budgets and workforce shortages across health and local government may limit the pace of delivery.
· Cultural change - shifting from professional silos to shared accountability requires significant trust-building and sustained leadership.
· Governance and data sharing - concerns about information governance and professional identity may act as barriers to joint working.
· National policy shifts - NHS reforms are ongoing, and changes in national direction could affect local plans.
· Managing expectations - neighbourhood working is a long-term transformation; benefits will emerge over time rather than delivering immediate cost savings.
· Geography and access - ensuring that integrated services are co-located or accessible through sustainable travel options will be essential to avoid creating new barriers.
York has already taken steps to mitigate these risks through participation in the ‘Realising the Potential of Integrated Neighbourhood Teams’ programme with the University of York, by building on the success of Local Area Coordination, and by aligning the model with wider strategies such as the Local Transport Strategy and Movement and Place Plan, and the City’s carbon reduction commitments. These are the strategies that transport infrastructure will consider when assessing any future business case for a health and wellbeing campus estate.
Policy Basis for Decision
8. The Council Plan for 2023-27 'One City, for All' sets out the Council’s vision for the next two years. The relevant priority actions in the Council Plan are:
· Work with the York Health and Care Partnership to strengthen York’s integrated early intervention and prevention model and further develop primary and secondary shared care models and emergency care, working closely with the voluntary and community sector.
· ‘One of the new Governments key initiatives is the trial of Neighbourhood Health Centres. These centres will aim to alleviate the pressure on GP surgeries by consolidating services such as family doctors, district nurses, and physiotherapists under one roof. By shifting resources to primary care and community services, the Government hopes to provide more integrated and accessible care for patients.’
· Deliver local area coordination, health trainers and social prescribing that supports people be independent and in communities, working alongside partners for their own health and wellbeing.
· Develop a neighbourhood model of delivery, exploring the benefits of establishing ‘hubs’ across communities.
· Deliver the City Community Mental Health Transformation Programme
· Develop the relationship between schools, family hubs and learning centres, such as ‘The Place’ (Sanderson House), in collaboration with other services and universities.
· Develop a ‘Caretaker’ proposal to reflect pride-in-place priorities in neighbourhood plans.
· From April 2026, there will be new contracting mechanisms for neighbourhood working, as set out in the NHS Ten Year Plan. Integrated Care Boards are expected to implement Multi-Neighbourhood Provider (MNP) contracts, which will commission services at scale across clusters of neighbourhoods rather than solely through individual practices or PCNs. These contracts are intended to align funding and accountability around population health outcomes, support shared workforce models, and enable partners across health, local authority and VCSE sectors to work under a single contractual framework.
Together with responding to ongoing actions to:
· Develop a city-wide Movement and Place Plan - with health, care and community services provided at a neighbourhood level, helping reduce city-wide travel for the majority of routine health, care and community services.
· Develop Local Transport Plan 4 and the Local Cycling, Walking and Infrastructure Plan (in line with government guidance and aligned to the Air Quality Action Plan) to help people travel easily in a sustainable, safe, and healthy way.
9. Whilst not specifically mentioned in the Council Plan the delivery of statutory Homelessness and Rough Sleeper Strategy 2024-27 is dependent on the same building blocks and design principles underpinning the Neighbourhood Model to ensure early intervention by multi-disciplinary teams is co-ordinated and timely.
10. The successful implementation of this model will enable the Council to address the Plan’s four key commitments in the following ways:
· Affordability - Accessing information, support and care closer to home and being given holistic support which will include financial advice will positively impact those most affected by the cost of living crisis, and financial exclusion more generally.
· Environment – The Neighbourhood Model (and four area map) will link in closely with York’s new Local Transport Strategy, and its Implementation Plan. This commits the Council to an audit of facilities across York (for example, GP surgeries, pharmacies, primary schools, open spaces) and looks to identify the neighbourhoods where facilities are missing. The audit will be accompanied by a review of the bus network which will assess the extent to which people can access facilities by public transport, and York’s Local Cycling and Walking Infrastructure Plan, which will identify active travel links. This audit will be one of the main actions to identify how to reduce car use in York by 20% by 2030, to assist York in reducing carbon emissions from transport by 71%.
· Equalities and Human Rights - Every human being has the right to the highest attainable standard of physical and mental health. The Council has a legal obligation to develop and implement legislation and policies that guarantee universal access to quality health services and to address the root causes of health inequalities, including financial exclusion, stigma and discrimination. The right to health is indivisible from other human rights - including rights to education, participation, food, housing, work and information. This model is person-centred and will help the Council to ensure equity of access to services, particularly for those who have protected characteristics.
· Health Inequalities - The new government’s proposed NHS reforms will shift healthcare from a late diagnosis and treatment model to one where considerably more services will be delivered in local communities. There is also a clear signal that there will be a far greater focus on prevention throughout healthcare and within services focused on helping people in relation to the wider determinants of health – such as financial exclusion, housing and crime. The model in this paper will put York ahead of the curve by setting out a truly collaborative model, in partnership with health.
11. The York & North Yorkshire Combined Authority’s Economic Framework (see background documents) priorities include ‘Healthy and Thriving Communities’, stating:
‘Collaboration will help us to ensure that we’re meeting local needs, particularly addressing the unique and diverse requirements of our residents, but also collective efforts can amplify our impact. Whether that’s working closely with our two constituent authorities, our Police, Fire and Crime colleagues, Public Health and the NHS, maximising voluntary and community sector organisations, or supporting our anchor institutions.’
12. In addition to the priorities set out in the Council Plan, the proposals are closely aligned with national health policy, particularly the NHS 10 Year Plan, which sets a clear direction for more integrated, preventative and community-based care:
· Alignment with NHS 10 Year Plan priorities – the NHS 10-year plan commits to shifting more care into community settings, focusing on prevention, early intervention and reducing pressure on hospitals. The Neighbourhood Model directly supports these aims by providing integrated, local access to health, care and community services.
· Neighbourhood Health Centre initiative – the new Government has announced trials of Neighbourhood Health Centres to bring services such as GPs, district nurses and physiotherapists under one roof. The York Neighbourhood Model is well-placed to complement and shape this initiative, ensuring that any national investment builds on existing local partnerships and neighbourhood delivery structures.
· Supporting population health management – the NHS 10 Year Plan emphasises place-based working, multi-disciplinary teams, and tackling health inequalities. The Shared Outcomes Framework and practice model proposed here mirror those priorities, positioning York ahead of the curve in delivering integrated neighbourhood care.
Financial Strategy Implications
13. The Neighbourhood Model represents a major transformation in the way services are designed and delivered. While the long-term ambition is to create efficiencies across the system by reducing duplication, preventing escalation of need, and enabling joint funding of roles, the implementation phase will necessitate careful realignment of existing resources. Faster realisation of efficiencies will require resources allocated through the Council’s Transformation Programme.
Current Position
14. Resources to support the early stages of implementation will be met from existing approved Council budgets.
15. A transformation/programme manager role will be created to oversee delivery, funded initially within Council budgets but with the potential for joint health funding as the model matures.
16. Partner organisations, including health and the voluntary and community sector, are contributing staff time and expertise through existing programmes of work.
Opportunities for Joint Funding
17. The integration of Council and health teams within Neighbourhoods (e.g. housing, Local Area Coordination, neighbourhood health leads) provides opportunities for joint or health-funded posts in future phases.
18. Neighbourhood-level commissioning, aligned to the shared outcomes framework, will be explored to support pooled budgets and flexible use of resources.
19. Early evidence suggests that reducing handovers and transitions, and increasing continuity of care, has the potential to deliver system-wide cost avoidance.
York Health and Care Collaborative (YHCC)
20. A minimal but essential resource is required to sustain the operation of the YHCC, which provides the primary forum for relationship building, shared learning and neighbourhood rotation.
21. The ask of partners to contribute to this resource, recognising its central role in enabling neighbourhood working was agreed at the York Health and Care Partnership in September 2025.
Medium-Term Implications
22. Further work will be undertaken to assess longer-term funding requirements, including the potential role of the Combined Authority, national transformation funding, and health system investment.
23. Financial planning will be informed by the evaluation of prototypes (e.g. Complex Frailty INTs) and the demonstrable outcomes achieved through neighbourhood working.
Recommendations and Reason
24. Executive is asked to:
I. Note the progress and plans made across Council teams and by partners, particularly in the health system, in developing and testing the Neighbourhood Model.
II. Approve the Shared Outcomes Framework (Annex B) and Practice Model (Annex C) as the foundation for delivering integrated neighbourhood working across the city.
III. Approve the Governance Structure at paragraph 58.
Reason: To provide a plan for the implementation of a Neighbourhood Model for York.
Background
25. Following the last report to Executive in December 2024 the following key considerations have informed workstreams needed to take the model from design principles to implementation.
Neighbourhood Operating Principles
26. The Neighbourhood Model is underpinned by a set of operating principles that define how services will work together at the most local level (as approved by Executive in December 2024). These principles are built on York’s existing strengths in community engagement and early intervention and draw on learning from other local and national models.
27. In addition to closer working of placed based teams (public realm and Neighbourhood caretakers), the core of the approach is relationship based practice, ensuring that services are designed around people in their places, rather than organisational structures. When delivered well, this practice looks like:
· Regular multi-agency forums to share best practice and build mutual understanding.
· Multi-Disciplinary Teams (MDTs) or ‘team around the person/issue’ approaches, that bring in the right expertise at the right time.
· Co-location where useful, recognising that networks can be both physical and virtual, and that trusted local contact points often matter more than buildings.
· Named local contacts to provide introductions and support, replacing impersonal referral processes.
· Shared triage and harmonised referral pathways, ensuring residents access the right services and support.
· Specialists will consult into neighbourhood teams, rather than operating as external referral points, supporting continuity and wraparound care.
28. These principles reflect a system wide shift from central control to frontline empowerment, with staff trusted to apply their professional judgement in the context of local knowledge. Importantly, they are not about creating new structures for their own sake but about weaving together what already works into a consistent city wide approach that reflects York’s character and communities.
Shared Outcomes and Practice Framework
29. A central element of the Neighbourhood Model is the development of a Shared Outcomes Framework (Annex B), supported by a consistent practice model. This ensures that all partners - across the Council, health, care, community services and the voluntary sector - are working towards the same goals, with clear accountability for delivery.
30. Why Shared Outcomes?
· To focus collective effort on the wellbeing of York’s population, not on individual organisational processes.
· To enable partners to pool resources and align decision making, minimising duplication.
· To create a shared vision that builds trust, changes culture, and sustains collaboration over the long term.
· To provide a basis for monitoring progress and evaluating impact in ways that are meaningful to residents as well as services.
Principles of the Framework
31. The framework is based on common principles from systems that have successfully implemented neighbourhood working:
· Population level focus - outcomes are measured for people and places, not just services.
· Locally owned - reflecting the unique needs of each neighbourhood, shaped through engagement and co-production.
· Relational and cultural change - embedding mutual accountability across organisations.
· Complementary - aligning with statutory duties and regulatory frameworks rather than duplicating them.
· Iterative - recognising that developing shared outcomes is a journey, not a one off exercise.
Practice Framework
32. To support delivery of these outcomes, a Neighbourhood Practice Framework has been developed (Annex C). This sets out:
· Why -The overall change we are seeking to deliver across the City
· What - the outcomes we aim to achieve together, focusing on early intervention, prevention, and holistic support.
· Who - the range of partners involved in neighbourhood working, from health and care professionals to community organisations, Councillors, volunteers and residents themselves.
· How (Workforce) - training, induction, and relationship-building mechanisms (e.g. practitioner forums, co-location, shared triage).
· How (System) - governance and structures, including Neighbourhood Partnership meetings, harmonised processes, and data sharing agreements.
· So? - the difference the model is making to residents, the workforce and their places and spaces.
33. The practice framework will be supported by area directories, building on the LiveWellYork platform. These directories provide an accessible, up-to-date resource of people, services and opportunities in each neighbourhood, enabling quicker connections and earlier help.
Next Steps
34. Delivering the Shared Outcomes and Practice Framework will require sustained consultation with residents and partners across all sectors. The process of co-production is as important as the outcomes themselves, ensuring they are rooted in lived experience and trusted relationships.
Neighbourhood Resources and Infrastructure
35. Implementing the Neighbourhood Model requires a clear alignment of people, roles and resources at neighbourhood level. The approach builds on existing strengths within the Council, health partners, and community services, while introducing new structures to support collaboration and accountability.
Neighbourhood Management Team
36. A dedicated management function will coordinate neighbourhood working, facilitate community engagement, and ensure democratic accountability through ward committees. This includes:
· Neighbourhood Management Team
· Environment and Communities Officers (ECOs).
· Community Involvement Officers - including posts linked to the Armed Forces Covenant and Holiday Activities and Food programmes.
· Programme Assistant to support coordination across workstreams.
Community and Specialist Roles
37. The model integrates a range of specialist and community-based roles into neighbourhood delivery, including:
· Health Trainers.
· Local Area Coordinators.
· Housing Management Officers and Housing Estate Officers.
· Welfare Benefits Advisors (including grant-funded outreach posts).
· Sport Development and Health Champions.
· Health Visiting teams.
· Neighbourhood Caretakers (supporting pride-in-place and environmental improvement).
· Community Champions (a volunteering model to build local resilience and engagement).
Clinical and System Leadership
38. The York Health and Care Partnership (YHCP) endorsed the appointment of a York ‘Place Coach’ on 11 September 2025. This new role will support the continued development of Neighbourhood Health across the city, facilitating collaboration between partners and sharing learning across the system. The Place Coach will act as a connector between the York Health and Care Partnership (YHCP), the York Health and Care Collaborative (YHCC), the Humber and North Yorkshire Neighbourhood Development Group, and the National Neighbourhood Health Implementation Programme (NNHIP), ensuring alignment of local delivery with regional and national priorities.
39. Neighbourhood Clinical Leads and Integrated Care Board (ICB) Leads will provide a health system anchor for each area, ensuring alignment of clinical services and resources. Named GP leads have already been identified across York’s four neighbourhoods, alongside developing ICB leadership roles.
Service Realignment
40. Council services are being reviewed to align with the four neighbourhood model, ensuring that core local services such as housing, public realm, volunteering, and Local Area Coordination are integrated into the neighbourhood approach. This realignment will also support joint working with schools, family hubs, and community-based health services.
Tools and Infrastructure
41. Developing plans include:
· Neighbourhood Directories: quick reference guides to services and practitioners, building on the LiveWellYork platform, to make navigation simple for staff and residents.
· Data and Insight Packs: neighbourhood level information to support planning, targeting of need, and evaluation of impact.
· Community Hubs: while not building led, the model will make use of existing facilities (e.g. schools, health centres, community buildings) as shared spaces where appropriate, ensuring accessibility and sustainability.
Case Studies and Stories
42. Case studies provide practical illustrations of how the Neighbourhood Model is already working in York, and how it can be scaled up. These examples show the model’s ability to adapt across different settings - from community led projects, to Council-led place improvements, to clinically led prototypes.
Community-led and Council-supported Initiatives
43. The Groves - A resident led initiative with targeted input from Council teams. This demonstrates how supporting local people to co-design solutions can generate lasting improvements and stronger relationships between services and the community.
44. Clifton ‘Clear/Hold/Build’ - A multi-agency approach to community safety and improvement, achieved without additional resources, but through collaboration and shared accountability.
45. Walmgate Area Improvement Plan - A co-designed place-based plan focusing on environmental improvements and resident priorities. This illustrates how the model can integrate ‘pride in place’ work with health and wellbeing outcomes.
Clinical and System Case Studies
46. Complex Frailty INTs - Developed by Nimbuscare in partnership with other providers across health, care and the VCSE, these teams provide intensive, neighbourhood led support for individuals with complex health needs. For example, one case involved a patient whose care was coordinated across primary, secondary and community services through a shared neighbourhood Multi-Disciplinary Team (MDT). This approach not only improved the patient’s wellbeing but also reduced demand on hospital services.
47. Development of a Neighbourhood Home Visiting Service - Developed at a city-wide level and designed around neighbourhood need, this service, which is currently being developed, will support residents who may struggle to access care, moving from a reactive to a preventative model.
Shared Learning
48. These case studies demonstrate:
· The flexibility of the model to work across different service areas.
· The importance of co-design and relational practice in achieving outcomes.
· The potential for both community led and clinically led initiatives to thrive within the same framework.
· The value of scaling what already works, rather than creating entirely new structures.
Programme of Work and Workstreams
49. To move from design to full implementation, the Neighbourhood Model will be delivered through a structured programme of workstreams. These workstreams bring together Council services, health partners, the voluntary and community sector, and residents themselves. Each is designed to build capacity, strengthen relationships, and deliver tangible improvements in how services are accessed and experienced. The workstreams currently under development are:
50. Workstream 1: Engagement and Community Planning
· Ongoing engagement with residents, ward committees and partners to shape priorities and define what ‘neighbourhood’ means locally.
· Development of meaningful consultation methods, recognising that not all residents identify with administrative boundaries.
· Visibility and accessibility measures, such as neighbourhood newsletters, drop-in forums, and use of digital engagement tools.
· Role of Councillors clarified and supported through tailored guidance and officer support.
51. Workstream 2: Shared Outcomes Framework and Relational Practice
· Further development of the shared outcomes framework, through sustained co-production with communities and partners.
· Embedding principles of relational practice into day to day operations across the Council and partner services.
· Working across systems to drive culture change and embed joint working.
· Using case studies and stories to demonstrate outcomes to residents and partners.
52. Workstream 3: Realigning Council Services and Targeting Need
· Integration of Council services into the four-neighbourhood model (housing, caretakers, Local Area Coordinators, volunteering, etc).
· Alignment of Council services with partner provision, including schools, family hubs, and health services.
· Identification of cross-cutting services (e.g. SEND, homelessness) that require city wide integration while still working closely with neighbourhood teams.
53. Workstream 4: Funding and Resources
· Exploration of the use of S106 and CIL in line with the model.
· Exploration of joint funding models with health partners - particularly for integrated roles.
· Exploration of external funding sources including developer contributions and regional and national government programmes.
· Creation of a transformation/programme manager role to support delivery.
· Securing minimal, but essential, resources to sustain the York Health and Care Collaborative (YHCC) and its new neighbourhood rotation model.
54. Workstream 5: Data and Insight
· Development of neighbourhood insight packs, bringing together system data and local intelligence.
· Expansion of the LiveWellYork platform into neighbourhood directories, to improve navigation and access.
· Exploration of shared data agreements across Council, health and VCSE partners to support integrated decision-making.
Measuring Success and Key Performance Indicators (KPIs)
The success of the Neighbourhood Model will be measured through a shared set of Key Performance Indicators (KPIs) which will be developed collaboratively with partners across the York Health and Care Collaborative (YHCC) and the voluntary and community sector. These measures will help to evidence impact, guide continuous improvement, and demonstrate the value of neighbourhood-based working.
The KPIs will reflect both system-level outcomes (such as health, wellbeing, and service efficiency) and local experience measures (such as access, satisfaction, and community confidence). Early indicators under consideration include:
1. Resident Outcomes and Experience
· Percentage of residents who report they can access help and advice locally.
· Improved self-reported wellbeing and confidence in managing health or care needs.
· Reduction in repeat or crisis service use (e.g. avoidable A&E attendances, repeat homelessness presentations).
· Increase in resident satisfaction with local services and neighbourhood pride.
2. Workforce and Partnership Measures
· Improved staff satisfaction and retention across neighbourhood teams.
· Number of cross-sector training and relationship building activities delivered.
· Evidence of collaborative casework and reduced handovers between services.
· Representation and diversity within neighbourhood workforce structures.
3. System and Financial Indicators
· Reduction in duplication of service activity across partners.
· Increased proportion of resources directed towards prevention and early intervention.
· Demonstrable system cost avoidance linked to earlier help and integrated delivery.
4. Community Capacity and Engagement
· Number of residents engaged in neighbourhood decision-making or volunteering.
· Uptake of community-based activities, health programmes, and early help offers.
· Growth of local partnerships and initiatives co-produced with residents.
These KPIs will be co-designed and refined with partners as implementation progresses, ensuring they remain meaningful, measurable, and rooted in local priorities.
Baseline data will be established through the Neighbourhood Insight
Packs (Workstream 5), enabling regular performance reporting
through the Programme Management Office and the York Health and
Care Collaborative.
55. Workstream 6: Workforce Development and Engagement
The success of the Neighbourhood Model depends on a confident, connected, and well-supported workforce across all partners. Workstream 6 focuses on developing a shared workforce strategy and engagement plan that aligns the culture, capability, and capacity of York’s multi-agency teams with the principles of neighbourhood working.
Strategic Objectives
· Build a unified culture of relational practice: Embed shared values across Council, health, and voluntary sectors, fostering trust, collaboration, and professional empowerment at neighbourhood level.
· Develop a sustainable and skilled workforce: Identify future workforce needs, skills gaps, and opportunities for joint recruitment, training, and career pathways across partners.
· Strengthen system leadership: Develop cross organisational leadership programmes that nurture neighbourhood level leaders able to bridge professional boundaries and champion integration.
· Embed staff wellbeing and retention: Co-design wellbeing initiatives and flexible working arrangements that reflect the principles of community based delivery.
· Enable learning and mobility: Support secondments, rotations, and job-shadowing between organisations to build shared understanding and resilience and role generosity.
Operational Priorities
· Joint Workforce Development Plan: Produce a shared plan with York Health and Care Collaborative partners, setting out training priorities, induction modules, and continuous professional development aligned to the Neighbourhood Practice Framework.
· Neighbourhood Induction Programme: Launch a cross-sector induction for new staff and volunteers, introducing York’s neighbourhood principles, shared outcomes, and co-production ethos.
· Practitioner and Leadership Forums: Expand existing multi-agency forums to include peer learning, reflective practice, and regular engagement sessions with neighbourhood leadership teams.
· Staff Engagement and Communication: Develop a coordinated communication plan to share stories, celebrate good practice, and maintain visible leadership presence within neighbourhoods. The first round of staff sessions will take place in December.
· Evaluation and Feedback: Use staff surveys and learning loops to assess confidence, satisfaction, and collaboration, ensuring insights directly inform ongoing workforce strategy.
56. Cross-Cutting Programme Actions
· Governance - establish Neighbourhood Partnership meetings and cross-organisational governance structures.
· Project Management - creation of a Project Management Office (PMO) to coordinate delivery across all partners.
· Learning and Development - shared induction, training, and relationship-building activities to embed relational practice. Teams sharing good practice from across neighbourhoods.
· Prototyping - development of the first Integrated Neighbourhood Team (INT) prototype, focused on Complex Frailty, to test the practice model at scale.
Governance and Next Steps
57. Effective governance will be central to the successful delivery of the Neighbourhood Model. The approach must be transparent, inclusive, and capable of holding multiple organisations to account while maintaining flexibility for neighbourhood level innovation.
58. Governance Structures
· Neighbourhood Partnership Meetings will be established in each of the four York neighbourhoods, bringing together Council services, health partners, the voluntary and community sector, and local Councillors.
· A cross-organisational Programme Management Office (PMO) will coordinate delivery, monitor progress against the shared outcomes framework, and ensure alignment across workstreams.
· Ward governance arrangements will be revised and strengthened, linking democratic decision making with the neighbourhood model and shared outcomes.
· System wide oversight and partnership decision making will be provided through York Health and Care Collaborative (YHCC) reporting to York Health and Care Partnership Executive and supported by partners’ commitment to sustain its resources.
· Council decision making will continue to follow internal democratic processes.
59. Data and Insight
· A set of data sharing agreements between Council, NHS partners, and the voluntary sector will be developed to underpin joint working.
· Neighbourhood insight packs will be created to combine quantitative data with lived experience, supporting continuous learning and targeted interventions.
· Outcome measures will be co-produced with residents to ensure evaluation reflects what matters most to communities.
60. Next Steps for Implementation
a) Formal adoption of the Shared Outcomes Framework and Practice Model by partners (already approved by York Health & Care Partnership Executive).
b) Establish Partnership Meetings and Governance Structures across all four neighbourhoods.
c) Recruit Programme Manager and set up PMO to coordinate the implementation programme.
d) Development of a programme plan and structure, staged for key decisions, to keep pace while PMO recruitment is underway.
e) Develop and approve data sharing agreements with key partners.
f) Produce first neighbourhood insight packs and test their use in planning and evaluation.
g) Prototype the first Integrated Neighbourhood Team (INT), initially focused on Complex Frailty, as a proof of concept.
h) Align ward and neighbourhood governance, and shared outcomes.
i) Continue neighbourhood rotation within YHCC, embedding shared learning and relationship building across the city.
Consultation Analysis
61. The York Health and Care Partnership (YHCP) Executive has been engaged in discussions around this model since March 2024, and the York Health and Care Collaborative (YHCC) is actively involved in development.
62. The Communities team has been undertaking ongoing engagement, facilitating conversations in community settings, community hubs, meetings and events. These conversations have been built around a series of themed prompts around ‘Environment and Green Spaces’, ‘Your Community’, ‘Connecting to Services’, ‘Getting About’.
63. The feedback has been overwhelmingly positive in valuing local green spaces and the difference that having somewhere local to walk and relax is important. Also featuring frequently in conversation was the importance of community hubs, somewhere local and accessible where people can socialise and find support if needed. The importance of social connections and access to information to know what is on locally came out strongly with suggestions of local newsletters and posters. Some sample comments:
· ‘Sometimes it feels difficult to know who to talk to about what’
· ‘I can make a difference by encouraging friendships, looking out for my neighbours, and trying my best to reduce loneliness’.
· ‘There are some volunteer litter pickers which is good to see’
These conversations have also offered an opportunity to share local information and volunteering opportunities.
64. York Health Care Collaborative brings together health and community professionals and with a focus on developing a whole system approach utilising the neighbourhood model framework to maximise the impact of delivery to address health inequalities and support residents to lead healthy lives.
Options Analysis and Evidential Basis
65. Options to be considered:
· Option 1 – Maintain the status quo (not recommended)
Continue with existing service structures and siloed delivery. This option does not address system pressures, fails to capitalise on prevention and early intervention, and risks York falling behind national reforms.
· Option 2 – Incremental change through individual service programmes (not recommended)
Make small, service-by-service improvements without a shared model. There would be some local benefits, but this option is unlikely to deliver whole system impact, there would remain duplication and there would be limited ability to shift resources upstream.
· Option 3 – Implement the Neighbourhood Model (recommended)
Establish Integrated Neighbourhood Teams, supported by a shared outcomes framework, governance arrangements, and realignment of resources. This is consistent with Council Plan priorities, NHS 10 Year Plan, and Central Government’s Neighbourhood Health Centre initiative. It builds on strong local schemes (Groves, Clifton, Walmgate, Frailty INT) and positions York as a leader in prevention and community-based delivery.
Evidential Basis
65. Local schemes: Demonstrated positive outcomes in resident engagement, community resilience, and system collaboration.
66. National learning: Evaluation of Local Area Coordination and NHS neighbourhood integration pilots shows reduced crisis demand, improved resident wellbeing, and better staff satisfaction.
67. Policy alignment: Fully aligned with Council Plan 2023–27, NHS 10 Year Plan, and Government commitments to community-based care.
Organisational Impact and Implications
68.
· Financial
The Neighbourhood Model represents a major transformation in the way services are designed and delivered. While the long term ambition is to create efficiencies across the system by reducing duplication, preventing escalation of need, and enabling joint funding of roles, the implementation phase will necessitate careful realignment of existing resources. Faster realisation of efficiencies will require resources allocated through the Council’s Transformation Programme.
· Human Resources
Staff and Trade unions will be engaged and consulted on any changes to operating practices, job roles and structures as a result of introducing an integrated neighbourhood model, which will be managed in accordance with the Councils workforce change policies. Where staff are co-located with teams from other organisations, an agreed understanding between the separate employers to detail how the arrangements will operate in practice, including any future jointly funded posts, may be needed. The additional resource required of transformation/programme manager to oversee delivery will be established and resourced in accordance with council policy. Training and development identified to support and embed Neighbourhood practice will need to be developed with funding identified.
· Legal
The proposals in this report are consistent with the Council’s duty to “make arrangements to secure continuous improvement in the way in which its functions are exercised, having regard to a combination of economy, efficiency and effectiveness” as set out in the Local Government Act 1999.
Statutory Guidance on discharging this best value duty specifically highlights the need for local services to citizen-focused, meet the needs of diverse communities and improve outcomes for the people who use them. The design principles for York’s future community and health operating model should continue to be developed in line with the best value duty and guidance.
Any service changes will be the subject of separate decision making processes and specific legal advice.
Legal Services must also be consulted with regards to any necessary legal agreements, funding arrangements, governance terms etc. relevant to the implementation of any proposals set out within this paper, in order to provide their input and ensure compliance with the Council’s internal rules and applicable legislation.
· Procurement
Should any requirements for services or works arise, Procurement must be a tool to deliver those outcomes. Services and/or works must be procured via a compliant process in accordance with the Council’s Contract Procedure Rules and where applicable, the Procurement Act 2023. Further advice regarding the procurement process and development of procurement strategies must be sought from the Commercial Procurement team.
· Health and Wellbeing
We are aware that the government’s NHS reforms will shift healthcare from a late diagnosis and treatment model, to one where considerably more services will be delivered in local communities. There is also a clear signal that there will be a far greater focus on prevention throughout healthcare and within services focused on helping people in relation to the wider determinants of health – such as poverty, housing and crime. The work proposed in this paper will put York ahead of the curve by setting out a truly collaborative model alongside health partners.
· Environment and Climate action
By optimising transport routes, including inclusive and accessible routes which prioritise walking, cycling or wheelchair use, focused on distinct neighbourhood strengths and assets, the Local Transport Strategy ambition of improving health generating travel options where movement is a barrier and reducing carbon emissions from transport will be supported.
· Affordability
If a neighbourhood model is implemented effectively then advice, information and support will be available from the network of resources available within the local area, and agencies whether community, voluntary, health or Council services will all be able to provide and engage support tailored to the need of the family or individual. This will ensure that residents can access the support they need to help them with their cost of living to maximise income and receive the financial advice they are entitled to. Advice and support will be available to those furthest away (both geographically and socially) from current services, as outreach services will operate where hubs are not available or accessible to the resident.
· Equalities and Human Rights
Every human being has the right to the highest attainable standard of physical and mental health. We have a legal obligation to develop and implement legislation and policies that guarantee universal access to quality health services and to address the root causes of health inequalities, including poverty, stigma and discrimination. The right to health is indivisible from other human rights - including the rights to education, participation, food, housing, work and information. This model is person centred and will help the Council to ensure equity of access to services, particularly for those who have protected characteristics.
A full Equalities Impact Assessment is attached at Annex A and highlight positive impacts for many protected characteristics.
The data protection impact assessment (DPIAs) screening questions were completed for the recommendations and options in this report and as there is no personal, special categories or criminal offence data being processed to set these out, there is no requirement to complete a DPIA at this time. However, this will be reviewed following the approved recommendations and options from this report and a DPIA completed if required. Information Governance will be closely involved in any conversations around data sharing.
Communications will form a key element of consultation and the delivery of any new model. Where appropriate joint communications with relevant partners will be arranged. Longer-term, the approach will support the council's communications strategy, in terms of supporting better focused engagement based around neighbourhood needs and priorities. The form of how this will work will be determined as the approach is rolled out. The model is likely to support better understanding of customers and better integration of communications for residents accessing support from different public service organisations.
· Economy
Workforce development planning, integrated ways of working all
focused on earlier and improved outcomes for residents and their
families will improve staff morale, health, recruitment and
retention across all sectors involved including the voluntary and
community sector, and the health and care workforce. Skills
development and access to learning as part of improved outcomes for
some residents and resulting employment opportunities will increase
life opportunities and long term benefits including health and
wellbeing.
Risks and Mitigations
70. Transformational change of this scale carries inherent risks. Recognising these risks early and setting out clear mitigations will be key to successful implementation.
Risks
· Shared understanding of integration - different organisations may hold varying interpretations of ‘integrated care’, leading to inconsistent practices and priorities.
· Financial and workforce pressures - ongoing constraints across both the Council and health partners may limit the resources available for delivery.
· Cultural change - moving from siloed working to shared accountability requires significant trust building and may challenge professional identities.
· Governance and information sharing - data protection and information governance concerns could slow progress on joint working.
· Policy shifts - national NHS reforms remain in development and changes in government direction could impact the model.
· Leadership tensions - cross-organisational leadership challenges may create friction in decision-making.
· Expectation management - elected members and senior leaders may expect immediate cost savings; however, the benefits of neighbourhood working will be realised over the longer term and need to be evaluated longitudinally.
· Geography and access - co-location of services and alignment with transport strategies is essential to ensure services remain accessible and do not create new barriers for residents.
Mitigations
· Collaborative Programme Development – CYC and partners have participated in the ‘Realising the Potential of Integrated Neighbourhood Teams’ programme with the University of York, ensuring joint vision and commitment from the outset.
· Building on Local Area Coordination (LAC) - independent evaluation of York’s LAC model demonstrates the value of early intervention and prevention. This learning is directly informing neighbourhood design.
· Neighbourhood Partnership Meetings - these will provide a local forum to build trust, share challenges, and agree solutions collectively.
· Shared Outcomes Framework - embedding mutual accountability through outcomes agreed across all partners will help align expectations.
· Governance and Data Agreements - clear governance structures and formalised data sharing agreements will address concerns around accountability and information use.
· Prototyping Approach - beginning with a focused prototype allows the model to be tested, refined, and evidenced before scaling up.
· Transport Integration - aligning the Neighbourhood Model with the Movement and Place transport strategy ensures accessibility and supports York’s wider carbon reduction targets.
Wards Impacted
All Wards
Contact details:
For further information please contact the authors of this Decision Report.
Author
|
Name: |
Laura Williams |
|
Job Title: |
Assistant Director Customer, Communities and Inclusion |
|
Service Area: |
Housing and Communities |
Co-author
|
Name: |
Pauline Stuchfield |
|
Job Title: |
Director of Housing and Communities |
|
Service Area: |
Housing and Communities |
|
Telephone: |
01904 551706 |
|
Report approved: |
Yes |
|
Date: |
23/10/2025 |
· People Scrutiny Committee, 8 October 2025, ‘Neighbourhood Model Update’, Agenda for People Scrutiny Committee on Wednesday, 8 October 2025, 5.30 pm (item 5).
· Executive, 12 December 2024, ‘Design principles of a ‘Neighbourhood Model’ for York’, Agenda for Executive on Thursday, 12 December 2024, 5.30 pm (item 68).
· Executive, 14 November 2024, ‘Establishment of a Joint Committee (Section 75 agreement) between Humber and North Yorkshire Integrated Care Board and City of York Council’ Agenda for Executive on Thursday, 14 November 2024, 5.30 pm (item 53).
· Children, Culture and Communities Scrutiny Committee, 5 November 2024, Design Principles of a ‘Neighbourhood Model’ for York Agenda for Children, Culture and Communities Scrutiny Committee on Tuesday, 5 November 2024, 5.30 pm (item 28)
· York and North Yorkshire Combined Authority Economic Framework, August 2024, PowerPoint Presentation
· Children, Culture & Communities Scrutiny Committee, 2 July 2024 ‘Raise York - Family Hub Network Development Update’Family Hub Network Development Update 2024-07.pdf (york.gov.uk)
· Decision Session – Executive Member for Culture, Leisure and Communities, 22 November 2019, ‘Connecting People and Places - A Community Hub Approach’ https://democracy.york.gov.uk/documents/s136045/Report.pdf
Annexes
Annex A: Equalities Impact Assessment
Annex B: Shared Outcomes Framework
Annex C: York Neighbourhood Model Practice Framework
Abbreviations
ABCD: Asset based Community Development
A&E: Accident & Emergency
CYC: City of York Council
ECO: Environment and Community Officer
EIP: Early Intervention & Prevention
GP: General Practitioner
ICB: Integrated Care Board
INT: Integrated Neighbourhood Teams
KPI: Key Performance Indicators
MDT: Multi-Disciplinary Teams
NHS: National Health Service
PMO: Project Management Office
SEND: Special Educational Needs & Disability
YHCC: York Health and Care Collaborative
YHCP: York Health and Care Partnership