Agenda item

This presentation by members of the York Health and Care Collaborative (a sub group of the York Health and Care Partnership) outlines the working approach and delivery mechanism for neighbourhood working in York and the all age approach to neighbourhood health, care and other local service integration, prevention and early intervention.

The Health and Wellbeing Board is likely to have a clear leadership role in developing Neighbourhood Health Plans going forward, as has already been announced in the Fit for the Future – 10 Year Health Plan for England, July 2025 and the work already undertaken by YHCC will help inform interim strategic planning that is expected of HWBB going forward.

HWBB members will be asked to note the progress made by YHCC in partnership and consider the board’s future responsibilities in light of available guidance expected imminently from Government.

The Director of Public Health introduced the item, noting that it was the board’s duty to publish a Neighbourhood Health Plan, and this would hopefully allow acute hospitals to work much more at a neighbourhood level, with external services more deeply integrated and embedded with the NHS, which he said was a timely alignment for York. He suggested that the board’s role in this process should be to steer the agenda and outlined how the model fitted in with York’s wards and

The item was then presented by The Director of Housing and Communities and the Director of Urgent Care, Nimbuscare.

The Director of Housing and Communities summarised how health services would fit into this model, advising that the local authority had planned for services to work within communities via an early intervention and prevention approach, to work with people as early and locally as possible. She noted that in York there were various existing models of integrated working to build upon, such as Local Area Coordinators, SEND hubs, Frailty hubs, Family hubs, and Mental Health hubs.

She advised that Neighbourhood Partnership Boards had been organised across the city, and work was being undertaken with the voluntary care sector to better respond to local issues. She detailed how the Integrated Neighbourhood Team would support the population on an individual level as well as through more complex cases identified by data. A consistent approach to working with the INT had been agreed between York Health and Care Collaborative and the council’s Executive.

The Director of Urgent Care went on to discuss Population Health Management. She advised that this involved using data to identify residents who needed multi-agency support, and working together to provide better support than the current single agency system was able to. She talked the board through a case study on how multi-agency social prescribing and trusted relationships looked in real terms.

The Director of Public Health advised that national guidelines concerning how Health and Wellbeing Boards needed to form their Neighbourhood Plan had not yet been received but were anticipated in the coming weeks. He stated that initial guidance suggested that boards would be required to offer leadership, and he hoped that partners would be able to further discuss this at the Local Government Association workshop being convened in March and at the subsequent meeting of the HWBB.

The Chair noted that York was in a strong position with this plan and the board simply needed to determine how deeply involved it wished to be with the neighbourhood plan.

Board members asked how “Caroline’s story” - the case study in the presentation – tied in to the Neighbourhood Model and what about York’s model had led to a different outcome in this case.

The Director of Urgent Care responded that the case study highlighted the need for different organisations to come together through a multiagency approach, working around the needs of an individual. She stressed that this was fundamentally different from partners looking after patients without interaction from other agencies. Partners were not fully at the stage where they had adopted a multi-agency approach, but were moving in that direction.

Board members asked about fixing problems upstream being preventative, and whether in future the Neighbourhood Model might thereby fix problems before they got to the point discussed in “Caroline’s Story”. 

The Director of Public Health answered that this case study showed the difference a proactive model of social prescribing made.  Traditionally, something goes wrong, and someone went to healthcare providers for support; the intention of the new model was different, rather than waiting for something to go wrong, people in high risk groups who are currently in good health can be identified on GP registers and providers can reach out to them to proactively make a personalised plan to attenuate risks. He noted that this was much clearer to see in a neighbourhood setting.

The York Place Director said that this discussion was the start of a conversation among board members that would need to continue over the next six months. She responded to the previous query stating that this was about creating a systematic approach for identifying need rather than relying on a single point of referral. and community champions, ward councillors and others could all provide early help and intervention, rather than the traditional reliance on primary care referrals. York Hospital and TEWV, needed to relate to neighbourhoods too.

The Chief Executive, York CVS commented that this was about centring care around individual people, and Social Prescribing was an ideal way of picking up on people who were otherwise off the radar of the system or isolated at home.

The Corporate Director of Adults and Integration said that the case study was positive, but even so Caroline had experienced a bad year, which had further impacted her health. Going forward, it would be even better to avoid all challenges. Thinking about may need assistance with movement by addressing problems earlier and utilising local teams to ensure fewer people around the patient.

The Manager of Healthwatch York suggested that the real challenge was around understanding neighbourhoods as real places and not just arbitrary compass directions or map zones.

The Managing Director, TEWV, endorsed the plan, adding that all organisations would need to properly engage with the scheme for it to work to its full potential. The Director of Communications, York and Scarborough Teaching Hospitals NHS Foundation Trust added that York Hospital was already discussing how to achieve this within their organisation.

On behalf of the board, the chair then

Resolved:   To receive the presentation.

Reason:      To be informed on the direction and purpose of York's neighbourhoods to inform health and well-being planning for the neighbourhood health reform.