Abstract

The Neighbourhood Health Programme, part of the NHS 10 Year Health Plan, aims to deliver care closer to home, reduce hospital pressures, and address health inequalities through the introduction of Neighbourhood Health Services across England. As part of the national rollout, the NWL Federation was selected as the pilot site for LLR/Northants, working with Charnwood and Hinckley & Bosworth Federations to improve outcomes for housebound COPD patients through an integrated neighbourhood care model.
The pilot responds to key challenges in North West Leicestershire, including a growing COPD population, high numbers of housebound patients, fragmented service delivery, and rising emergency admissions—a 50 admission increase in 2024 compared with 2023. Among 145 identified patients, the average number of repeat medications was 11, with an average of 2.5 hospital admissions in the previous year.
The model supports NHS priorities by delivering proactive, integrated MDT care for complex, high risk patients. Fortnightly MDT meetings bring together clinical directors, ACP’s, pharmacists, pharmacy technicians, nurses, social prescribers, care coordinators, social care link workers, and consultant respiratory physicians. Interventions include scheduled home visits, joint MDT reviews, personalised care plans, symptom management, medication optimisation, escalation planning, and patient education. Patients are supported to access pulmonary rehabilitation, smoking cessation, vaccinations, mental health support, transport, and social care.
Early insights demonstrate improved coordination, increased patient engagement, and greater awareness of service gaps across teams. Among the first 98 patients reviewed, the interventions that were implemented included: care coordinator referrals (23), social prescribing referrals (14), COPD reviews (12), complex care plan reviews (12), structured medication reviews (7), community respiratory team referrals (16), pulmonary rehabilitation referrals (3), inhaler optimisation support (8), diagnosis updates (15), referral to hospital team (2), safeguarding referrals (2), and increased care packages (4).
Challenges include lack of dedicated funding, workforce capacity, digital access, and patient identification. Key learning highlights the value of MDT working, proactive care, tailored interventions, and delivering neighbourhood care at scale.
The pilot demonstrates that a neighbourhood care model can enable better outcomes for vulnerable patients and more efficient use of NHS resources, with potential for expansion to wider populations and additional long term conditions.