A collaborative blueprint: how patient power builds neighbourhood health - By Dr Jeremy Carter

A collaborative blueprint: how patient power builds neighbourhood health

By Dr Jeremy Carter

31st July 2025

When we talk about collaboration and neighbourhood working the conversation is usually framed around providers. But, what if our greatest and most under-utilised asset is our own patients?

We are familiar with harnessing the knowledge and experience of our patients through our practice and PCN patient participation groups. However, taking this further, we can unlock a new model of care—one that builds community and promotes prevention.

By looking to the lived experience, and generosity of our patients, we can co-deliver services that truly meet the needs of our population, while also reducing the ever-increasing demand on our staff.

Providing community based, often preventative services, also fits well with central themes of the NHS 10 Year Plan.

Our experience was that as we began this process, it drew in a multitude of other community partners, from voluntary organisations, local businesses, and the police, to create a true community-led movement.

The model: collaborative practice in action

As a PCN we partnered with Altogether Better to develop a ‘Collaborative Practice’ approach to selected cohorts of our population. We are not pioneers; Altogether Better have been delivering collaborative practice with many practices for a considerable time. The concept in principle is simple - that some patients can be managed, at least in part, with a social model of care rather than a purely medical model. Issues arising from many long term conditions, ageing, social isolation and mental health conditions all lend themselves to support in this way. The support itself is provided by volunteer ‘Health Champions’—our own patients and members of the local community.

We approached this as a PCN rather than individual practices, and now provide a range of services, using a population health management and data and needs-driven approach, including provision of blood pressure monitors to those unable to get to the surgery, a cancer support group, bereavement group as well as walking groups to promote social engagement and physical activity.

From concept to reality

We presented the concept to the PCN at a joint education session to ensure a PCN-wide understanding and buy-in to the project. Altogether Better then facilitated the process of building our cohort of health champions, from sending initial expressions of interest to supporting them through workshops. The PCN managed various administrative issues, such as arranging DBS checks for all champions, ID badges, performing risk assessments, and ensuring insurance coverage.

To decide on the initial projects, the PCN, with engagement from member practices, looked at population data focussing on attendance data and condition prevalence, and we initially selected two areas of focus. Given the strong drive to improve cardiovascular health, and our population demographic, we identified a need for delivering home blood pressure monitoring capability to patients unable to easily attend the surgery. Also, a walking group was established to tackle loneliness, social isolation and improving mental wellbeing - the root cause of some of our more frequent attenders. The wider preventative benefits of physical activity are an additional benefit of this service.

Despite the significant work involved in setting up these groups, it took us about four months - from initial meetings in August 2024 to delivery of the first walking group in December 2024.

Compared to the often slow-motion cogs of change, this programme can be delivered quickly on the ground. Since then, we have expanded to a group of over 20 health champions, and have rapidly expanded the offering beyond the original plan, as a result of patient interest and feedback. We now have two different walking groups and have added weekly bereavement support groups and cancer support groups.

A true community movement

The shift to a true community spirited collaborative venture has gone beyond our PCN and health champions, deep into the local community. Local businesses like The Hungry Plum café and The Pier Ceylon opened their doors to host our groups. After our walks, the Salvation Army is always ready with a cup of tea, and the model has even drawn in our local community policing team, who regularly join in to connect with residents in a positive, healthy setting.

Using the generosity, time and lived experiences of our patients, in conjunction with the local community resources has allowed delivery of support that previously was not available. It also demonstrates collaborative, neighbourhood working in practice, in the truest sense.

Expanding the offerings

Running alongside our wide-ranging collaborative practice work with Altogether Better, this year our PCN has also partnered with the charity Head in the Game. While similar in concept, also assisted by patient volunteers, this programme focuses more specifically on mental health, with the aim being to improve mental fitness and wellbeing through free, inclusive activity – again reducing social isolation and building social connections through physical activities. There is a diverse range of groups including football, tennis, Boccia, and, table tennis as well as a men’s walking group. Primarily this gives patients a safe, welcoming space to stay active, builds resilience and protect their mental wellbeing but it also provides links to improve awareness of the more clinical mental health support services available locally, as well as access to counselling support if needed.

The ongoing management of the collaborative practice service is delivered by our PCN collaborative practice team, with representatives from all member practices to ensure ongoing PCN-wide ‘buy-in’ and to drive momentum. Our social prescribing team, delivered by Red Zebra is also closely involved in developing and promoting our collaborative practice services. In addition we have a PCN administrator with ownership of the project to drive the day to day developments, which has been invaluable.

The foundations for the future

I believe the agenda on the table when discussing neighbourhood collaborative working is often large clinical providers, using medical models, trying to reduce acute attendance, across large population footprints.

Local communities and neighbourhoods are already demonstrating a new way of working, with true cross organisational collaboration, delivered in the local community. This preventative, relationship-centred work at PCN level population is not a 'nice-to-have' side project. It is the vital, load-bearing foundation for any Neighbourhood Health Service that genuinely hopes to succeed.