The North West Plymouth Integrated Neighbourhood Collective brings together local health, care, voluntary sector organisations and the community to develop a neighbourhood-based, person-centred model of integrated support.
The initial focus is on the neighbourhood of Whitleigh, an area with a strong sense of local identity and well-used local community assets, including an active Wellbeing and Family Hub. It is also an area where residents experience high socio-economic disadvantage, high rates of hypertension, health inequalities and depression and a high number of missed outpatient appointments. Primary Care and community services see many people whose wider social needs heavily affect their health.
The Collective seeks to better understand people’s experiences and help partners work together differently – moving away from organisational silos, wrapping support around individuals, and improving outcomes.
The work also aligns with city and national ambitions to:
- Shift from hospital to community
- Shift from treatment to prevention
- Strengthen neighbourhood working and multidisciplinary team (MDT) integration
Our Aims
- Develop integrated, relationship‑based ways of working at neighbourhood level. Understand the wider determinants shaping high health service use.
- Improve access, experience and outcomes for residents with complex or persistent needs.
- Wrap support around the person, not around organisational processes. Support prevention and early intervention to reduce avoidable healthcare demand.
- Learn from activities and grow the approach with system wide partners
Changes we want
For Residents
- Improved experience of accessing and navigating support.
- More joined‑up and consistent offers across health, care and community services.
- Improved wellbeing, safety, connection and sense of belonging.
For Staff
- A supported culture that enables people to “do good work in the simplest way”.
- Greater ability to act on what they see, not just organisational processes.
- Improved morale through developing trusted relationships, collaboration and place‑based working.
For the Local System
- Reduction in inappropriate or avoidable use of Primary Care and emergency services.
- Better identification of people who could benefit from early intervention.
- Stronger relationships, clarity of roles and reduced duplication between organisations.
- A shared neighbourhood model that can inform citywide Integrated Neighbourhood Teams.
What we’ll do
- Identify a cohort of residents with long term health conditions, using GP, Livewell, PCH and community data.
- Peer researchers, Community Builders and staff gathering insight from residents to understand experiences of healthcare and advice/support mechanisms.
- Co‑locate multidisciplinary teams in local venues: Four Greens Wellbeing Hub and Budshead Surgery.
- Facilitate person‑centred, asset‑based support grounded in what matters to individuals.
- Test and adapt local system pathways based on what’s learned.
- Understand from residents and staff what difference this makes to their wellbeing and working practice.
- Share our learning with other system partners.