The government has this week issued more guidance on what changes it expects on the ground in the short to medium term from its neighbourhood health reforms – as set out in its 10 year plan, which aims to shift care away from hospitals and into the community.
It includes how new Integrated Care Teams (ICTs) should work across local health and care systems and the actions it wants to see for ‘high-priority cohorts” including people with dementia and COPD.
In a foreword to the new guidance, care minister Stephen Kinnock said the framework was part of the government’s aim to remove “rules, regulations and roadblocks” in the way of “staff working tirelessly to change the way the health and care system works to make it better for communities.”
He added the guidance “is designed to support ICBs and local authorities, including health and wellbeing boards (HWBs) and their local voluntary, community and social enterprise organisations (VCSEs) and wider system partners to deliver …the truly modern service that people, communities and staff are crying out for”.
Here’s everything care leaders need to know:
How will care home providers’ role change in local health and care systems?
The government’s new neighbourhood health framework signals a move away from care homes as isolated settings towards facilities being integrated into the local community as core ‘neighbourhood assets’.
As part of this Integrated Care Boards (ICBs) and local authorities are expected to jointly plan ‘neighbourhood health models’ to bring an end to siloed commissioning between health and social care. This approach will see care home funding and health support (like GP ‘in-reach’ into homes) to be planned as a single, integrated pathway coordinated around shared care plans.
The new approach is underpinned by a ‘home first’ mandate, and a reduction in long-term care home placements will be seen as central measure of success.
Commissioners are expected to invest in ‘step-up’ and ‘step-down’ intermediate care to keep older people in their own homes for longer, and the government wants to see care home places increasingly commissioned for short-term rehabilitation over permanent residency.
How will the new approach affect health support for care home residents?
The Department of Health and Social Care said the framework is aligned with the 2025/26 Better Care Fund (BCF), which encourages commissioners to use pooled budgets to fund multidisciplinary teams (MDTs) that provide specialist support (mental health, frailty, and palliative care) directly into care homes.
MDTs typically include community nurses, pharmacists, physiotherapists, and social workers who ‘reach into’ care home to provide proactive care, aiming to prevent hospital admissions.
Longer term the government wants to see local commissioners plan care home capacity so it’s aligned with the needs of ‘priority cohorts’ - specifically those with high frailty and conditions such as dementia and COPD or at the end of life.
How will services change for people within priority cohorts (dementia and COPD)?
The government has identified people with dementia and COPD as high‑priority cohorts.
and it wants new Integrated Neighbourhood Teams (INTs) – made up of GPs, community nurses, mental health specialists, social care workers, and voluntary sector partners - to plan care for these key groups as part of a single, joined-up service for a local population (typically 30,000 to 50,000 people).
The Department said INTs will plan assessment, care planning, coordination and follow‑on support and set-up a range of MDTs focused on delivery for priority cohorts. For dementia these will include ensuring rregular multidisciplinary meetings including specialists such as Admiral Nurses, memory team clinicians, and Alzheimer’s Society link workers working directly with GP care coordinators to provide joined-up health and care interventions around a patient or resident’s needs.
MDTs will be expected to agree a single action plan for each patient/resident, stored on a shared care record, so the INT nurse, the GP, and care home staff all work from the same script without needing to duplicate paperwork.
Are there any targets set to measure success of the new framework?
The government has set a goal of reducing A&E admissions for people in priority cohorts, including those with dementia and COPD 10 per cent within the next two years (by March 2029). They have said this will be achieved by enhanced "in-reach" support to help residents stay in their familiar environment during periods of agitation or illness.
The Department’s framework also sets commits to 95 per cent of people with complex needs (including dementia) must have a documented, shared care plan by next year (2027), accessible to all team members including out-of-hours services.
Will funding change to reflect the reform goals?
The focus is on redirecting NHS resources and the government said the changes will ‘not alter the accountability or funding responsibilities of local authorities’, even where a local health and wellbeing board (HWB) agrees to amend public health, adult and children’s social care or other local government services to reflect agreed local priorities for neighbourhood health.
However devolved care budgets aimed at tackling high priority cohorts could start to make a difference to how services are delivered within and around care homes in the medium term.
How will care staff roles be affected?
The government said the immediate goal is for existing roles to work in different ways to deliver 'proactive, preventative and personalised care' that stops health needs from escalating, requiring staff to work 'seamlessly across boundaries' to make care 'easier for staff to deliver.'
In future the forthcoming '10 Year Workforce Plan' (expected imminently this spring) will trigger a 'fundamental reimagining' of roles, skills, and ways of working’, the Department said. This long-term shift aims to ensure 'careers will develop fluidly' across the system, supported by 'shared planning assumptions' that help leaders manage the transition of the workforce into community-based 'neighbourhood health' settings.
What will happen next?
The government said it wants to see plans agreed to underpin its reforms within the current financial year, including how INTs will be established to focus on high priority cohorts, and how devolving care budgets could work in their area.
The wider reforms towards establishing neighbourhoood health and care will need to be worked out and planned to begin from ‘at least the 2027 to 2028 financial years’, the Department said, emphasising success will ‘hinge on’ collaboration between ICB and local authorities on joint plans.
