Teaming up for improved population health: A model for whole system integration

The increasing complexity of both population health burden and the health and care system has led to fragmentation of pathways, budgets and services. In turn, this has led to the recognition that better system integration, partnership working and understanding of communities is required to meaningfully tackle health inequalities and future-proof the health system. The NHS 10-year plan released in July 2025 recognises this, and sets out a bold ambition for a system which feels like a 'single, coordinated, patient-orientated health service'- a Neighbourhood Health Service. In Derby and Derbyshire, there is already a strong foundation of success in neighbourhood working which uses distributed leadership and a peer-support and learning model to create person centred initiatives for its communities. One of the key transformation programmes, Team Up, has put wraparound care for those experiencing frailty or who are housebound. It has already reduced hospital stays and ambulance call outs for some of the most vulnerable members of society. Together, the system uses a strategic approach to population health, and transformation models to create a targeted, proactive, person-centred healthcare system for our communities, which delivers care in the ways and places which matter to them.