Haresign Consulting Services

Build an Integrated Neighbourhood Team footprint. NHS England's neighbourhood-health model organises care around populations of ~30,000–50,000 — add one or more PCNs (and individual practices) to reach that scale, then size the combined population, map it, segment the Core20PLUS5 priority cohorts and find the neighbourhoods to focus on first.

Population-weighted from where each practice's patients actually live (NHS patients-by-LSOA). Contains public sector information licensed under the Open Government Licence v3.0: MHCLG Indices of Deprivation 2019; ONS Census 2021; NHS QOF prevalence. Looking for a single practice/PCN profile instead? See Population & Inequalities.

Build your neighbourhood

Combine several PCNs (or add individual practices) into one footprint — e.g. group two or three PCNs to reach ~30,000–50,000 patients. Overlapping practices are de-duplicated automatically on review.

Add a PCN or practice above and hit Review footprint to assess your neighbourhood.

Integrated Neighbourhood Team — needs assessment

Aligned to the NHS Neighbourhood Health Framework: understand the population, then plan proactive care, joined-up access, lower acute pressure and the capacity to deliver it.

Neighbourhood overview — the three shiftsHow the footprint scores against the shifts the 10 Year Health Plan asks of neighbourhoods: hospital→community, analogue→digital, sickness→prevention.

Three-shifts profile · footprint vs England

England = 100 on every axis (dashed line); higher is better. Community = avoiding emergency admissions · Digital = online/app uptake · Prevention = screening & vaccination · Continuity = seeing a preferred clinician · Capacity = clinical workforce per head.

Population & needWho the neighbourhood serves — the foundation every other aim builds on.

Footprint map

Every neighbourhood (LSOA) covered by the footprint's practices, shaded by IMD decile (darker = more deprived). Boundaries: ONS LSOA 2021 (generalised).

Priority cohorts (Core20PLUS5)

Estimated people in each INT priority group, applying neighbourhood census rates to the registered list.

Frailty & high-risk cohorts

The older, higher-risk groups the neighbourhood model targets to reduce avoidable admissions (a stated national objective). Registered-list counts (PDS) plus a modelled frailty estimate.

Population mix

Patients by age band and by national IMD decile.

Where to focus — highest-need neighbourhoods

The footprint's LSOAs ranked by a combined need score (deprivation + ill-health + ageing). Each row shows why it ranks high and which member practices serve it (with patient counts) — so you know who to convene first. Start here.

Aim 1

Proactive care & preventionKeep people well at home — anticipate and manage risk before it escalates.

Long-term-condition burden

The proactive-care caseload to plan around, from QOF disease registers and a deprivation- & age-aware multimorbidity model.

Largest disease registers — estimated people on the register

Prevention — vaccination & screening · vs England

The 'sickness → prevention' shift. Footprint-exact, patient-weighted across the member practices (Fingertips National GP Profiles). Higher is better.

Aim 2

Access & continuityCare organised around the person — joined-up, continuous and easy to reach.

Neighbourhood access & continuity scorecard

Patient-weighted across the footprint vs England. Sources: GP Patient Survey, GPAD appointments, NHS App / online consultations / telephony.

Continuity, access & experience — footprint vs England

Activity

Digital channels

Aim 3

Acute pressureReduce avoidable admissions and crisis end-of-life care.

Avoidable admissions & end-of-life

Ambulatory-care-sensitive (avoidable) emergency admissions and end-of-life crisis admissions vs England. Lower is better.

Aim 4

Capacity & integrationThe workforce to deliver neighbourhood care — and cut duplication.

Workforce capacity

FTE per 1,000 registered patients across the footprint vs England (NWRS). Higher = more capacity per head.

FTE per 1,000 patients — footprint vs England

Neighbourhood team — skill mix

The multidisciplinary team delivering care across the footprint (NWRS). Note: PCN-employed ARRS roles (pharmacists, paramedics, social prescribers…) are reported in a separate PCN return and may not all appear in practice-level figures.

Wider direct-care team (FTE)

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