Achieving integrated care through community and neighbourhood working – A High Impact Change Model

This resource focuses on how health and care partners can work differently with communities to build individual and community resilience and improve health and wellbeing.


We want to encourage health and care partners to think about how they can take their next step and make community and neighbourhood working even more effective.

It highlights evidence and good practice by local and national stakeholders and includes ‘I’ and ‘We’ statements from Think Local Act Personal’s Making it Real to help frame the changes in a person-centred way.

We have long advocated the benefit of taking decisions as close to the communities they impact as possible and of the value of involving communities in decisions that affect them:


Who is this guide for?

This guide will be of interest to:

  • NHS and council colleagues, particularly commissioners, providers and those working to implement integrated and personalised care

  • Colleagues working with communities or at neighbourhood level to help improve health and wellbeing  


What makes the difference?

These six high impact actions provide a helpful list of things to consider when working with communities and wider partners to improve health and wellbeing and can form the foundation for discussions with partners.

The high impact action list is not exhaustive and recognises that community and neighbourhood working will look different in different areas based on the assets that exist locally, the partners who are working together and their priorities.

The changes are also interdependent and inter-related, with crossover between the services and approaches highlighted in each one.

Change 1: Coproduce with communities set priorities, make decisions and design and deliver services in partnership with local people, understand what they want and need and then build it with them

Change 2: Invest in communities – the assets and services in communities are not a “free” resource to support health and social care. To realise the benefits, systems need to recognise the value of community and invest time, energy and resources to help develop and sustain community capacity

Change 3: Use asset and strengths-based working – look at what people and communities can do for themselves and the assets that already exist and build from this

Change 4: Housing and the Voluntary, Community and Social Enterprise (VCSE) sector as trusted partners – including both as equal partners in strategy and delivery, with the funding and autonomy to work closely with communities

Change 5: Maximising independence and recovery – ensuring that the services and support increases people’s independence, enables people to help themselves and prevent and or reduce ill health

Change 6: Social connection and peer support – making it easier for people to form relationships, to share their learning and expertise, and to support each other. Helping to both improve people’s wellbeing and build community capacity


Each high impact action includes:

I and We statements

Taken from Think Local Act Personal’s Making it Real to show what the change means in practice for individuals and practitioners.

Tips for success

Advice and insights to implement the change.

Supporting materials

Useful documents, reports or resources relevant to the action.

Case studies

Relevant practical examples.


To request a PDF copy of this resource, please email chip@local.gov.uk.