Special edition of the Partnership update

Neighbourhood Health in West Yorkshire: building on what we know works

By Kim Shutler and Mel Brown, Senior Responsible Officer, West Yorkshire Neighbourhood Health

Hello

We are Kim and Mel

Across West Yorkshire, partners are coming together around a shared ambition: to shape health and care around neighbourhoods, putting people and communities at the centre of how things work.

This isn’t a new idea. For years, many of you have been working in neighbourhood-based ways – building relationships, joining up support and finding practical solutions that make a real difference locally. What feels different now is the opportunity. There is a clear national focus on Neighbourhood Health, backed by policy, strategy and the support needed to make change happen in a meaningful and sustainable way. That creates a real moment for us in West Yorkshire.

Neighbourhood Health is being led by our five places: Bradford District and Craven, Calderdale, Kirklees, Leeds and Wakefield District, because that’s where the strongest connections sit and where impact is felt most directly. Across those places, the NHS, councils, VCSE organisations and partners such as the West Yorkshire Combined Authority are working together, recognising that the challenges we face and the solutions we need, cut across organisational boundaries.

Nationally, there’s a clear direction of travel in the year ahead: improving access, supporting people earlier and more proactively and creating better alternatives to hospital-based care where possible. Neighbourhood teams are part of how we turn that into reality, helping people work as one team around neighbourhoods rather than as separate services.

Importantly, this isn't just about future plans. Across West Yorkshire, neighbourhood approaches are already making a difference.

In Bradford District and Craven, partners have introduced a digital tool to help identify people who may be at greater risk of falling. The approach was first tested in one neighbourhood and has now been expanded more widely, helping teams offer support earlier to those who need it most. By preventing falls and supporting people to stay independent, services can help people remain healthier and more confident in their own homes.

In Wakefield District, six neighbourhood teams are bringing together health, care and community services to support people with more complex needs. Early results are encouraging, with a 24.2% reduction in A&E attendances among people supported through multidisciplinary teams. Across the district, there has also been a 3.1% reduction in emergency hospital admissions for people aged over 65, supported by services including virtual wards, urgent community response teams and acute respiratory infection (ARI) hubs.

Elsewhere, partners are seeing the benefits of neighbourhood working in different ways. In Calderdale, five neighbourhood teams are using population health data to identify local priorities and support people living with frailty or approaching the end of life, helping them access more coordinated care closer to home.

In Kirklees, six neighbourhood teams are focusing on frailty and mental health, using shared data to identify people most at risk of needing urgent care. This approach has contributed to a 7.8% reduction in non-elective admissions compared with the previous year. Kirklees is also working closely with local communities, including through innovative outreach with the University of Huddersfield, using pop-up tents, mini-buses and other local settings to hear directly from residents about what matters to them.

Meanwhile, Leeds is building on a long history of neighbourhood working across its 15 neighbourhoods, with a strong focus on prevention, early intervention and proactive support for around 46,000 people with complex needs. Across places, Home First approaches are helping more people recover in their own homes, reducing unnecessary hospital stays and supporting greater independence.

We also know this work is happening at a time of real pressure. Many organisations and teams are dealing with change, uncertainty and competing demands. That context matters. Neighbourhood Health isn’t about adding more on; it’s about working differently, in ways that are more sustainable for staff, make better use of collective strengths - and ultimately lead to better experiences and outcomes for people.

The opportunity now is to build on what already works and take it further, moving from great local practice in pockets to a more consistent, shared approach across West Yorkshire. Done well, this will support staff to focus on what matters, help organisations collaborate with greater trust and clarity and make care feel more joined up, human and responsive for the people we serve.

This isn’t something being designed behind closed doors or delivered by one part of the system alone. Neighbourhood Health will only succeed if it’s shaped by those delivering it and by communities themselves. Whether you work in health or care, the VCSE sector, local government, or alongside communities in other ways, you have a role to play.

We see this as a genuine invitation: to get involved, share learning, test new ways of working and help shape what Neighbourhood Health becomes in West Yorkshire. The early results we are seeing across our places show what is possible when organisations work together around the needs of local people. This is an important moment and, together, we can build on what we know works to create lasting improvements for communities across West Yorkshire.

Thanks for reading

Kim and Mel

More about Neighbourhood Health teams

Neighbourhood Health teams are central to West Yorkshire’s ambition to deliver more care closer to home, support people earlier and reduce inequalities.

In July 2025, NHS England published Fit for the Future - the 10 year health plan for England. The plan describes three key shifts for health and care:

• hospital to community
• treatment to prevention
• analogue to digital.

Neighbourhood Health teams are a key part of delivering those shifts.

In West Yorkshire, this work also builds on the 2022 Fuller Stocktake report and the West Yorkshire Health and Care Partnership Blueprint for Integrated Neighbourhoods: Creating Healthier Communities. The blueprint sets out how teams of health workers will provide care closer to people’s homes, helping to meet physical, mental and social health needs and reduce inequalities in access and outcomes. These teams are known as Neighbourhood Health teams.

Neighbourhood Health teams will use population health data to identify people who may need support earlier and connect them with the right services. They will work closely with residents and communities, reduce unnecessary referrals and hand-offs, and bring together health, care, VCSE, housing and other local services around people’s needs. The ambition is for people to receive holistic, person-centred support closer to home, with the same standards of care wherever they live in West Yorkshire.

Teams are being developed across Bradford District and Craven, Calderdale, Kirklees, Leeds and Wakefield District, with plans tailored to each place. Delivery is focusing on priority groups including people living with frailty, dementia and those needing end-of-life care. This approach means neighbourhood teams can respond to local need while working within a shared West Yorkshire framework.

The programme will be supported by workforce transformation, organisational development, digital improvements, better use of buildings and facilities, and resource and financial planning. A programme of work supported by funding of approximately £4 million to £4.5 million is helping accelerate progress. This includes funding for technology-enabled service transformation, digital infrastructure, data utilisation, transitional capacity and capability, putting people’s voices at the centre of integrated Neighbourhood Health, and supporting modern general practice.

Success is being measured by reducing preventable unplanned care, increasing early intervention, improving patient and staff experience and addressing health inequalities.

Putting people at the heart of Neighbourhood Health

Over the past six months, we have been working with people with lived experience, VCSE organisations, Healthwatch, providers, commissioners and Neighbourhood Health teams to create a new co-produced framework for involvement across West Yorkshire.

The framework helps Neighbourhood Health teams involve people and communities in meaningful ways, so their experiences and ideas shape decisions, set priorities and improve services. Practical guidance and simple evaluation tools will help teams learn, improve and share good practice. By bringing community insight together with data, Neighbourhood Health teams can better tackle inequalities and design services with local people while supporting national Neighbourhood Health priorities. Learn more about how teams will use the framework across West Yorkshire on our involvement pages.