Key points
- Integrated neighbourhood teams are a centrepiece of the Government’s 10 Year Health Plan for England
- It is vital that neighbourhood teams include mental health support for people of all ages, from childhood to later life
- Integrated neighbourhood teams could enable people with long-term health conditions to get ready access to mental health support close to home
- Community mental health services work at neighbourhood level in many parts of England. Some neighbourhoods also have specialist mental health workers in primary care. Building on these will be crucial for success
- Developing equitable and holistic neighbourhood care will address deeply entrenched health inequalities and prevent escalation of mental health difficulties
- Neighbourhood teams will benefit from connecting with local authority public health and social services, and from coproducing services with voluntary, community and user-led organisations.
Introduction
The NHS Ten Year Plan is centred on the concept of a Neighbourhood Health Service. It states that health services will increasingly be organised around clusters of general practices, serving populations of around 50,000 each. This is being done to achieve the Government’s ambition to shift the balance of the NHS from treatment to prevention, from hospitals to communities, and from analogue to digital.
The Plan envisages that every local area will have integrated neighbourhood teams, working from ‘neighbourhood health centres’ that will provide people with the full range of health services they need close to home. In this model, hospitals will only be required for the most specialised procedures.
This vision can only be achieved successfully if mental health support is at the heart of the Neighbourhood Health model. It must be fully embedded and enmeshed with physical health care, with mental health expertise available to every part of an integrated neighbourhood team.
Note: The term ‘neighbourhood’ is used by the NHS in England to describe ‘natural communities’ made up of one or more general practices and the areas they serve. Each neighbourhood has a population of around 50,000, but they vary widely. They are smaller geographical areas than ‘place’, which corresponds usually to an area covered by a county or unitary council, and ‘system’, which means the larger still area covered by an integrated care board.
What’s already in place? Neighbourhood mental health services today
Integrated neighbourhood teams have the opportunity to connect with mental health services that already work at this level.
Community mental health services for adults have been reoriented over the last five years to serve neighbourhoods through the Community Mental Health Framework (NHS England, 2019). The ambition of the Community Mental Health Framework is to knit together primary and community mental health services, providing a ‘whole person, whole population’ service that meets people’s needs holistically and inclusively. Where this is working well, it means people using mental health services are supported close to home by multi-disciplinary teams.
Specialist mental health workers are increasingly being employed in Primary Care Networks (PCNs) through the Additional Roles Reimbursement Scheme (ARRS). This is creating additional capacity in primary care to respond to people’s mental health needs without requiring referrals to secondary mental health services.
The NHS in England is also developing a set of neighbourhood mental health centres, providing a community-based alternative to hospital admission for someone in a mental health crisis. The first six are starting work this year. These are laying the foundations for mental health support that’s closer to home, with less reliance on inpatient services.
Connecting mental and physical health care
Almost 40% of people living with a long-term physical condition also have a common mental health problem, such as depression, anxiety or post-traumatic stress disorder (PTSD) (NHS Digital, 2025). Similar proportions have experiences of trauma and suicidal feelings. It is estimated that around 10% of the entire NHS budget is spent on physical health care for people with unmet mental health needs (Naylor et al., 2012).
It’s therefore vital that neighbourhood services supporting people with physical health conditions provide support for their emotional wellbeing and mental health (Centre for Mental Health and National Voices, 2021). This means that team members need to have sufficient knowledge and skill in mental health to provide basic emotional support and work in a trauma-informed way, and that specialist mental health support is available alongside their physical health care.
Five tips for practitioners in neighbourhood teams
- Ask patients how they are at every opportunity. Sometimes people just want to be asked how they’re feeling. Creating a space for them to express how they are feeling can be a vital first step to getting the right support.
- Be aware of what help is available to support the emotional health of people using your service.
- Give information and advice to help people to manage their condition, and be available when people need extra support with their health.
- Reassure people that it’s okay to seek emotional support at any time while living with a long-term condition.
- Show compassion: Small gestures of care can help people who are struggling with their mental or physical health.
- Challenge inequality: Be aware that for people from marginalised and excluded communities there are additional barriers to support and low levels of trust that need to be rebuilt.
(Adapted from Centre for Mental Health and National Voices, 2021)
Neighbourhood health care can also help to close the 20-year mortality gap for people living with a mental illness. This can be achieved by offering annual health checks to everyone registered with their GP as having a severe mental illness, and following it up with relevant services including support with physical activity, help to stop smoking, screening and immunisation services, dentistry, and sexual health. To find out more about this topic, visit www.equallywell.co.uk.
Children and young people
Mental health difficulties are the most common health needs for children and young people, currently affecting around one in five of this age group (NHS Digital, 2023). Neighbourhood health care for children needs to integrate mental and physical health services.
Unlike other age groups, young people do not always feel comfortable seeking mental health support through their GP, meaning that other routes to get help, including online and in schools or youth clubs, are important (Khan, 2016).
The NHS plans to expand school-based Mental Health Support Teams (MHSTs) to all schools and colleges in England by 2029/30, so connecting neighbourhood health teams with schools is essential to bring support together effectively. The expansion of Better Start Family Hubs, and the creation of a national network of Young Futures early support hubs for young people’s mental health, are also important opportunities to provide holistic support outside school settings, in locations where families and young people feel welcome and safe.
Later life
Older people have better mental health than other age groups, but significant numbers of people in later life (around one in ten) have a common mental health problem (NHS Digital, 2025). The chance of having poor mental health is greater for older people who have physical health problems, those living in poverty, those who are caring for a family member, and those living in residential or nursing care (Iskander-Reynolds, 2024).
Health services have tended to underplay and normalise mental distress in later life as an inevitable result of ageing, reduced mobility and greater frailty. This means problems are not recognised and help isn’t offered, despite the high recovery rate achieved for this age group in NHS Talking Therapies.
Integrated neighbourhood teams have a unique opportunity to change the narrative about mental health in later life, and offer older people support to enjoy good wellbeing and get support when they need it. This includes social prescribing to boost social connection and physical activity, and better access to NHS Talking Therapies.
Holistic and equitable care
Deeply entrenched social and economic inequalities contribute significantly to mental and physical ill health. Poverty, misogyny, racism, and multiple other forms of discrimination, marginalisation and disadvantage undermine the building blocks of health and make us ill.
Neighbourhood teams can mitigate or counteract these inequalities. They can do this by:
- Providing help with housing, money, work and benefits: Welfare advice must be embedded within every mental health service, tailored to people’s needs. There is growing evidence that this can enhance people’s incomes, help them manage problem debts, and as a result may reduce the number and duration of hospital admissions
- Adopting the Patient and Carer Race Equality Framework: This is a nationally mandated approach to systemically tackle racism in mental health services
- Adapting services to meet people’s needs: For example, ensuring that mental health support is LGBTQ+ friendly, veteran-aware, and adapted to the needs of autistic people
- Working with trauma-informed principles: This has been demonstrated to benefit everyone, but makes services more effective for those who have experienced traumatic events (Beadon Ekers and Mayers, 2024)
- Connecting with substance use services: Providing integrated care and support to people with co-occurring drug or alcohol problems (Abdinasir, Woodhead and Bell, 2025)
- Reaching out to meet people ‘where they’re at’: Locating mental health services in places that are accessible and not stigmatised – for example in youth clubs, village halls or faith groups – and using digital and online approaches to engagement.
Planning, developing and monitoring neighbourhood health care
Neighbourhood health services cannot work in isolation. They can draw on advice and support from partner organisations in their local areas. And they can engage actively with the communities they serve in the places they live and work. For example, they can connect with:
Local authority public health teams – to access up-to-date and relevant mental health needs assessments, suicide surveillance, and prevention activity
Voluntary, community and social enterprise (VCSE) sector – to connect with communities and offer support through trusted organisations to groups that are poorly served by statutory services
User-led organisations – to work coproductively to design, deliver and monitor mental health support so that it meets people’s needs on their own terms
Social services – to partner with both adult and children’s services to offer people holistic support that enables independent living and equal citizenship
Education – from early years services and schools, to colleges and universities, neighbourhood teams can form strong connections with education providers to reach out and provide early help for mental health.
References
Centre for Mental Health and National Voices (2021) Ask How I Am
Available from: https://www.centreformentalhealth.org.uk/publications/ask-how-i-am/ [Accessed 24 July 2025]
DHSC (2025) 10 Year Health Plan for England
Available from: https://gov.uk/government/publications/10-year-health-plan-for-england-fit-for-the-future [Accessed 24 July 2025]
Iskander-Reynolds, A. (2024) Mental health in later life
Available from: https://www.centreformentalhealth.org.uk/publications/mental-health-in-later-life/ [Accessed 24 July 2025]
Khan, L. (2016) Missed opportunities
Available from: https://www.centreformentalhealth.org.uk/publications/missed-opportunities/ [Accessed 24 July 2025]
NHS Digital (2023) Mental Health of Children and Young People in England, 2023
Available from: https://digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-young-people-in-england/2023-wave-4-follow-up [Accessed 24 July 2025]
NHS Digital (2025) Adult Psychiatric Morbidity Survey, 2023/24
Available from: https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/survey-of-mental-health-and-wellbeing-england-2023-24 [Accessed 24 July 2025]
NHS England (2019) The Community Mental Health Framework for adults and older adults
Available from: https://www.england.nhs.uk/publication/the-community-mental-health-framework-for-adults-and-older-adults/ [Accessed 24 July 2025]
Naylor, C. et al. (2012) Long-term conditions and mental health
Available from: https://www.centreformentalhealth.org.uk/publications/long-term-conditions-and-mental-health-cost-co-morbidities/ [Accessed 24 July 2025]
