The NHS Neighbourhood framework provides some clear direction on targeting population cohorts. Knowing where to start can be the first hurdle.

At Scale have been working with Children and Young People health and wellbeing  projects for many years so we were really exited when one of our PCN clients wanted to develop a Neighbourhood CYP Model to respond to a small cohort of children and young people who were repeatedly attending A&E with a focus on asthma. The PCN wanted to create a blueprint not just within the CYP cohorts but could be replicated across other targeted cohorts based on the MDT approach with shared learning and lessons learnt.

The PCN was particularly looking Before the pilot, support for these children could feel fragmented. Families were being advised by multiple services (GP, emergency department, paediatrics/respiratory, and school nursing) without a single joined-up plan, and information wasn’t consistently shared between settings. This resulted in families repeating their story, uncertainty about who to contact when symptoms deteriorated, inconsistent follow-up, and avoidable escalation to A&E. The shared aim was to coordinate care around the child, improve day-to-day management and reduce avoidable emergency attendances.

What was done

• Working with the PCN, we supported mobilisation of an ICB-initiated pilot by embedding two CYP Care Coordinators into the neighbourhood model. Although employed by the NHS Trust, their day-to-day delivery was aligned to PCN priorities, enabling practical cross-organisational working.
• The PCN utilised search tools, data and clinical intelligence to identify children under 18 with frequent A&E attendance (starting with asthma) and to prioritise those where coordinated follow-up could make the biggest difference.
• The PCN led the development of regular multidisciplinary team (MDT) discussions with GPs, hospital clinical nurse specialists and operational colleagues to agree one plan, allocate actions and remove barriers for each child.
• The PCN and partners were able to strengthen links with school nursing and other local services so that plans were shared, understood and followed through across settings, not held in one part of the system.
• The MDT team captured learning and codified the approach as a repeatable neighbourhood blueprint that can be applied to other cohorts/conditions (for example constipation), using the same MDT and care coordination model.

Outcomes

• The PCN-led MDT improved the quality and consistency of care planning for children discussed, with clearer responsibilities and fewer gaps between services.
• By intervening earlier and strengthening follow-up, the pilot supported a reduction in avoidable A&E attendances for children in scope.
• Issues were resolved faster when children were ‘stuck’ between services, reducing delays, duplication and avoidable hand-offs.
• Working relationships strengthened between primary care, hospital specialists and school nursing, improving confidence and continuity for families.
• Families reported a clearer ‘route through the system’—knowing who to contact, what the plan was, and feeling less burdened by repeating information across services.

Benefits

• For children and families: a clearer route to support, fewer crises and emergency visits, and a more joined-up experience across GP, hospital and school settings.
• For clinicians and teams: a reliable MDT forum for shared decisions, improved communication, and less time spent chasing information across organisations.
• For the wider system: reduced unscheduled care demand, better utilisation of specialist input, and a scalable neighbourhood model for other priorities.

Why this meets NHS Neighbourhood Framework content and outcomes

• Place-based, neighbourhood delivery: Focus on a defined local cohort (CYP frequent attenders) and coordinate support with acute and community partners.
• Integrated neighbourhood team working: Enabled MDT working that brought together primary care, specialist nursing and school nursing around shared outcomes for each child.
• Proactive, preventative care: the approach shifts from reactive emergency use to earlier identification, planned support and escalation prevention.
• Reducing inequalities and unwarranted variation: targeting those with highest emergency use supports more consistent pathways and standards of care.
• Better outcomes and experience: improved continuity and coordination helps reduce avoidable A&E activity and strengthens family support and navigation.

For a chat about how we can support your Neighbourhood Delivery or just an informal chat please drop me a line rachel.edwards@atscale.co.uk and visit our website for more information www.atscale.co.uk