At the November 2024 COIN meeting, participants concluded a three-meeting discussion about how COIN thinking could inform the development of Neighbourhoods for the NHS. This is the resulting letter that has been submitted to the UK NHS Consultation process. It can also be viewed at www.youtube.com/watch?v=RdDVz5j9QlU.

The government’s plan to develop out-of-hospital care through Neighbourhoods presents an opportunity for high-quality, low-cost care - through collaboration, as equal partners, between health workers, care workers and everyday citizens. Achieving this at scale requires the application of the science of community development - developing trusted relationships across boundaries, and coordinated actions that build community cohesion. Community-Oriented Integration Network (COIN) is a network of people with extensive experience of doing this. We welcome discussions about policy that will help Neighbourhoods to do this.

The difficulty of achieving integration is well known.  At the 1978 Alma Ata conference, 134 countries agreed that medical practice needs to be integrated with other efforts for health - to achieve ‘Strong Primary Health Care’. Poor understanding of how to do this has prevented such integration. To avoid NHS collapse, the experience of those who understand integration, including COIN, must inform the next NHS 10-year plan. 

In the 1980s, COIN members led the Association of General Practice in Urban Deprived Areas (AGUDA), facilitating inter-city learning about integrated working. In the 1990s, through Fundholding, Primary Care Facilitation Programmes and Research Networks we explored different ways to sustain integration. Between 2008 & 2018, through the London Journal of Primary Care, we distilled the concept of Community-Oriented Integrated Care  (www.tandfonline.com/toc/tlpc20/current), revising this in 2022 to Community-Oriented Integrated Practice (www.healthmatters.org.uk/Library/coip_0322.pdf) - to denote that individual caring actions are not enough and the science of COIP needs to be understood and applied throughout whole systems (https://bjgp.org/content/74/746/416). 

COIP recognises that everything is constantly adapting to changes in everything else. This means that medical insights need to be seen as snapshots of complex stories-in-evolution, and protocols as ‘food for thought’ - not absolute truths to be transactionally applied. 

Previous inattention to processes of co-adaptation has obstructed collaboration, including: 

• Reduced capacity of local government to develop compassionate communities.

• Social services’ preoccupation with safeguarding, without the skills to help people to build supportive relationships around their situations.

• Specialists who ignore things that fall outwith their specialist training processes.

• GPs who lack skills and incentives to consider social and contextual factors beyond or behind the complaints or symptoms with which individuals present.

• Researchers who fail to recognise that knowledge is context-dependent.

• Training and teaching at all levels of education that is focussed on ‘straight lines’ at the expense of understanding complexity.

• Carers who lack support from, and integration with, statutory services.

Neighbourhoods could play a key part in changing this, by promoting shared developmental spaces (e.g. schools & faith groups, music & exercise clubs, sports events & festivals) where people learn to appreciate others and collaborate for the greater good. The homes where Carers live are particularly valuable developmental spaces because they are shared by Patients & Carers, Health & Social Care Practitioners, families, friends and many others who are often more prepared than usual to collaborate for health and care across boundaries. 

Evaluating Neighbourhoods

For “I’s” to become “We’s” - individuals to become communities - people need to creatively adapt to each other, through shared adventures, shared vision, shared stories. This co-evolution is invisible to evaluation that assumes that the world works only in transactional, compartmentalised ways. 4th generation evaluation gets past this limitation through repeated stakeholder reflection on different kinds of data in the light of their lived experiences. For example, data of hospital admissions and place of death, amalgamated by Neighbourhood areas, could help local people to discuss the value of different strategies for Carer support. 

Ongoing, facilitated debate between case studies, e.g. Neighbourhoods or cities, informed by different kinds of data, could be a winning strategy. It is relatively easy to organise. It witnesses, in real-time, tangible outcomes from collective efforts. It emboldens people to lead multiple micro-changes to improve quality and cost-effectiveness. It develops facilitation skills in local populations that build trusted relationships and compassionate communities. 

Neighbourhoods could also help to re-enthuse general practice, by providing opportunities to treat discrete diseases in the contexts of family, community and environmental health. 

Initiatives to Develop Community-Oriented Integrated Practice in Neighbourhoods

In 2024, COIN brought together five initiatives that are developing Community-Oriented Integrated Practice in different parts of the system. See www.youtube.com/@coin1562: 

1. Healthcare Curricula. Anglia Ruskin University aims to become part of the local fabric of society by recruiting local people, working with schools/colleges and preparing medical, nursing and other students to provide whole person, team-based care, with appropriate communication, reflection, evaluation and relationships. 

2. City Health Conference. London RCGP Faculties will hold a City Health Conference in June 2025, at which primary care practitioners will explore the theory and practice of Community-Oriented Integrated Practice. 

3. Primary Care Networks (PCNs). The Complete Care Community Programme is supporting 65 PCNs to pilot next-stage thinking in locality-based practice.

4. Carers Course.  Brent Carers and Central London Community Health are piloting a course to help Carers develop compassionate communities around their homes.

5. City-Wide Collaborations. (Liverpool City Region) Capacity Development International & Liverpool School of Tropical Medicine are developing shared leadership for health and care that involves the active participation of Local Communities, Creatives, City Council, Public Health, Primary Care Networks and others, to facilitate whole-city collaboration for health and care.

Leaders of these exemplars recognise that the dis-connect between social services and the NHS is a major obstacle to quality and cost-containment. Re-connecting them is a priority.

Inter-disciplinary collaboration at more central places, including government, is also needed.

This image shows how Neighbourhoods can become compassionate communities. It reminds us that, to value other perspectives and develop community spirit, people need to creatively interact with others, helped by ‘umbrellas’ that shield them from the ‘rain’ of everyday demands. Good facilitation helps participants to look ‘outwards’ for the common good, rather than the common tendency to look ‘inwards’ and reinforce existing prejudices. Policy can develop facilitation skills and pathways between ‘umbrellas’ that help different groups to shape collaborative projects, co-adapt, and become compassionate communities.

       Community-Oriented Integration Network  

COIN Planning Team: 

Paul Thomas: FRCGP. MD. Carer. Author: Integrating Primary Health Care (2006). Collaborating for Health (2018). Pthomas300006@gmail.com 

Laura Calamos: PhD, APRN, FHEA. Prof of Family Nursing. lcphdfnp@gmail.com 

Lucja Kwapisiewicz: COIN Coordinator. Head of Committee Services at British Society of Gastroenterology. lucja.kwapisiewicz@gmail.com   

Chris Brophy: Solicitor. Director of Resolving Together Ltd. chris@resolvingtogether.com.  

Linda Lang: PhD. Educationalist. prof.lindalang@gmail.com. 

Kathrine (Kat) Nielsen. MD/PhD student. ksnielsen@health.sdu.dk. 

Tony Burch. Age UK. tonyburch@gmail.com. 

COIN Blogs: https://www.healthmatters.org.uk/coin.php