Building neighbourhood care in East and Central Brighton: Lessons we learned from creating PCN community groups

Adam Fazakerley is a GP and health systems leader in Sussex, he believes in the urgency of creating a more sustainable health system.
Becky Jarvis has been a GP in Brighton for over 30 years and worked in mental health commissioning as a clinical lead for 10 years.

Primary Care Networks (PCNs) were created to enable neighbourhood level relational care. In East and Central Brighton, we succeeded in delivering such care but discovered a fundamental tension along the way.

In our first article,* we described the challenges of neighbourhood working within a Primary Care Network (PCN). We also reflected on our early attempts to commission voluntary and community sector (VCSE) organisations, and how, without the capacity to evaluate outcomes or develop shared outcomes, the benefits were difficult to evidence.

Against this backdrop, a one-off £50,000 wellbeing grant from our Integrated Care Board (ICB) created a rare opportunity. It allowed us to test whether community-based activity, delivered directly by our staff, could improve wellbeing and reduce pressure on general practice. This article describes what we built, what we learned, and why this phase became a turning point in our journey towards neighbourhood working.

Local Context

Much of the demand in East and Central Brighton comes from social rather than medical need: loneliness, poverty, and housing.¹ These issues routinely surface in GP consultations but are difficult to resolve with medication.

Therefore, we tried a different approach, recognising that evidence supports community-based interventions to tackle the social determinants of health.² We felt that accessible community groups could improve wellbeing and reduce avoidable GP attendance. However, like many PCNs, we lacked the capacity and infrastructure to deliver this work, and so the £50,000 grant gave us the ability to experiment in a focused, time-limited way.

Developing Community Groups

With the funding, we created a programme of free, open-access wellbeing groups that were set up in familiar community spaces. They required no referral and were deliberately simple to join.

Our offer included:

• Mindfulness groups, supported by a strong evidence base for improving mental wellbeing.³
• Yoga for chronic pain, effective for long-term musculoskeletal conditions.⁴
• Movement and wellbeing classes.
• Qigong in the park, a low-cost intervention combining exercise, social connection, and exposure to nature, with emerging evidence for pain and wellbeing benefits.⁵
• Art-based creative sessions, designed to support recovery and reduce isolation.⁶

 Staff from across the PCN, including social prescribers, pharmacists, and mental health colleagues, set up and attended the sessions. This allowed patients to receive advice and support in a relational, informal environment, without navigating clinical pathways.

Our aim was simple. We wanted to provide low-threshold, supportive spaces that helped address the non-medical drivers of poor health. We also wanted to bring patients to our staff, rather than rely on them co-ordinating care and arranging appointments.

The Successes

The response was encouraging. Attendance grew steadily, patients described feeling more confident, less anxious, and more connected. Many formed ongoing relationships with each other that reduced social isolation. We received reports of patients, who had been attending their GP almost weekly with anxiety and chronic pain, reported needing fewer appointments, improved self-management, and a greater sense of stability after engaging with the groups. 

Staff also found the work meaningful. The groups allowed them to support patients in a preventative, relational way, aligned with the original intentions of primary care. Team morale improved, and staff valued the creativity and autonomy the model allowed.

For a relatively small investment, the impact was significant.

The challenges

However, despite early success, several limitations quickly became clear:

1. Lack of ongoing funding: The programme depended entirely on the one-off £50,000 grant. Once it ended, most groups could not continue. There was no mechanism to sustain facilitator costs, coordination, venues, or outreach.
2. Limited capacity to manage flow: Groups bonded quickly, which benefited those attending but restricted access for new participants. Without dedicated staff time to support turnover and manage referrals, capacity remained small.
3. Engagement was harder than expected: Even with enthusiastic social prescribers and direct general practice messaging, the membership of the groups remained static which inherently limited the number of patients benefiting.

These challenges echoed the themes that we articulated in our first article. PCNs are funded for staff roles, but not the estates, management support, or coordination needed to make neighbourhood working operational.

On reflection

In hindsight, we did consider simply commissioning VCSE organisations. However, our earlier experience with VCSE commissioning had shown the limits of commissioning these organisations to undertake the work. Although the organisations provided valuable support, we lacked the capacity to evaluate outcomes, measure impact on general practice, or establish shared goals. As a result, their interventions remained separate.

Using the £50,000 solely to outsource new services would not have resolved these issues. It would have been more expensive, harder to integrate with our staff, and unlikely to create the shared accountability needed for neighbourhood working.

However, one group, Qigong in the park, stood out as a notable exception to commissioning VCSE organisations. Participants valued it so highly that they chose to continue funding it themselves when PCN funding ended. More than three years later, it remains active. Evaluation data from this group showed a reduction in GP appointments, a reduction in medication use and an increase in regular exercise, demonstrating the potential of community-based interventions when they are trusted, consistent, and locally embedded. Our experience also highlights how rare it is for such work to sustain itself without stable infrastructure.

Lessons Learned

This phase of our journey taught us several lessons:

• Community-based, relational care is effective. It improves wellbeing, confidence, and social connection, and can reduce GP demand.
• Sustainability requires infrastructure. Short-term funding cannot maintain venues, staff, coordination, or outreach.
• Commissioning alone is insufficient. Without shared outcomes, evaluation capacity, and integration, VCSE contracts remain disconnected.
• Neighbourhood working depends on partnership. PCNs and VCSE organisations both bring value, but effective neighbourhood models require shared spaces, shared responsibility, and shared outcomes.

The potential of community-based interventions

This stage of our work showed the potential of community-based interventions to address social need and ease pressure on general practice. It also exposed how fragile these approaches are without infrastructure and partnership.

We had the essential aspects of neighbourhood care: connection, prevention, and community, but not the resources to sustain it. This realisation led directly to the development of our neighbourhood Health Hub, which provides the space, coordination, and stability that community-based care requires. In our third article we will describe how we developed this model and what it enabled.

References

1. Brighton & Hove City Council. Joint Strategic Needs Assessment (JSNA) [Internet]. Brighton: Brighton & Hove City Council; 2026. Available from: https://www.brighton-hove.gov.uk/joint-strategic-needs-assessment-jsna [accessed 16/3/26]
2. Mervyn, K, Amoo, N and Malby, R (2018). Challenges and insights in inter-organizational collaborative healthcare networks: an empirical case study of a place-based network. International Journal of Organizational Analysis (2019) 27 (4): 875–902, DOI https://doi.org/10.1108/IJOA-05-2018-1415.
3. Shonin E, Van Gordon W, Griffiths MD. Does mindfulness work? BMJ. 2015 Dec 29;351:h6919. DOI: 10.1136/bmj.h6919
4. Zhang X, Chang T, Hu W, Shi M, Chai Y, Wang S, Zhou G, Han M, Zhuang M, Yu J, Yin H, Zhu L, Zhao C, Li Z, Liao X. Efficacy and safety of yoga for the management of chronic low back pain: an overview of systematic reviews. Front Neurol. 2023 Oct 27;14:1273473. DOI: 10.3389/fneur.2023.12734
5. Sotiropoulos S, Papandreou M, Mavrogenis A, Tsaroucha A, Georgoudis G. The Effects of Qigong and Tai Chi Exercises on Chronic Low Back Pain in Adults: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cureus. 2025 May 18;17(5):e84342. DOI: 10.7759/cureus.8434
6. Goodman-Casanova JM, Guzman-Parra J, Mayoral-Cleries F, Cuesta-Lozano D. Community-based art groups in mental health recovery: A systematic review and narrative synthesis. J Psychiatr Ment Health Nurs. 2024 Apr;31(2):158-173. DOI: 10.1111/jpm.12970

Featured Photo by Ben Guerin on Unsplash