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, community and social enterprise sector (VCSE) organisations, and how, without the capacity to evaluate outcomes or develop shared outcomes, the benefits were difficult to evidence. In our second article* we described how we used a one-off £50,000 wellbeing grant from our Integrated Care Board (ICB) to test whether community-based activity, delivered directly by our staff, could improve wellbeing and reduce pressure on general practice.
We needed a place where existing services could work together, consistently, for the same population.
GPs in East and Central Brighton face demand driven by social rather than medical need, hence the need for introducing neighbourhood care. Articles 1 and 2 described why neighbourhood working often fails: PCNs are asked to deliver it without the space, coordination, or finances needed. The Health Hub was our practical response, showing that neighbourhood working is achievable using local assets and PCN staff. This article explains how a simple weekly drop-in became the foundation for genuine neighbourhood collaboration.
From intention to reality
National policy promotes integration, prevention, and care closer to home.¹ But as Article 1 described, PCNs are expected to deliver neighbourhood working without the resources to do so. Article 2 showed that even when community-based interventions improved wellbeing, they were short lived without the necessary ongoing resources.²
The Health Hub came from a simple realisation; we did not need more services. We needed a place where existing services could work together, consistently, for the same population.
Why the Health Hub?
Patients in East and Central Brighton face high levels of deprivation. The result is that GPs are often dealing with social rather than medical need.³
Having already tried two different approaches to neighbourhood working, we considered the idea of starting a Health Hub. Commissioning VCSE organisations was valuable, but the commissioner role did not lead to integration. In addition, PCN-led community groups improved wellbeing, but depended on short-term funding and were also difficult to scale. In fact, both approaches ran into the same problem. Without infrastructure, shared vision, and joint system-led goals, neighbourhood working remained extremely difficult.
The Health Hub
The Health Hub is a weekly, open-access drop-in held in a community venue in one of our most deprived areas. It is deliberately simple:
• No appointments
• No referrals
• No eligibility thresholds
People walk in and speak directly to the professionals they need. Staff work side by side and solve problems together. It is not a new service; it is a different way of organising what already exists.
How it Works in Practice
Each Friday morning, a mix of services come together in the same space:
• Social prescribers
• Housing and homelessness teams
• Mental health practitioners
• Clinical pharmacists
• Occupational therapy and physiotherapy
• Welfare and benefits advisors
• VCSE organisations
• Community champions
Over 15 months, 1,269 patients attended. Nearly half came from one of the most disadvantaged neighbourhoods locally.
From our evaluation, the data told a clear story:
• 50.4% said they would have gone to their GP if the Hub had not existed
• 27% saw more than one professional in a single visit
• 58% were supported entirely by non-clinical teams
Our aim was to provide the infrastructure and invite patients and organisations to come and share the space.
Building collaboration before complexity
None of these groups needed major new funding; they happened because there was a principal location where services and teams could come together consistently.
One of the most important lessons came early on in the process. The deep integration of services and teams takes time and commitment.
Several national policy frameworks focus on the top 1% of patients with the most complex needs.⁴ But asking teams to come together across organisations and geographies to manage these patients, without having worked together properly first, is ambitious. The Health Hub gave teams a place to start by bringing them together in one place. By working on everyday problems first, they got to know each other, took time to understand roles, and built trust.
What changed?
The biggest shift was behavioural, for both patients and staff. Patients started to see the Hub as somewhere they could go for help that was not purely medical, and staff worked alongside each other, rather than referring on. GPs had a reliable alternative to issuing repeated appointments and/or prescribing medication, and finally we had estates to invite other organisations to join us and work collaboratively.
Once it was established, other work started to build around the Hub. We partnered with our hospital trust and conducted Respiratory Clinics alongside social support. We do a Pain Café for those with chronic pain and opioid reduction. We have run targeted sessions on falls prevention, cardiovascular health, trauma, and bereavement support were also introduced. None of these groups needed major new funding; they happened because there was a principal location where services and teams could come together consistently.
Feedback
Our patients described the Hub in simple terms:
- Welcoming
- Easy to access
- Not rushed
- A place where they felt comfortable asking for help
- Many said they would otherwise have gone to their GP.
Why the Hub Works
The Hub works because it provides a few basic things we, as a general practice, did not have before:
• A consistent place for services to come together
• Access to multiple types of support in one visit
• Real-time collaboration
• A visible neighbourhood front door
They sound simple, but together they make neighbourhood working in our area possible.
Why this model is scalable
This model is relatively low cost and simple to replicate. The workforce already exists across health, social care and the VCSE sector. Community venues are widely available and affordable. The change is not about creating new services; it is about bringing people together in the same place.
That said, the Hub did not happen by accident; it required leadership, coordination, a willingness from our Integrated Care Board, and our member practices. It also needed the right incentives. If national priorities continue to focus on activity measures like screening, vaccinations and admissions, then organisations will focus there. If neighbourhood outcomes and integration are prioritised, behaviour will change.
Conclusion
Across this series, the message is fairly simple: neighbourhood working is possible, but it cannot replace core general practice. It has to sit alongside it, with its own space, coordination and resources. Funding cannot be taken from core general practice; otherwise, GPs will struggle to engage with neighbourhood working.
Neighbourhood care needs staff, space, coordination, and funding alongside day-to-day work. It also needs time for teams to work together before being asked to manage the most complex patients. In our experience, the Health Hub did not add complexity, it simplified things. It created a shared space where services could work together in a way that made sense to patients. It reduced pressure on general practice and improved access, particularly for people who often struggled to engage.
But it is not perfect. We are still waiting for some partners to commit staff and resources. Many remain hesitant due to the confusion of the purpose of integrated neighbourhood teams. In our experience frontline staff are excited to work together when given permission. It is easy to feel lost at the lack of estates in primary care, however there are opportunities. Local councils and community venues are waiting for collaboration, investment and a vision of how to work together.
*Deputy Editor’s note – See previous articles in series: https://bjgplife.com/building-neighbourhood-care-in-east-and-central-brighton-a-structural-tension-at-the-heart-of-pcns/ and https://bjgplife.com/building-neighbourhood-care-in-east-and-central-brighton-lessons-we-learned-from-creating-pcn-community-groups/
References
1. NHS England. The NHS Long Term Plan [Internet]. London: NHS England; 2019 [cited 2026 Jan 10]. Available from: https://www.longtermplan.nhs.uk/.
2. Mervyn K, Amoo N, Malby R. Challenges and insights in inter-organizational collaborative healthcare networks: an empirical case study of a place-based network. Int J Organ Anal. [Internet]. 2018 [cited 2026 Jan 10]; 26(1):8–27. Available from: https://openresearch.lsbu.ac.uk/item/86qzq.
3. Marmot M. The health gap: the challenge of an unequal world. London: Bloomsbury Publishing; 2015.
4. Goodwin N, Stein V, Amelung VE. What is integrated care? In: Amelung VE, Stein V, Goodwin N, Balicer R, Nolte E, Suter E, editors. Handbook Integrated Care. Cham: Springer; 2017. pp. 3–23.
Featured Photo by Ben Guerin on Unsplash
