Participatory democracy is good for you! Neighbourhood governance in a Neighbourhood Health Service 

This blog is part of a series written by organisations championing community power. As new neighbourhood governance arrangements are introduced across England through the English Devolution and Community Empowerment Bill, each blog explores how neighbourhood governance can enable local people to have real influence over their places. The series accompanies A Blueprint for Community-Powered Neighbourhood Governance, written by We’re Right Here, with input from Local Trust, Hope Not Hate, Locality, and Power to Change.

Over the last five years, colleagues at Locality and I have spent a lot of time thinking about how to make our health system more prevention-focused, neighbourhood-based, and community-led.

We’ve spoken to hundreds of community organisations across the country to understand what works – and, more often, what doesn’t – about the health system at the hyper-local level.

We know that, as the actors most deeply rooted in their communities, they are central to the health of the neighbourhoods they serve.

But, equally, we know just how much they’ve been sidelined by a health system that has historically failed to understand the most important driver of a person’s health – not how efficiently they can be processed through a treatment service, but the basic circumstances of their lives.¹

Support for these determinants of health (traditionally called “social” or “wider” but increasingly referred to as “core”) has long felt alien to the medical model of the NHS. The government’s “10 Year Health Plan for England” has recognised that a pivot towards them is the only way the NHS will remain financially sustainable in the long-term.² But this is not something it can do alone.

Anchored in their neighbourhoods and run by and for local people, community organisations have the knowledge, connections, and trust needed to address the fundamentals of local people’s health. We know that, on average, they address 91% of the core determinants of health. They support people into good work, open up access to local green space, and run community hubs for people to connect – and that’s just scraping the surface.³

So, as the government attempts a generational shift in the way the health system works – with a commitment to create a “Neighbourhood Health Service” – it is crucial that these organisations sit at the heart of decision-making about the health of their communities.

Governance in the health system is not easy to understand, so let’s focus on the most relevant bit. Since the creation of Integrated Care Systems under the Health and Care Act 2022, the term “neighbourhood” has been used to describe the most local level of health service coordination.

In effect, the health system’s definition of a neighbourhood has been the area loosely covered by the group of GP practices that make up the nearest Primary Care Network (PCN). This presents two big issues.

Firstly, the average population size covered by a PCN is 50,000 – and, in fact, more than a third of PCNs are even bigger.⁴ These scales are now being replicated under the new model of “neighbourhood providers”, but there are few places – certainly outside of major cities – where residents would consider their neighbourhoods to be of that scale. Indeed, the government’s own Pride in Place Programme is funding neighbourhood regeneration in areas of around 10,000 people.⁵

Secondly, as independent businesses, GP practices often group together in PCNs on the basis of financial or corporate expedience, rather than a shared connection to a local area.⁶

This means that often, as well as being far too big, the “neighbourhood” footprint they cover doesn’t correspond to any conception commonly held by local people (based on, for example, physical or human geography, local socioeconomic conditions, or community infrastructure).

The net effect of all this is that communities often find it frustratingly hard to work with primary care services. For example, one community organisation I’ve spoken to described how they often receive social prescribing referrals from their PCN for individuals who live in a completely different part of the city. With no connection or means of travelling to the location of the service, those people simply don’t attend.

This is a perfect example of the structural barriers put up by the health system that prevent the true integration of community organisations. And it’s a lose-lose-lose situation for the organisations, the system, and the local people that both are trying to serve.

But now is the opportunity for change. The government is grappling with how to configure a true Neighbourhood Health Service at the same time as working out the details of new neighbourhood governance arrangements flowing from the English Devolution and Community Empowerment Bill.

We wholeheartedly support We’re Right Here’s calls for those arrangements to genuinely empower local people and community organisations. This is crucial to ensure that decisions about local public services – particularly those supporting health and its core determinants – reflect the real needs and strengths of the local area.

The campaign’s principles for community-powered neighbourhood governance will ensure this happens. And two are of particular relevance given what I’ve laid out above: that arrangements should meaningfully include the community groups and organisations already working in and for local areas, and that they should be shaped around areas that people actually recognise as their neighbourhoods.

And those arrangements shouldn’t just be made between local authorities and communities – as a key part of the neighbourhood realm, the local health system should be at the table too.

By adopting this approach, the government can help to bring together all its ideas of neighbourhoods – across governance, public services, and regeneration – into one clear, joined-up conception.

Oh, and one other thing – did you know that community power and democratic participation are also core determinants of health?⁷ Now, that is a win-win-win.

Read A Blueprint for Community-Powered Neighbourhood Governance.

Footnotes

1. The King’s Fund, 2013, “Broader determinants of health: trends”. ↩︎
2. UK Government, 2025, “Fit for the Future: 10 Year Health Plan for England”.  ↩︎
3. Locality, 2022, “Community anchor organisations and the wider determinants of health”.  ↩︎
4. The King’s Fund, 2024, “Primary care networks (PCNs) explained”.  ↩︎
5. Ministry of Housing, Communities & Local Government, 2025, “Pride in Place Programme prospectus”.  ↩︎
6. Locality, 2024, “Keep it Local for Better Health: How Integrated Care Systems can unlock the power of community”.  ↩︎
7. The Marmot Review, 2010, “Fair Society, Healthy Lives”.  ↩︎