National Neighbourhood Health lead visits Wakefield to learn from local teams

Wakefield continues to play a key role in shaping the future of neighbourhood health, welcoming Dr Minal Bakhai, Senior Responsible Officer for the NHS National Neighbourhood Health Implementation Programme (NNHIP) to our district last week.

The visit was an opportunity to showcase how neighbourhood working is making a real difference for local people and communities.

Dr Bakhai joined a Pontefract and Knottingley Primary Care Network (PCN) multi‑disciplinary team (MDT) meeting, designed to improve outcomes for patients with complex respiratory needs. The session looked at opportunities to improve patient experience, reduce exacerbations, prevent avoidable hospital admissions, and strengthen COPD-related pathways through a more joined-up approach.

From stronger partnerships to better support for people with long‑term conditions, the PCN team was keen to share the early impact of their work.

Dr Pauline Riddett, Clinical Director of Pontefract and Knottingley PCN, said: “Our respiratory MDT is making a real difference for patients with complex needs. By bringing together GPs, nurses, health coaches, healthy housing teams, the ambulance service, social prescribers, hospital respiratory nurses and physios with public health colleagues, we’re able to spot issues earlier and respond more quickly.

“This holistic approach means we are not just treating symptoms we are reviewing the whole picture from cold homes and transport challenges to confidence in joining a rehabilitation class.

“It was a pleasure to show Dr Bakhai how our neighbourhood is working together to help people stay well at home and feel more supported in their community.”

After the MDT, Dr Bakhai met partners at Wakefield Town Hall for a showcase of the district’s risk‑stratification model. Powered by Wakefield’s linked population data system, the model enables teams to proactively identify patients at greatest risk of unplanned emergency admission. The approach brings partners together around a shared view of local need, ensuring the right people are seen at the right time.

Dr Bakhai said: “It’s been brilliant to see neighbourhood health in action… [and] to see that focus on whole-person, whole-family care, partnership working by default, and dissolving some of the bureaucracy that gets in the way of delivering great care.

“It’s been really inspiring to hear staff talking about how motivating it is to work in such a collaborative manner where they’re able to do their best work for their patients.

“The site is exceeding expectations in regard to impact, not just on hospital activity and emergency admissions but also improving person and community activation and whole-person wellbeing and health outcomes.”

The learning from the national implementation sites, including Wakefield District, will help shape the national roll‑out of neighbourhood health across England.

Next steps include the expected publication of guidance and Neighbourhood Health Plans, which will be overseen by local Health and Wellbeing Boards.